SAFETY AND

OCCUPATIONAL HEALTH
PROGRAM ASSESSMENT

IMPLEMENTATION
GUIDE

Version 2.0
October 2004
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 TABLE OF CONTENTS

“WHY DO THE WHAT?”

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 INTRODUCTION

To comply with requirements of OPNAVINST 5100.23G, the Process Review &

Measurement System (PR&MS) QMB, under guidance of CNO, developed this self-
assessment guide to assist activities to better understand the implementation of the
PR&MS key processes. This method applies five PR&MS modules (Mishap Prevention,
Regulatory Compliance, Supervision, Training, and Customer-focused Support) to each
major program. Application of the self-assessment processes presented in this guide will
assist commands in identifying gaps in the SOH programs and provide recommendations
for improvements.

An overview of the process can be viewed on the following pages. Examples provided in
this overview are not intended to be all-inclusive.

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An effective SOH Program is integrated through all levels of the command. This
integration is illustrated in the following flow chart (Figure 1).

Figure 1

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 SELF-ASSESSMENT SYSTEMS ARCHITECTURE
THE CONCEPT

Conceptually, the systems architecture for self-assessment, Figure 2, aims to ensure that
the self-assessment identifies safety and health needs consistent with the business and
management needs of the command. The dynamics of the systems architecture gives due
consideration to employee interaction, safety and health program requirements, and
progress towards stated organizational objectives and PR&MS goals.
The framework for the self-assessment system is built on three fundamental components—
Plan and Prepare, Management System and Business Processes, and Support Processes.
These components exchange important safety, health, support, business and management
information. Within each component there is a reliance on well-defined processes as well
as the management of the relationships within those processes.
 The plan and prepare component outlines processes, actions and responsibilities for the
planning and preparation of successful self-assessment efforts. This component houses
the disciplines for identifying requirements and confirming that planned self-
assessments meet the needs of the command. Included in this component are the
administrative processes for recording and assessing self-assessment results.
 The management system and business processes component outlines processes, actions
and responsibilities for the planning, execution and follow-up of business and
management strategies relative to mission accomplishment. This component houses
the disciplines for identifying the needs of the command and assessing critical success
factors. Included in this component are training, corrective action, and documentation
control processes. The process for continuous organizational improvement is
embedded in this component.
 The support processes component houses the services and partnerships necessary to
achieve safety and health program excellence and mission accomplishment.
Component Relationships: The plan and prepare component interacts with the command’s
overall management system and business processes component by inserting self-
assessment results into the command’s business planning, management review, and
corrective action processes. The relationship continues with the identification of specific
safety and health training needs and improvements that can drive organizational
excellence. The plan and prepare component relates to the support processes component
by accounting for safety and health program support requirements in self-assessment plans.
This relationship continues by identifying the degree of support satisfaction for
management review and subsequent business adjustments.
Information Exchange: All three components of the self-assessment system exchange
safety and health information in the form of organizational goals and objectives,
performance measures, and employee interactions. The plan and prepare component
exchanges PR&MS goals and important safety and health information for mission
objectives and important business information coming from the management system and
business processes. This exchange promotes the integration of safety and health
considerations into the command’s business planning and management review processes.

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Similarly, the information exchange with the support processes component promotes
clarity in the support of safety and health programs.

SA = Self-Assessment
Figure 2

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 OVERVIEW

SELF-ASSESSMENT PURPOSE (Why do the What?)

The purpose of the PR&MS self-assessment is to identify the current status of the
command SOH program. It should describe where it is, where do you want to go, and how
you will get there. This guide provides basic format, procedures, and methodology for
developing a command SOH self-assessment. It provides a basic performance protocol for
the PR&MS self-assessment.

Command self-assessments of the SOH program can provide significant input to ensure the
activity’s safety and health programs and processes are tailored to meet the needs of the
activity while ensuring thoroughness and appropriateness of the SOH program
requirements.

An annual safety and health self-assessment underpins the command’s efforts to

continually improve safety and health programs and can provide valuable information in
aligning a comprehensive safety and health program to the mission of the activity. A well-
executed self-assessment can also provide focus for management review and determining
subsequent follow-on actions.

SELF-ASSESSMENT PLANNING PRINCIPLES

Planning is an essential part of the self-assessment process for two compelling reasons:
1. From a formal standpoint, the self-assessment tests assumptions that process "A"
provides adequate controls to satisfy the governing requirement(s), or that operation "1" is
being performed in accordance with the requirements specified by process "A."
2. From a practical standpoint, one full cycle of the self-assessment schedule (one year, for
example) must evaluate the effectiveness of every element of the safety program. The first
self-assessment will be the baseline, therefore, the most difficult to complete. Each
subsequent self-assessment evaluates program progress compared to the baseline. An
assessment in which parts of program requirements are omitted from examination defeats
the intent of the self-assessment discipline. Planning provides insurance against such
omission.

PREPARATION AND PLANNING

Defining Purpose
Self-assessing with a purpose provides unity and coherence. Before any effective planning
for a self-assessment can be done, there must be a clear understanding of the purpose.
With most formally scheduled self-assessments there is a well-established purpose to
verify the effectiveness of the program, process, or operation. However, for a self-
assessment that either is not included in a formal schedule or is taken out of sequence there
is a suggestion of purpose(s) other than routine. As a matter of habit, for every self-
assessment the purpose should be confirmed and/or defined.

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1. Defining Scope

A key fundamental element of self-assessing is defining determining the scope of the

individual self-assessment. Scope should be defined in terms of processes or functions to
be assessed, the breadth of requirements against which the self-assessment will be
conducted, and the time span for evidence that will be examined.
2. Requirements Baseline

Establishing a requirements baseline is a function of the scope of self-assessment.

Identifying which level or levels of the requirements hierarchy will be involved, which
documents of the hierarchy will be involved, and the relevant paragraphs within documents
is critical to an effective self-assessment.

3. Background Research

Few self-assessments are born in a vacuum. It is essential to determine the background of

programs, processes, or operations to be assessed. Such information will normally include
the history of previous self-assessments of the same programs, processes, or operations;
recent problems involving or affecting them; cost or schedule pressure in affected areas;
and the current status of each.

