Occupational
Health and Safety
Model for
Self Insurers
July 2005
Contents
Introduction ..................................................................................... 1
Definitions........................................................................................ 2
The Self Insurer OHS Model........................................................... 4
Management Responsibility........................................................ 5
OHS Management System ......................................................... 8
Design Control ............................................................................ 9
Document Control..................................................................... 11
Purchasing ................................................................................ 13
OHS Risk Management ............................................................ 15
Process Control ........................................................................ 17
Inspection and Testing.............................................................. 19
Corrective Action ...................................................................... 21
OHS Records............................................................................ 23
OHS Audits ............................................................................... 25
OHS Training ............................................................................ 27
Statistical Techniques............................................................... 29
Implementing the Self Insurer Model ......................................... 31
Strategic Framework................................................................. 31
Consultative Framework ........................................................... 31
Information System................................................................... 32
Training & Education Strategy.................................................. 32
Self Insurers Audit Program...................................................... 33
Self Insurer Audit and Reporting Guidelines ............................ 34
Procedure ................................................................................. 34
WorkCover Audits ......................................................................... 36
The Audit Process .................................................................... 36
Appendix A .................................................................................... 38
Audit Report Summary (Performance Level)............................ 38
Appendix B .................................................................................... 39
Definition of Performance Levels.............................................. 39
Self Insurer OHS Model WorkCover NSW – July 2005
1
Introduction
In 1993 a joint WorkCover and Self Insurer Association working party was
formed to develop an agreed occupational health and safety (OHS) audit
program consisting of the key components – a Quality OHS System Model
and set of Audit Guidelines. The Model and Supporting Guidelines has
been undertaken by WorkCover in 2001 to reflect changing OHS legislative
provisions and the introduction of Australian Standards for OHS
management. Current revision was conducted in 2004.
Self Insurers have the flexibility to use a variety of proprietary or In house
OHS management system. The revised Self Insurer OHS Model details the
criteria which shall be implemented in the workplace of all Self Insurers.
These criteria shall be used for purposes of audit verification by WorkCover
and the licencing requirements of Self Insurer organisations. WorkCover
shall measure the Self Insurers performance against the Model criteria. This
information shall be used as a part of the licence review process. Self
Insurers are required to tailor the Model criteria to meet the specific health
and safety needs of all personnel in their employ and to account for OHS
issues arising from the conduct of the organisation’s business activities.
In developing the original Model, philosophies commensurate with
international system standards for the management of quality assurance
were applied to health and safety process in an effort to provide Self
Insurers the flexibility to integrate OHS with other areas of management.
These principles are perpetuated in the revised Model and Guidelines
ensuring consistency with principles and philosophies of the ISO 9000
series. This revision however, enables Self Insurers to avail themselves of
more recent Australian Standards for OHS Management such as AS 4801
Occupational health and safety management system specification with
guidance for use and AS 4804 – Occupational health and safety
management system – General guidelines on principles, system and
supporting techniques.
The alignment of the OHS Model with recognised standards of
management provides a suitable framework for the evaluation of health and
safety system and the effectiveness of such system to deliver injury and
illness prevention in the workplace.
Self Insurer OHS Model WorkCover NSW – July 2005
1
Definitions
The following definitions relate to the Self Insurer OHS Model and
Guidelines. Many of these are based on terminology defined in AS 4801 --Occupational health and safety management systems -Specification with
guidance for use.
Audit
A systematic examination against defined criteria to determine whether
activities and related results conform to planned arrangements, and
whether these arrangements are implemented effectively and are suitable
to achieve the organisation’s policy and objectives.
Competent Person
A person who has acquired through training, qualification, experience or a
combination of these, the knowledge and skills necessary to establish,
implement and/or maintain the provisions of this Model as it applies to their
organisation.
Continual Improvement
The process of enhancing the implemented OHS management system to
achieve improvement in OHS performance.
Contractor
Any individual or organisation responsible for the performance of work
specified in a contract including vendor, seller, supplier, fabricator,
manufacturer or consultant.
Hazard
A source or a situation with a potential for harm in terms of human injury or
ill-health, damage to property, damage to the environment or a combination
of these.
Hazard Identification
The process of recognising that a hazard exists and defining its
characteristics.
Incident
Any unplanned event resulting in, or having a potential for injury, illness,
damage or loss.
