There are opportunities for program improvement following an actual incident. A critique should be conducted to assess the response to the incident. Lessons learned from incidents that occur within the community, within the business’ industry or nationally can identify needs for preparedness program changes. Best practices and instructional guidance published by trade associations, professional societies, newsletters and government website can be resources to evaluate and improve your preparedness program.
Gaps and deficiencies identified during reviews should be recorded and addressed through a corrective action program. Reviews, evaluations and improvements should be documented and maintained on file.
Businesses should improve the effectiveness of their preparedness programs through review of policies, performance objectives, program implementation and changes resulting from preventive and corrective actions.
TRIGGERS FOR PROGRAM REVIEWS
Reviews of the preparedness program should be conducted periodically and whenever the effectiveness of the program is questioned. The goal of program reviews is to provide assurance that the program meets the needs of the business and complies with regulations. Changes that should trigger a review of the program include the following:
- Regulatory changes
- New or changed processes
- New hazards identified; vulnerability to hazards changes
- Tests, drills or exercises identify weaknesses
- Post incident critiques identify issues
- Funding or budget level changes
- New product or service launched or withdrawn
- Company, division or business unit acquired, integrated or divested
- Significant changes to critical suppliers or supply chain
- Significant increase in the workforce population on-site
- Significant changes to site, buildings or layouts
- Changes to surrounding infrastructure
If any of these changes or triggers occurs, the program coordinator should initiate the appropriate program review.
SCOPE OF PROGRAM REVIEWS
Program reviews should assess compliance with policies; determine whether performance objectives are being met; assess the adequacy of program implementation; and determine whether preventive and corrective actions have been taken on previously identified deficiencies.
The following should also be reviewed:
- Plans and procedures have been reviewed and are up-to-date
- Team rosters have been updated to ensure membership is current
- Contact information for team members, public agency contacts, contractors, vendors and suppliers
- Resources (e.g., systems, equipment, and supplies) are in place and properly maintained
Resources for Program Reviews
- Lessons Learned Information Sharing – U. S. Department of Homeland Security
- U. S. Chemical Safety and Hazard Investigation Board – The CSB is an independent federal agency charged with investigating industrial chemical accidents. The CSB website provides reports on current and completed investigations as well as videos.
- Technical Report Series – U.S. Fire Administration
- OSHA Compliance Assistance: Success Stories and Case Studies – U.S. Occupational Safety & health Administration
- Fatality Assessment and Control Evaluation (FACE) Program – National Institute for Occupational Safety and Health, Division of Safety Research
Gaps and deficiencies identified during program reviews should be recorded and addressed through a corrective action program. Gaps or deficiencies in the program may be identified during training, drills, exercises, post-incident critiques, regulatory compliance audits, insurance surveys and from lessons learned.
CORRECTIVE ACTION PROGRAM
The corrective action program should document information on deficiencies. A table similar to the one on this page can be used. Include a full description of the deficiency; the action that should be taken; the resources required to address the deficiency; and justification for the need to correct the deficiency. Action on deficiencies should be assigned to the person or department best able to address the issue. A due date should be assigned and the corrective action database reviewed regularly to track progress. The status column should be updated until the deficiency has been addressed.
All program gaps or deficiencies are not equally important. Prioritization of corrective actions is helpful because funding and time are usually limited. Prioritization can also identify significant deficiencies that should be reported to management and corrected as quickly as possible. Criteria or categories for corrective action may include the following:
- Hazards to health and safety
- Regulatory compliance
- Hazards to property, operations, the environment or the entity (e.g., image or reputation)
- Conformity to national standards
- Following industry best practices
Significant deficiencies should be reported to management along with appropriate information to explain the problem, how to correct it and the reasons it needs to be addressed in order to gain management support for action. Management should also be periodically informed of the status of corrective actions until deficiencies have been resolved.
Source: FEMA, “Program Improvement” http://www.ready.gov website. Accessed July 15, 2014. http://www.ready.gov/business/program/corrective
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