4. Identifying Scope

The statement of self-assessment scope will have established which organizational units
are to be examined. It is desirable to determine during the planning phase, which
organizational entities, such as programs, departments, processes and functions are subject
to the current self-assessment effort. It is during this part of planning that points-of-contact
for the examiner should be established. Points of contact can facilitate any personnel
interviews necessary for incorporation into the self-assessment.

5. Determining Evidence

The technical core of the planning effort is determining types of evidence to be examined.
“Evidence” in this case can be documentation, data, observed behavior, questionnaires, etc.
Although this will not always be possible (or feasible within the available time) to make a
before-the-fact list of every type of evidence to be encountered, that should be the goal.
This would include a list of interviewees.
6. Data Fields

Most evidence that is examined during the self-assessment consists of some kind of
documentation, and as such, becomes part of the data for the current self-assessment.
Documentation and pertinent data fields need to be defined and a determination made as to
whether all of the documents and data of a particular type will be subject to evaluation. It
is helpful to have an understanding of how each type of document is prepared and
controlled so the examiner can choose from the most current document and data files or
those of historical nature. It is also desirable to determine during planning how large each
data field is. The examiner often has to work with an order-of-magnitude estimate, but
even that helps in establishing a sampling plan.

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7. Interviews

Questions to conduct interviews with employees, process owners, and program managers
should be considered. Answers to these questions provide additional evidence for the self-
assessment and becomes part of the data for the current self-assessment.

8. The Sampling Plan(s)

Having prepared a list of the kinds of documents to be examined during the self-
assessment, a list of interviewees, and having at least estimated how many of each type are
pertinent to the self-assessment, the examiner makes sampling plans. Formal or informal,
there will be one such plan for each kind of data. The examiner decides whether to do
judgment of statistical sampling and determines how large each sample must be (QA
personnel can assist). If statistical sampling is to be employed, the examiner normally
selects the required random number array for each sample at this time.

9. Self-assessment Sequence/Schedule

The self-assessment should be considered a living document. Every self-assessment plan

should include at least a tentative schedule of events. The sequence of events may be of
little or no real significance for the self-assessment, but it does provide a time saving
transition when the examiner completes the assessment in one area and is ready to move to
another. As an incidental bonus, the act of thinking out a schedule helps the examiner to
decide whether the sequence in which the evidence is examined is likely to affect the self-
assessment results.

10. Self-assessment Checklists/Procedures

To perform a self-assessment, use of a checklist is advisable. The examiner may have

standard checklists or procedures available, or may find it desirable to generate an original
checklist for each self-assessment. Even when a standard checklist or procedure is
available, the examiner may have to tailor the checklist or procedures to a specific
assessment.

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 The Self-Assessment Plan

The formal self-assessment plan, based on the planning effort previously discussed in the
Overview, provides formal documentation of the anticipated self-assessment activities. In
practice, the plan tends to be brief. It references the checklist and/or procedure, tells what
kind of sampling is intended, and contains the basic self-assessment sequence. It is seldom
an in-depth treatment of the material the examiner has considered or generated, as most of
what is important will be reflected in documentation of the self-assessment as it is
performed.

THE TEN-STEP SELF-ASSESSMENT PROCESS

This document is a formal, written self-assessment guide. A sample cover memo,

implementing use of this guide at the local activity is provided in Appendix A, Self-
Assessment Process Memo. Activities may elect to identify this guide into a formal
instruction, a Standard Operating Procedure (SOP) or other guidance.

1. How to Define the Scope

The activity self-assessment process looks at the command SOH Program through the eyes
of the six key processes of PR&MS. Start with the Needs Assessment to identify the
relevant programs, serviced population, and resources needed. The best place to begin is
OPNAVINST 5100.23 (series). Assess the applicability of each chapter to the activity.
All chapters may not be applicable. Include other major program areas, which are not
specifically addressed by OPNAVINST 5100.23 (series), such as Fall Protection,
Explosive Safety, Traffic Safety, etc. Self-assessments must be conducted annually, and
you will need to determine whether the current year data is adequate for review, or if you
need to identify trends over a timeline of several years. See
http://safetycenter.navy.mil/osh/shore/prms/, Needs Assessment Matrix, for examples of
tools for this purpose.

2. How to Determine Baseline Requirements

The baseline assessment establishes the foundation of the command self-assessment. See
Appendix B, Sample Baseline Self-Assessment Outline.

Step 2-1: What governing documents need to be reviewed? Examples include the
OPNAVINSTs, CFRs, ANSI standards, local SOPs, etc.

Step 2-2: Determine what portions or paragraphs within these documents are applicable.

3. How to Conduct Background Research

Step 3-1: If there is a previous self-assessment that has been conducted, review it and
determine if actions have been completed or addressed. Were there gaps? Any changes in
the program since the last review? If not, go to Step 3-2, How to Determine Baseline
Requirements.

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Step 3-2: Look at leading and lagging indicators such as mishap logs, unsafe/unhealthful
reports, hazard abatement records, mishap investigation reports, relevant union/labor
issues, near miss reports, job hazard analyses (JHAs), industrial hygiene surveys, process
instructions, operational risk management (ORM) surveys, standard operating procedures
(SOPs), etc., for historical review.

Step 3-3: Compare this data to benchmark data previously identified in prior self-
assessments and/or performance measurements or metrics, higher-level directives/ordered
reductions.

4. How to Identify Scope

For the program being assessed, identify which work units, codes, departments, etc., are
involved in the process and identify the affected population for all programs. For example,
when assessing the confined space entry program, include those trades who routinely enter
confined spaces. If people outside the safety office test confined spaces (qualified
persons), review their records (training, calibration logs, entry permits). When reviewing
the respirator program, go where respirators are used. Select a group of sites (10-20%
total) for a visit. Determine if respirator users are storing respirators properly, if
respirators are in use. Ensure they are donned properly and can employees demonstrate
proper donning and doffing. Identify and document decisions regarding who will be
interviewed and/or which will receive surveys if surveys are used.

Identify points of contact throughout the organization needed during the program
assessment. Do not focus on the lowest levels, integration means throughout all levels of
the command structure. Write down name, code, telephone number, and email address.
Schedule appointments to ensure personnel are available to participate. Remember, the
assessment may not be their first priority, be considerate of their schedule.