Occupational Health and Safety Management System (OHSMS)
That part of the overall management system which includes organisational
structure, planning activities, responsibilities, practices, procedures,
processes and resources for developing, implementing, achieving,
reviewing and maintaining the OHS policy, and so managing the OHS risks
associated with the business of the organisation.
Self Insurer OHS Model WorkCover NSW – July 2005
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OHS Objectives
Overall OHS goals in terms of OHS performance, arising from the OHS
policy that an organisation sets itself to achieve and which are quantified
where practicable.
Occupational Health and Safety Performance
The measurable results of the OHSMS related to the organisation’s control
of health and safety risks based on its OHS policy, objectives and targets.
Performance measurement includes measurement of OHS management
activities and results.
Occupational Health and Safety Policy
A statement by the organisation of its commitment, intentions and principles
in relation to its overall occupational health and safety performance which
provides a framework for action and for the setting of its occupational health
and safety objectives and targets.
OHS Risk
In relation to any potential injury or harm, the likelihood and consequence of
that injury or harm occurring.
OHS Target
A detailed performance requirement, quantified wherever practicable and
pertaining to the organisation, that arises from health and safety objectives
and that needs to be met in order to achieve those objectives.
Quality Management
That aspect of the overall management function that determines and
implements the quality policy.
Quality System
The organisational structure, responsibilities, procedures, processes and
resources for implementing quality management.
Risk Assessment
The overall process of estimating the magnitude of risk and deciding what
actions will be taken.
Risk Control
The process of elimination or minimisation of risks.
Risk Management
A system whereby all risks within an organisation are identified and
analysed, and an action taken accordingly to reduce them to a safe,
acceptable level by providing an appropriate minimum standard of
protection at a cost commensurate with the risk.
Safety
A state in which the risk of harm (to persons) or damage is limited to an
acceptable level.
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The Self Insurer OHS Model
The Self Insurer OHS Model consists of thirteen elements and seeks to achieve
continuous improvement in OHS performance through the progressive
development of more effective management system. Rigorous system review
shall drive the development of continuous improvement initiatives. The elements
of the Self Insurer Model are shown below and the details of each element in
the Model are outlined in this section.
OHS
System
Model
Management
Responsibility
Process
Control
OHS Management
System
Inspection and
Testing
Design
Control
Corrective
Action
Document
Control
OHS
Records
Purchasing
OHS
Audits
OHS Risk
Management
OHS
Training
Statistical
Techniques
All elements implemented by Self Insurers
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Management
Responsibility
Management shall be responsible for the development of OHS policy and
the implementation of an OHS system reflecting policy provisions to
safeguard the health and safety of all persons in the workplace. The
consultative process shall be implemented to ensure the needs of all
employees, contractors, labour hire employees and visitors are
represented and served by policy provisions and OHS system elements.
OHS Policy
Senior Management in consultation with all employees and/or their
representatives, shall define and document its policy for, and commitment
to occupational health and safety (OHS). The policy shall be endorsed
and supported by the most senior person within the organisation such as
the Chief Executive Officer or Managing Director. The OHS policy shall
include a commitment to:
the risk management process and ensure consistency with the
nature of workplace activities and scale of OHS risks
comply with relevant OHS legislation and other requirements
placed upon the organisation or to which the organisation
subscribes;
establish measurable objectives and targets for OHS to ensure
continuous improvement aimed at elimination of work related illness
and injury;
appropriate OHS training is provided to all employees;
the consultation process to ensure all employees including
contractors and labour hire employees are included in the decision
making processes impacting on workplace health and safety;
the dissemination of OHS information to all employees, contractors,
labour hire employees and visitors to the workplace;
effective implementation of the OHS Policy.
The OHS policy shall be documented and readily accessible in the
workplace. Policy provisions shall be implemented consistently in all
areas of business activity and on all sites where business activities are
undertaken.
Organisation
Resources shall be identified and verification procedures implemented to
ensure OHS provisions are organised in a manner ensuring a safe and
healthy place of work.
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Responsibility, Authority and Accountability
Responsibilities shall be defined in position descriptions or aggregated in a
format that is readily accessible by the position holder.
The authority to implement these responsibilities shall be defined in position
descriptions or aggregated in a format that is readily accessible by the
position holder. The organisation shall define an accountability process to
ensure that responsibilities are performed effectively.