5. How to Determine the Evidence.

Get organized! For the program being reviewed, specify what needs to be assessed. For
example, when evaluating the training program, look at the people, processes and paper
involved in that program (i.e., training plan, lesson plans, critique sheets, personnel
interviews, actual observed performance vice preferred performance). The point here is to
know if the evidence demonstrates that the program works.

People – personnel interviews, observations in the workplace, surveys, etc.

Processes – document reviews, observations in the workplace, SOPs, etc.
Paper – instructions, test chits, training records, etc.

6. How to Determine Data Fields

Review trends and patterns, analyze for causes and determine priorities. Data should be
broken down by divisions, departments, or work centers to track internal progress.
Analysis needs to be reflected in conclusions, and recommendations for improvements,
which are prioritized where applicable. Corrective action must address underlying causes
and not merely symptoms. Information should be bench marked against Navy, federal,

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national, or other appropriate private sector data. The analysis process should be reviewed
periodically for appropriateness and changed/improved as necessary.

Periodic monitoring of metrics and reporting of findings and progress should be shared
with the command via policy council, Executive Steering Committee, or other higher
authority.

Where appropriate, determine if data is shared with the entire command and is
integrated/incorporated into training and work processes. Is data analysis used to monitor
and drive continuous improvements?

For example, if reviewing the mishap reporting and record-keeping program, data fields
could include trends over the past 5 years to show improvement or identify areas of
concern. Mishap analyses should be reviewed to determine cause and effect. Timeliness
of reporting may be another data element. Look for data that is being used. Do not create
new data just for the assessment purpose.

7. How to Conduct Interviews/Surveys

Prepare questions in advance. Try to avoid yes/no answers. Keep interviews brief – no
more than 30 minutes. Use “conversational tone”, not “inquisitional tone”. Deflect any
gripes or complaints about lack of policy or direction by explaining this is the SOH
program assessment. Offer to take notes documenting concerns/issues. In addition to
process-specific questions, include questions regarding understanding/perception of their
role within the self-assessment process and PR&MS. Ask for suggestions for process
improvements. Sample interview questions are incorporated in Appendix C, Sample
Interview Questions.

It may be advisable to use surveys in addition to, or sometimes in place of, interviews.
Similar to interviews, prepare questions in advance. The questions should be formatted so
that responses can be analyzed and, perhaps, graphed. Sample survey questions are
provided in Appendix E.

8. How to Create the Sampling Plan

Pull together the information/documents from items 1-7 above, such as list of interviewees,
survey questions, records to review, sites to visit, etc. Develop a schedule. Do not make
the mistake of selecting too few sampling points or too many. One (site visited, lesson
plan reviewed, supervisor interviewed, etc.) may not be enough; 100% may be too many.

9. The Self-Assessment Sequence/Schedule

This is a plan of action and milestones (POA&M). When will it start? It is possible to
assess the program throughout the year. If that is how it is to be tackled, plan for it. What
will be done first? What comes next? Determine whether order of assessment matters.
For example, will it matter if the hearing conservation program is evaluated before
scheduled hearing conservation training? It probably will so evaluate after training.

10. The Self-Assessment Checklist/Procedures

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It may be desirable to use checklists for the program being evaluated or establish separate
criteria. Various checklists for specific programs are available on websites (see Appendix
F, Safety Websites Checklists). Checklist items often tend to spotlight the kind of
evidence required to determine the success or failure of a program and may eliminate the
requirement to develop them locally.

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 OVERVIEW OF SELF-ASSESSMENT PROCESS

Identify Applicable Programs Broad-Based Program Goals for

using OPNAVINST 5100.23 PR&MS Modules (Mishap
Series and other references, Prevention, Regulatory Compliance,
which apply to the activity. Supervision, Training, Customer-
Focused Support) established

Evaluate individual programs

based on goals for each
module and document as Complete “Program Review Sheet”
“Current Status”. on each applicable program

Program Document “Recommendation(s)”

Deficiencie for noted program deficiencies on
Yes
s “Program Review Sheet”.
Identified?

No For each program, score each

module using scoring criteria
defined in implementation guide.

Average model scores for Mishap Prevention,

Regulatory Compliance, Supervision, Customer-
Focused Support, and Training. The result is the
Self Assessment Score or Overall Program Score.

Develop detailed Plan(s) for

Score of Improvement for each module
‘3’ or with scores of 3 or less.
less?
Yes

No

Activity establishes schedule for re-

assessment (at least annually) based on
outcome. Improvement Plans provided to
Commanding Officer/OSH Policy Council for
approval/ review/monitoring.

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 PROGRAM REVIEW SHEET

Program review sheets are designed to provide a format to document the annual self-
assessment of applicable individual programs (e.g., respiratory protection, confined space
entry, etc.) with PR&MS modules applied in a single document.

The completed document should describe where each program is (current status), where it
needs to go (recommendations, goals, objectives), and how to get there (POA&M). This
guide provides basic format, procedures, and methodology for developing a command
SOH self-assessment. It provides a basic performance protocol for the PR&MS self-
assessment, which addresses items such as mishap prevention, regulatory compliance,
training, supervision, customer-focused support, personnel participation, and adequacy of
resources.

The review process is as follows:

 Identify applicable program areas and create a program review sheet for each.
 Each module has 6 bullets: Goal, Current Status, Adequacy of Resources, Personnel
Participation, Recommendation(s), and Score.
 A sheet is required for every program identified on the Scoring Grid Sheet.
 Electronic templates will be provided for all the program elements identified on the
attached Scoring Grid.
 Add/delete programs to the scoring grid sheet as applicable
 Program Review Sheets are provided at Appendix G.

GOALS:
 Broad-based goals were developed for each PR&MS module and applied to each SOH
program as shown below rather than establishing specific goals for each program

 Mishap Prevention
For the Mishap Prevention Process there are four elements to consider. The
first one is the command’s injury/illness incidence rate. The second element
assesses the command’s process(es) to compile the mishap and hazard data
needed to prevent mishaps. The third element evaluates the data analysis
process in place at the command. The last element examines the process(es)
used by the SOH office to notify process owner of pertinent SOH data and what
those process owners do in response to the analysis data to prevent mishaps.

Sample Goal: To develop a systematic approach for applying operational risk

management (ORM) to assess safety and health risk to eliminate occupational
injuries/illnesses.

 Regulatory Compliance
The first step is to determine the command’s regulatory compliance
requirements and then develop a strategy to meet them. Resources should also
be identified to achieve the regulatory requirements and a strategy developed to
execute, monitor, and sustain/maintain compliance.

Sample Goal: To achieve and sustain regulatory compliance.

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  Supervision and Leadership or Accountability
Actions to be taken by management and supervisors to plan, organize, direct,
oversee, and evaluate the activity of subordinates and command personnel to
safety accomplish work and ensure SOH considerations are integrated into core
business, work processes, and performance descriptions/evaluations and
demonstrate by in and support for the SOH program.

Sample Goal: To ensure all managers and supervisors are equipped, qualified,
prepared and accountable for safely conducting daily operations.

 Training
Based on two separate performance measures. The first measurement is a
compliance-based matrix match against statutory requirements, and the second
is employee interface/challenges to evaluate training effectiveness.

Sample Goal: To ensure the workforce is fully trained and qualified to

safely accomplish the command mission.

 Customer-focused Support
Centers on surveying customers to determine their needs and follow up actions
to assess the quality and satisfaction of SOH services provided.

Sample Goal: To provide SOH support, services, and guidance that meet
customer needs.

 Self –Assessment
The Self-Assessment section will contain the overall program score and
recommendations for improvement, which can be transferred to a POA&M or
process improvement plan. If the program is in 100% compliance, no program
improvement initiatives are required. If the average score is 3 or less, there
must be improvements needed. Remember, the assessment is supposed to
drive process improvement. What is identified as needing correction must get
attention. Specifically identify WHAT has to be done, WHO should do it,
HOW to tell when it is done, HOW to measure improvement. The assessment
should identify and quantify actions and resources needed to correct process
deficiencies. The self-assessment should also identify further process
improvement opportunities for programs that already meet basic requirements.
These can be included as recommendations for programs that score higher than
3, but lower than 5, without a requirement for special program improvement
initiatives.

Sample Goal: To review processes, measure performance and implement

improvement initiatives.

CURRENT STATUS:
 Summarize the current status of the program as it relates to the goal using supporting
documentation (statistics, metrics, surveys, etc.).

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ADEQUACY OF RESOURCES:
 Identify existing human and funding resources (staff members, non-labor budget,
availability of contract support, etc). Are there enough resources to execute the
program element being assessed? For example, is there adequate funding to provide
safety shoes for employees where required? Determine whether or not existing
resources are adequate.
 If resources are inadequate, identify possible solutions to eliminate the shortfall.
 Remember that ‘human resources’ can be found within the Safety Office (Safety
Specialist, Safety Engineer, Industrial Hygienist), outside of the Safety Office but
within the Command (Facilities Department, Comptroller Department), and outside the
Command (Public Works Center, Region, Naval Medical Clinic, etc.).
 “Funding resources” may be included in the command budget, hazard abatement
funding potential, etc.
 Resources can include adequate computers, training aids/facilities, monitoring or
testing equipment, etc.

PERSONNEL PARTICIPATION:
 Provide examples of methods in which personnel at all levels of the organization
participate in and/or support the program element. Examples include committee
membership, reporting unsafe/unhealthful working conditions, submitting suggestions
for improvement, responding to surveys, attending training as scheduled, completing
periodic medical exams as scheduled, etc.
 It is important that examples of participation include an assessment of effectiveness.
Simply having a committee established is not the same as having effective committee
meetings.
 This section answers the following question: “How do employees actively participate
in the SOH Program?”

RECOMMENDATION(s):
 Summarize recommendations for improvement.
 If plans for improvement are recommended, they will be separate documents.

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SCORE:
 Each PR&MS module (except self-assessment) for each program is assigned a score
using the following criteria:

Scoring Criteria

Score 1: No Compliance (“Not at all”): Programs may be inadequate to support a

safe and effective environment.

Score 2: Minimal Compliance (“Rarely evident”): Major program improvements

are required immediately. Critical deficiencies may exist.

Score 3: Partial Compliance (“Sometimes”). No critical deficiencies have been

noted but major improvements should be implemented.

Score 4: Significant compliance (“Most of the time”). No critical deficiencies

have been noted but specific improvements should be implemented.

Score 5: Substantial compliance (“Always”)

 Scores of 1, 2 or 3 require a Plan for Improvement (PFI). PFI’s can be in any format
but are developed as separate documents and are typically presented to the
Commanding Officer, SOH Policy Council, Committee, Board, etc., for tracking until
goals are achieved (and, consequently, scores improve).
 The scoring system is easy to understand and explain to CO’s, executive boards, and
supervisors, and can be easily converted to charts/graphs for comparison.

SELF-ASSESSMENT:
 Scores for the 5 modules (Mishap Prevention, Regulatory Compliance, Supervision,
Training, and Customer-Focused Support) are averaged to determine a self-assessment
score for each program review sheet.
 The module score is then entered into an excel spreadsheet scoring grid. The
spreadsheet will calculate the averages.
 This becomes the overall program score in the Self-Assessment section.

PERFORMANCE MEASUREMENTS SCORING GRID

http://safetycenter.navy.mil/osh/shore/prms/ With minimal knowledge of Excel
spreadsheets, the scoring grid can be manipulated to accommodate any number of
programs with a few simple adjustments.
 List each applicable program for your activity in Column B of the spreadsheet inserting
or deleting rows as necessary. Spreadsheet Note: Remember when inserting rows, that
the formula(s) will need to be copied to the new rows.
 Column A is a program identifier code developed for the purpose of concise, neat
graphs. Programs are represented by numeric codes.
 Columns C through G are the PR&MS module scores (transferred from the review
sheets).

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 Column H – Self-Assessment. As the module scores are entered, the average (of the 5
modules) will be calculated in Column H resulting in the self-assessment score for the
individual program.
 On Row 45, overall module scores are averaged. While these averages are useful,
they could provide a false sense of security regarding the overall SOH program
status.