A senior management representative shall be identified with responsibility,
authority and accountability defined, for ensuring the OHS system, including
all elements of the Self Insurers Model, are implemented and maintained.
The responsibility, authority and accountability for all personnel who
manage OHS activities including senior managers, divisional managers,
branch managers, line supervisors and any others shall be clearly defined
and documented. Such activities shall include management, conduct,
Implementation and verification processes impacting on workplace OHS.
Responsibility, authority and accountability shall be defined for persons
performing OHS activities such as safety officers, first aid officers or fire
emergency wardens. These responsibilities may reside outside of position
descriptions.
Responsibility, authority and accountability shall be defined for all persons
verifying OHS activities. This shall include all management, supervisors,
employees, contractors, consultants, safety representatives and any other
professional engaged to verify OHS activities.
Verification
The organisation shall define OHS verification requirements, provide
adequate resources and assign trained personnel. Verification activities
shall include:
inspection
testing and monitoring
OHS system audits;
compliance verification (legislation, standards, industry codes
of practice).
Verification activities shall be conducted by trained personnel independent
of the area involved. The training, qualification, certification and/or
experience shall be defined for such activities.
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Review and Evaluation
Executive management shall review the capacity, suitability and
effectiveness of the organisation’s OHS system and its resources to satisfy
the requirements of the Self Insurer OHS Model and maintain adequate
records thereof. Such reviews shall be conducted regularly at appropriate
intervals to ensure continuing suitability and effectiveness of the system to
satisfy the organisation’s OHS needs in all areas of business activity.
The outcomes of the review process shall be used to modify and amend
system’s criteria such as policy, objectives, responsibilities, planning
arrangements procedures and instruments (tools and forms) to ensure
relevance, currency and continuous improvement. The resources provided
to support OHS policy provisions shall be assessed and reviewed regularly
to evaluate adequacy.
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OHS
Management
System
A system for managing health and safety which includes all elements of the
Self Insurer OHS Model shall be implemented in the workplace.
The OHS system shall provide a foundation upon which policy initiatives are
implemented and health and safety strategic objectives achieved. The
structured, well managed system shall have the commitment of senior
management with defined OHS responsibilities, authority and an
accountability process to ensure that responsibilities are performed
effectively.
The OHS System
Management shall establish and maintain in consultation with employees an
OHS system accounting for all business areas and the health and safety
needs of all personnel arising from the conduct of the organisation’s
business activities. System planning arrangements, procedures and
instruments (tools and forms) shall be established, implemented and
maintained for the development and implementation of OHS policy
provisions and OHS system requirements. Such system planning
arrangements, procedures and instruments (tools and forms) shall address
all elements of the Self Insurer OHS Model.
Responsibility and Authority
Management shall be responsible and have authority for undertaking the
necessary consultative processes, providing the necessary resources and
establishing policy to ensure a structured OHS system is implemented and
maintained. Such responsibility, authority and accountability shall be
defined in position descriptions, aggregated format, system planning
arrangements, procedures or instruments (tools and forms). The
responsibility, authority and accountability of all employees including
contractors, labour hire employees and visitors to site to carry out OHS
system requirements, shall be defined and appropriate training provided to
ensure competence in the conduct of system requirements.
Records/Documentation
The system including its planning arrangements, procedures and
instruments (tools and forms) shall be documented and the provisions
implemented through appropriate information and training processes.
Health and safety targets and objectives to facilitate measurement of the
OHS system performance is to be established and documented. Records of
system review shall be maintained.
Review and Evaluation
System planning arrangements, procedures and instruments (tools and
forms) shall be reviewed regularly to ensure compliance with OHS system
requirements, relevance and currency. The capacity of OHS system
provisions to achieve health and safety targets and objectives shall be
assessed. The processes for addressing system gaps shall be documented
and implemented. Review outcomes shall be used to implement reform and
ensure continuous improvement.
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Design Control
The design process may introduce risk to an organisation unless the
process is controlled and due consideration given to OHS issues during the
design phase. Design control seeks to eliminate risks emanating from the
design process though the implementation of procedures that identify and
account for risk in design activities such as the construction and use of
plant, equipment, facilities and processes.
Design Control Procedures
Organisations shall establish and maintain procedures to ensure the
identification and elimination or otherwise control of OHS risks resulting
from the design process. Such procedures shall account for legislative
requirements and give due consideration to National Standards and Codes
of Practice where applicable.