Note: The formula will need to be manipulated to accommodate the number of

programs evaluated - easy to do:
 Count the number of programs in column A
 In the Row labeled “Average Model Score” (row 45), click in column C (total
score of “Mishap Prevention”)
 In the formula bar (at the top of the spreadsheet under the toolbar), you will see a
formula which looks something like this SUM(C2:C36)/35
 The number following the slash (in this example: 35), represents the total number
of programs being reviewed. This number calculates the average, so its accuracy
is critical.
 The range represented by the cell numbers within the parentheses (in the example
“C2: C36”) will be the cell numbers used for the computation. Make sure the
range in the formula coincides with the program row numbers. In the sample grid,
the first program is on row 2 and the last is on row 36, hence the range C2: C36,
D2: D36, E2: E36, etc.

 Grid scores make it very easy to spot trouble areas – just look for 1’s, 2’s, and 3’s. To
make it even easier, you can change the font to bold red.
 Self-assessment scores provide an individual program success rate. Row 45, Average
Model Scores, averages scores for all modules, providing an indicator of broader
(module) issues.
 Once the spreadsheet workbook is completed, graphs will be automatically generated.
If they are set up correctly, the graphs will self-adjust as changes are made to the grid
score sheet. See the “sheets” tab at the bottom of the Excel workbook.

PLANS FOR IMPROVEMENT

 Plans for Improvement are typically more detailed than the review sheets. They
include elements such as specific taskings, goals, timelines, re-assessment dates,
equipment purchases, training needs, etc.
 The Command should designate who (what code/entity) will track completion of
specific taskings, to ensure timelines are met.
 A plan for improvement is included in Appendix H, Sample Improvement Plan.
Activities may already have a prescribed format.
 The activity will establish their own follow up schedule for Plans for Improvement (bi-
monthly, quarterly, etc.). Following implementation of corrective action, the scores are
reassessed at the activity prescribed interval, and the grid adjusted.

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RE-ASSESSMENT SCHEDULE
 The grid score spreadsheet is equipped with columns to record the date the program
was assessed and the date the program needs to be re-assessed. (Spreadsheet can be
sorted by date to quickly identify deadlines).
 All programs must be evaluated at least annually.
 Commands may want to assess several programs each quarter to avoid a massive self-
assessment project at the end of the year. (Others may choose to assess all programs at
one time). The worksheet becomes a “living document”.
 If deemed necessary, activities should establish criteria for more frequent reviews
(semi-annual, quarterly, etc.) which may be based on:
 Overall Program (Self-Assessment) Score of 3 or less
 Module Score on an individual program of 1 or 2
 Program of special interest or high visibility at the activity
 Safety Council recommendation

Example: Ergonomics Program had an overall program score of 2.5. Plans for
Improvement were written and implemented. Program was reassessed 6 months later.
Score improved to 3. Plans for Improvement were reviewed with additional
recommendations. The 6-month re-assessment date was retained because the score had
not been increased above 3. Six months later, the program is reviewed and scores 4.5.
Since significant improvement had occurred, the program review schedule is re-
established at annual intervals.

ADDITIONAL INFORMATION

As stated earlier, the workbook is a living document, continuously changing as programs

are assessed and re-assessed. In order to maintain records to show progress, save the
worksheet periodically as a dated “archive” file. Quarterly intervals are recommended.
For example, assume the worksheet is named “OSHPA FY05”. Save the worksheet on 1
October 04 which provides a “snapshot” of status at the beginning of the fiscal year. Save
as “OSHPA Oct 04”. Continue assessing/re-assessing programs and manipulating the
OSHPA FY05 worksheet as needed, and saving under the name OSHPA FY05. In
December, save the worksheet again as “OSHPA Dec 04”, and so on. This provides
snapshots of program assessments throughout the year, which can be extracted, for
comparisons.

16
 APPENDICES

A Self-Assessment Process Memo

B Sample Baseline Self-Assessment Outline
C PR&M Self-Assessment Process
D Sample Interview Questions
E Sample Survey Questions
F Safety Checklists Websites
G Program Review Sheet
H Sample Improvement Plan

17
 APPENDIX A
Self-Assessment Process Memo

5100

MEMORANDUM FOR THE RECORD

Subj: SELF-ASSESSMENT PROCESS

Ref: (a) OPNAVINST 5100.23 Series, Chapter 3

Encl: (1) CNO SOH Program Assessment Guide

1. Reference (a) requires Navy activities to conduct an annual self-assessment of program and
program elements following Process Review and Measurement System (PR&MS) self-
assessment module guidelines.

2. The activity will use enclosure (1) to conduct their self-assessment.

3. The SOH Policy Council shall review and concur with the self-assessment and Plan for
Improvement, prioritize, if necessary, and shall review the progress achieved in
implementing improvement actions ___________ (state at what frequency, e.g., monthly,
quarterly, etc.).

NOTE: For Commands without SOH Councils, the CO, Commander, or

OIC shall review and approve the annual self-assessment and plans for improvement.

__________________
Signature
 APPENDIX B

Sample Baseline Self Assessment Outline

(Sample Cover Letter) 5100.xx
Ser xxxxxxxx
Date
From: Division/ Department responsible for SA
To: Commander, (Activity Name Here)

Subj: SOH SELF-ASSESSMENT UTILIZING THE PROCESS REVIEW AND

MEASUREMENT SYSTEM

Ref: (a) OPNAVINST 5100.23F

Encl: (1) Process Review and Measurement System Self-Assessment Process (Appendix C)
(2) Sample Interview Questions (Appendix D)
(3) Sample Survey Questions (Appendix E)

1. (Activity, department, division name or code) has completed its annual SOH self-assessment
utilizing the Process Review and Measurement System (PR & MS) contained in reference (a),
Appendix 2B. This is the (first, second, third…) SOH self-assessment conducted by (activity
name) utilizing the PR & MS process. Identify scoring method used here (i.e. Scoring of each
module was performed utilizing PR&MS Self Assessment Guide, Malcolm Baldridge National
Quality Award criteria, etc.).

2. The following describes the various processes followed in conducting the enclosure (1) self-
assessment:

a. Describe participants involved in the assessment process. Example: “The evaluation team
consisted of the SOH Director (Code xx), SOH Division Head (code xx), two industrial
hygienists, and three safety specialists. The (union representation) was (provide union reps
here), or was invited to provide representation but did not participate.”

b. Identify methods of input for the self-assessment here. Examples: Documentation,

validation, interviews, etc. Example narrative: “To provide more meaningful input from the
workforce, a survey questionnaire (enclosure (2)) was developed. The questions developed for
the survey were pertinent to the specific elements in the enclosure (1) PR & MS. “

3. Describe plans for improving areas of weakness identified by the self-assessment. Example
narrative: “In accordance with reference (a), this assessment will be discussed in the (date) SOH
Policy Council meeting. During this discussion, weak areas will be highlighted, and
improvement actions will be discussed. From this, a command SOH Program Improvement Plan
will be developed, completion of improvement actions tracked, and periodic status reports
discussed in the SOH Policy Council meetings. In addition, the assessment and program
improvement plan will be deployed to the command workforce. Widespread dissemination is
imperative in order for improvement to be realized.”
 APPENDIX C

PROCESS REVIEW AND MEASUREMENT SYSTEM SELF-ASSESSMENT

(Command Name Here)

COMPLETED (Date Here)

Provide narrative for each PR&MS module reviewed in the self-assessment. Narrative should
describe how the process for each module is implemented and functions within the command
structure. Narrative should cover at least the elements and areas listed below.

1. MISHAP PREVENTION PROCESS MODULE

 Conduct an analysis of the command processes for compiling, reporting and
analyzing mishap and hazard data
 Analyze significant processes/areas
 Report key data/analysis to process owners and their review
 Identify/consider potential controls
 Conduct a value assessment
 Select alternatives
 Implement controls
 Assess impact of controls
 Modify controls as needed
 Summary of analysis and progress to date

2. REGULATORY COMPLIANCE PROCESS MODULE

 Conduct an analysis of the applicable regulatory compliance
 Describe development of compliance strategies
 Describe what methods the command utilizes to meet the requirements
 Describe how the command identifies and provides resources to meet the
requirements and maintain compliance
 Describe how the command will execute the compliance strategy
 Explain plan for monitoring compliance
 Summary of analysis and progress to date

3. SUPERVISION PROCESS MODULE

 Evaluate SOH elements in standards
 Determine employee understanding
 Assess integration initiatives

4. TRAINING PROCESS MODULE

 Identify requirements needs
 Identify audience
 Identify specific information to be delivered
 Identify media
 Assemble resources needed to provide the training
 Notify command personnel of training requirements, dates and required attendees
 Deliver the training and evaluate the effectiveness
  Modify training as required
 Summary of analysis and progress to date

5. SELF-ASSESSMENT PROCESS MODULE

 Describe how the program elements are identified and will be evaluated
 Describe development of the assessment plan for each element
 Describe the plan for improving areas identified
 Describe how the self assessment will be adjusted and improved
 Summary of analysis and progress to date

6. CUSTOMER-FOCUSED SUPPORT PROCESS MODULE

 Describe the formal process for determining customer needs
 Describe how the command has determined customer needs
 Describe how customer needs are surveyed
 Explain how surveys/workshops/focus groups/etc. improve products or services
 Explain how customers are advised of survey results
 Detail how customers are involved in the development of improvement initiatives
 Describe how improvement initiatives are tracked toward implementation
 Explain customer feedback mechanism

7. INJURY COST CONTROL PROCESS MODULE

 Under development

C-2
 APPENDIX D

Sample Interview Questions

1. How effective is the annual Safety and Occupational Health (SOH) command-wide self-assessment,
which utilizes the Navy Process Review and Measurement System (PR & MS)?
Comments/Remarks

2. How effective is the command’s program improvement plan (e.g., Safety and Occupational Health
Program Improvement Plan) in correcting SOH program deficiencies?
Comments/Remarks

3. How effective is the command’s top management in supporting and emphasizing, through words and
actions, SOH program improvements?
Comments/Remarks

4. How effective is the command in establishing and implementing new safety and health requirements?
Comments/Remarks

5. How effectively do you feel your department utilizes mishap/hazard data (mishaps, safety and
occupational health deficiencies, PPE compliance, etc.) to prevent or control mishaps?
Comments/Remarks

6. How effective is the command in analyzing work processes and taking measures to prevent mishaps or
exposure to occupational health hazards?
Comments/Remarks

7. How effective is management’s priority for the worker’s safety and protection from occupational health
hazards compared to completing a job on time?
Comments/Remarks

8. How effective is management supervision in ensuring workers do not engage in unsafe acts or
unnecessarily expose themselves to occupational health hazards?
Comments/Remarks

8A. How effective is management in holding workers accountable for not wearing the proper personal
protective equipment?
Comments/Remarks
9. How do you ensure that all training provided to your workers is current and satisfactorily trains your
workers to perform their work safely?
Comments/Remarks

10. How do you ensure that your workers perform their work in the safe manner that they have been
trained; and if the safe work methods inhibit efficient, productive work, what methods are implemented
to address these concerns?
Comments/Remarks

11. What is the one improvement item you would like to see implemented in the command's safety and
health program?
Comments/Remarks

12. How can we reduce the number of injuries and lost workdays in our command?
Comments/Remarks

13. How effective is the command in utilizing the light duty program to bring employees back to work
following an on-the-job injury?
Comments/Remarks

14. How well do you think the command provides light duty work to accommodate injured workers?
Comments/Remarks

15. How efficient is the HRO’s FECA/Compensation Office in reviewing claims and identifying
opportunities to reduce FECA costs?
Comments/Remarks

D-2
 APPENDIX E

Sample Survey Questions

Check one: Supervisor_____ Worker_____

Circle the number that best reflects your response in regards to the following questions.

Poor Exceptional
1. How effectively does the annual SOH program self- 1 2 3 4 5
assessment identify weaknesses in the program?
Comments/Remarks:

2. How effective are SOH program improvements in taking 1 2 3 4 5

into account the assist shops/codes and other resources
needed to correct SOH program deficiencies?
Comments/Remarks:

3. How effective is the command's top management in 1 2 3 4 5

supporting and emphasizing, through both word and
action, SOH program improvements?
Comments/Remarks:

4. How effective is the command in establishing and 1 2 3 4 5

implementing new safety and health requirements?
Comments/Remarks:

5. How effective is Safety Office in providing feasible and 1 2 3 4 5

practical recommendations for complying with safety
and health requirements?
Comments/Remarks:

6. How supportive is the command in providing funding for 1 2 3 4 5

complying with safety and health requirements?
Comments/Remarks:
7. How would you rate your knowledge on the proper 1 2 3 4 5
selection and use of personal protective equipment?
Comments/Remarks:

8. If you become aware of an unsafe working condition or 1 2 3 4 5

an occupational health concern and communicate the
hazard to your supervisor, how would you rate the
command’s responsiveness to your concerns?
Comments/Remarks:

9. How effectively do you feel your department utilizes 1 2 3 4 5

mishap/hazard data (mishaps, safety and occupational
health deficiencies, PPE compliance, etc.) to prevent or
control mishaps?
Comments/Remarks:

10. How effective is the command in analyzing work 1 2 3 4 5

processes and incorporating or referencing occupational
safety and health requirements into written work
procedures to prevent mishaps or exposure to
occupational health hazards?
Comments/Remarks:

11. How high is management's priority for your safety and 1 2 3 4 5

protection from occupational health hazards compared to
completing a job on time?
Comments/Remarks:

12. How effectively do you see work processes designed or 1 2 3 4 5

equipment/tools engineered to prevent mishaps or
exposure to occupational health hazards?
Comments/Remark:

13. How well are hazards in your workplace adequately 1 2 3 4 5

identified and corrected in a timely fashion?
Comments/Remarks:

14. How well is work organized/coordinated so that 1 2 3 4 5

E-2
 hazardous situations are avoided?
Comments/Remarks:

15. How effective are daily pre-job briefs in emphasizing 1 2 3 4 5

SOH requirements and cautioning workers about job site
hazards?
Comments/Remarks:

16. How effective are supervisors in scheduling and 1 2 3 4 5

spending time on the waterfront to oversee high-risk
evolutions?
Comments/Remarks:

17. How effective are supervisors in providing you guidance 1 2 3 4 5

in determining and complying with safe work practices?
Comments/Remarks:

17A. How effective are supervisors in encouraging process 1 2 3 4 5

improvements for a safer work environment?
Comments/Remarks:

17B. How effective are supervisors in holding workers 1 2 3 4 5

accountable for wearing the proper personal protective
equipment?
Comments/Remarks:

18. How effective are supervisors in assisting workers to get 1 2 3 4 5

improved tooling and/or equipment to improve job
safety?
Comments/Remarks:

19. How well are current methods and equipment, safe work 1 2 3 4 5
practices, and occupational safety and health precautions
and warnings incorporated into your trade training?
Comments/Remarks:

20. (For apprentices and military personnel only.) How 1 2 3 4 5

E-3
 effectively are you mentored (by both supervisors and
journeyman workers) to ensure that you practice and are
aware of safe work practices and safety and occupational
health concerns related to your work? Circle one
[Apprentice / Military]
Comments/Remarks:

21. How well do supervisors and management provide 1 2 3 4 5

follow-up and feedback to your concerns on the content
and quality of SOH information discussed during any of
the training you receive?
Comments/Remarks:

22. How effectively does occupational safety and health 1 2 3 4 5

training (e.g., asbestos, lead, respiratory protection, fall
protection, electrical safety training) prepare you to
safely perform your work?
Comments/Remarks:

23. Rate the effectiveness of SOH training in the following

areas:
SOH Grams 1 2 3 4 5
Computer-based training (supervisors only) 1 2 3 4 5
Trade skill training 1 2 3 4 5
General SOH training (asbestos, lead, 1 2 3 4 5
respiratory protection, fall protection, portable
grinder safety)
Comments/Remarks:

24. How would you rate the quality of medical treatment 1 2 3 4 5

received from the Naval Medical Clinic for on-the-job
injuries?
Comments/Remarks:

25. How would you rate the efficiency of HRO’s 1 2 3 4 5

FECA/Compensation Office in processing workers’
compensation claims for workplace injuries?
Comments/Remarks:

26. How well do you think the command provides light duty 1 2 3 4 5

E-4
 work to accommodate injured workers?
Comments/Remarks:

27. How would you rate your knowledge on the reporting 1 2 3 4 5

procedures for injuries/illness and on the process of
obtaining medical treatment for an on-the-job injury?
Comments/Remarks:

E-5
 APPENDIX F

Safety Checklists Websites

http://www.safetyinfo.com/safetyinfo/html/aa-members/checklists.htm

http://www2.mms.org/vitalsigns/sept02/ph3.html

http://www.ncsu.edu/ncsu/ehs/www99/left/forms/checklists/

http://hr.cch.com/safety-sites/safety.asp

http://pie.che.ufl.edu/guides/safety_health/

http://www.safetycenter.navy.mil/services/checklists.htm

http://www.nws.usace.army.mil/PublicMenu/Menu.cfm?sitename=safety&pagename=Checklists

http://www.oneoshasafety.com/aa-members/checklists.htm

http://members.tripod.com/TheCarvingBench/ESSENTIALS/SAFETY%20101.HTM

http://www.hill.af.mil/safety/chklists/ChecklistIndex.htm

http://www.rmis.rmfamily.com/sites/sfmgtcheck.php

http://www.workcover.nsw.gov.au/Publications/Industry/Rural/shearsafetychecklists.htm

http://www.education.tas.gov.au/admin/hr/policies/ohs/wkpracticeschecklists/
safetychecklists.htm

http://www.safetyinfo.com/safetyinfo/html/aa-g-indexes/checklists.htm

http://www.habitatstl.org/construc/safetypr/safetyma/sitechec/

http://safety1.blr.com/single_type.cfm/type/59?source=MKD&effort=468

http://www.esafetyline.com/ncma/edocs/rosters/checklistroster.htm

http://www.cholaaxa.com/risk_manager.html

http://www.geercgroup.com/ci/resource_center/property_casualty/public_entity/
pc_pe_res_safety.shtml

http://www.futuretech101.com/safchek.htm

http://www.hronline.com/forums/ohs/9903/msg00346.html
http://www.safetyawarenessgroup.com/press_releases.html

http://www.hawaii.navy.mil/Safety/safety/SafetyChecklists.htm

http://doi.contentdirections.com/mr/blr.jsp?doi=10.1224/11001400

http://www.cdc.gov/elcosh/docs/other/checklists.html

http://safety1.blr.com/single_type.cfm/type/32

http://safety1.blr.com/single_type.cfm/type/59

http://safety.army.mil/pages/sbo/workplace/checklists.html

http://www.esp-safety.com/Products.html

http://www.comm-2000.com/default.aspx?
returnURL=default.aspx&MSCSProfile=584C39EC14974C113536C602F8F7C5B7C3D8CFBB
ED4D0D33FCD549ED5A3088C5DCCBA4A9D28123470512BC20214FE5DCEA53F2382915
07058D23CAED85A91174C3D56FCC9299FD25D13F1DD430B3A09E561567161AFEE3ED8
817BA7BD8F82333AE1D44DB296627C2B78B28B6E6FDA87A6C61F9178935F809406FA09
EC1A0A4DAD8237972613AE0A5

http://www.tamucc.edu/~eduweb/AppliedConnections/english/english1/checklists.html

http://www.environmental-center.com/publications/blr/11001400.htm

http://www2.hrnext.com/Article_List.cfm/Nav/2.2.0.0?CFID=4261914&CFTOKEN=35561239

http://www.rmlibrary.com/db/checkchem.htm

http://www.ucalgary.ca/~ucsafety/labinspc/chklsts.htm

http://www.ehs.cornell.edu/lrs/inspections/checklists/SI.Checklists.htm

http://www.lrpdartnell.com/cgi-bin/SoftCart.exe/scstore/p-7801.SAFETY.html?
L+scstore+zjfq1040

http://www.princeton.edu/~ehs/Checklst/selfadit.htm

http://myweb.tiscali.co.uk/safetysite/Checklists-%20Forms.htm

http://www.business.com/directory/human_resources/workplace_health_and_safety/

http://www.osha.gov/SLTC/smallbusiness/chklist.html

http://www.environmental-center.com/publications/bh/0750671351.htm

F-2
http://www.esafetyline.com/ncma/directory1.htm

http://www.ehs.cornell.edu/lrs/inspections/checklists/si.frame.htm

http://www.alonebuyersfriend.com/safety.html

http://www.guerrillasafety.com/resources.html

F-3
 APPENDIX G

Sample Program Review Sheet

[ACTIVITY NAME]
Safety and Occupational Health Program Assessment
Review of
OPNAVINST 5100.23G Chapter xx – Name of Program
Mishap Prevention
Goal: (SAMPLE) To develop a systematic approach for applying operational risk management (ORM) to
assess safety and health risk to eliminate occupational injuries and illnesses.

Current Status:

Adequacy of Resources:

Personnel Participation:

Recommendation:

Score: (1, 2, 3, 4, 5)
Regulatory Compliance
Goal: (SAMPLE) To achieve and sustain regulatory compliance.

Current Status:

Adequacy of Resources:

Personnel Participation:

Recommendation:

Score: (1, 2, 3, 4, 5)
Supervision
Goal: (SAMPLE) To ensure all managers and supervisors are equipped, qualified, prepared and
accountable for safely conducting daily operations.

Current Status:

Adequacy of Resources:

Personnel Participation:

Recommendation:

Score: (1, 2, 3, 4, 5)
 Training
Goal: (SAMPLE) To ensure the workforce is fully trained and qualified to safely accomplish the
command mission.

Current Status:

Adequacy of Resources:

Personnel Participation:

Recommendation:

Score: (1, 2, 3, 4, 5)
Customer-Focused Support
Goal: (SAMPLE) To provide SOH support, services, and guidance that meet customer needs.

Current Status:

Adequacy of Resources:

Personnel Participation:

Recommendation:

Score: (1, 2, 3, 4, 5)
Self-Assessment
Goal: (SAMPLE) To review processes, measure performance and implement improvement initiatives.

Current Status:

Adequacy of Resources:

Personnel Participation:

Recommendation:

Score: (This score should be the sum of mishap prevention, regulatory compliance, training, supervision,
and customer-focused supports scores, divided by “5”)

Reassess: 31 Jan 05
Reviewer
Name/Title (printed): I. M. Safe, SOH Manager

Signature: Date:

G-2
 Scoring Guidelines

Score 1: Substantial compliance.

Score 2: Significant compliance. No critical deficiencies have been noted but specific improvements
should be implemented.
Score 3: Partia1 Compliance. No critical deficiencies have been noted but major improvements should be
implemented.
Score 4: Minimal Compliance. Major program improvements are required immediately. Critical
deficiencies may exist.
Score 5: No compliance. Programs may be inadequate to support a safe an effective environment.

Assessment Tools (Optional)

Documentation Reviewed:

OPNAVINST 5100.23 series ____________________

SOH Program Checklist ____________________
Inspection Reports ____________________
Training Logs ____________________
Job Hazard Analysis ____________________
IH Survey ____________________

Interviews Conducted:

# of Employees _____
# of Supervisors _____
Others

Worksite Evaluation (Notes):

G-3
 Appendix H
Sample Process Improvement Plan

Process Review and Measurement System - Plans for Improvement Updated: Date
OPPORTUNITY FOR
ID# DESCRIPTION PLAN FOR IMPROVEMENT PROGRESS NOTES ACTION
IMPROVEMENT
 (Name, activity,
department or code)
MODULE:  (Name activity, department or Example narrative: “…
Assign Supervision Identify document, process, code) Example narrative: “… Name,
recommended a
tracking IDENTIFIED: etc. which addresses injury revise and issue the activity,
committee with
code Date prevention, or program area Supervisor’s Handbook to all dept. or
representative from each
inadequately current and new supervisors.” code
RE-ASSESS: Date Group, headed by (name).
Estimated Completion
Date (ECD)
 (Name) Example narrative: “…
add reporting of military
MODULE: mishaps to GMT”
Mishap Reporting of military employee  “Develop systematic process to Name,
Assign mishaps (both on- and off- ensure that mishap reports activity,
tracking Prevention duty) is erratic. involving military personnel are  (Name) ECD: TBD dept. or
code forwarded to (Name).  (Name) ECD: TBD. code
IDENTIFIED:
Date  Improve the details and
(Repeat – FYxx Assessment)
RE-ASSESS: Date consistency of the Naval
Medical Clinic log of military
personnel treated for injuries.