Where the design process involves the design of a facility, item of plant or
equipment, then the design process shall be managed through
implemented procedures that identify any risks associated with:
construction methods -including processes and materials;
use and maintenance - especially risk arising out of the nature of the
design itself;
removal, demolition or decommissioning activities – especially where
there is risk arising from the materials or processes used in the design
Procedures ensuring adequate definition of OHS requirements in design
documentation shall be established and personnel responsible for reviewing
design shall be suitably skilled and experienced. Procedures for ensuring
designs meet specified OHS requirements shall be implemented and
verification obtained where applicable.
Design Control Responsibility
Design personnel shall be responsible with authority and accountability
established for ensuring that OHS requirements are incorporated in design
processes, including any products such as plant or facilities compliant to
legislative requirements and conform to OHS specifications. Verifiers shall
be appropriately skilled and/or qualified to identify risk associated with the
design process. The training, qualification, certification and/or experience
shall be defined in position descriptions, system planning arrangements,
procedures or instruments (tools and forms).
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Design Control Records
Records such as design registration and design verification in meeting OHS
requirements shall be maintained. Any OHS risk introduced to the
workplace as a consequence of the design process shall be recorded and
records maintained for review purposes.
Review and Evaluation
The design process shall be reviewed regularly to ensure the process
employed safeguards the health and safety of persons and meet OHS
system requirements. Review procedures shall identify any risk introduced
by way of the design process and improvement mechanisms shall be
implemented to prevent recurrence and ensure continuous improvement.
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Document
Control
Documentation provides definition and an auditable trail of activity when it is
appropriately controlled and managed. It ensures consistency and
uniformity in the application of procedures and specifications for OHS in the
workplace.
Documentation
The information and activities relevant to the elements of the Self Insurer
OHS Model and the means by which the requirements of the Model are
implemented in the workplace, shall be documented in a suitable print
and/or electronic form. These documents shall be reviewed and approved
for adequacy by authorised personnel prior to issue.
Document Control Procedures
Procedures to control system documentation including policy, system
planning arrangements, procedures and instruments (tools and forms) shall
be established and maintained. Such procedures shall ensure:
documents are legible, dated (with dates of revision), readily
identifiable and maintained in an orderly manner for a specified
period;
documents are able to be readily located;
documents are periodically reviewed and revised as necessary to
maintain relevance and currency;
current versions of relevant documents are readily accessible at all
locations where operations essential to the effective functioning of the
OHS system are performed;
obsolete documents are promptly removed from all points of issue and
points of use;
archival documents retained for legal or system evaluation purposes
are suitably identified.
Any changes to documented procedures are recorded and communicated
to employees. A master list (document control register) or equivalent control
procedure shall be established and maintained to identify the current
revision of documents.
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Document Control and Responsibilities
Responsibility and Authority
One person within the organisation shall be responsible for the
maintenance of the document control system. Responsibility for the creation
and modification of documents within the system shall be designated to
person/s in authority or those charged with responsibility for particular work
activities, operations or work areas. Such responsibilities shall be
documented in position descriptions, system planning arrangements,
procedures and instruments (tools and forms).
Review and Evaluation
System documentation including policy, planning arrangements, procedures
and instruments (tools and forms) shall be reviewed for their compliance to
document control requirements.
Corrective action shall be undertaken to address nonconforming
documentation. The procedures implemented to control documents shall be
reviewed and the efficiency with which the system is maintained shall be
evaluated. Corrective actions shall be implemented where identified to
ensure continuous improvement.
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Purchasing
The purchasing element is about the development and implementation of
procedures for screening the health and safety practices of organisations
and or individuals supplying goods, services or human resources such as
contractors or labour hire companies. It also seeks to ensure that goods
(materials, plant and equipment) comply with predetermined OHS
specifications and standards before they are admitted to the workplace for
use. The introduction of goods and services to an organisation can
introduce risk unless appropriate procedures are implemented to ensure
potential risk is identified and the risk controlled.
Procedures
Procedures shall be developed and implemented for measuring the
capacity of suppliers of goods, services and human resources to comply
with OHS specifications and requirements as required by the organisation is
OHS management system and OHS legislation, standards or codes of
practice.
Procedures shall be developed and implemented to ensure contractors and
suppliers have implemented appropriate system of health and safety
management. This shall include the processes used to select
subcontractors, the procedures implemented to interface with
subcontractors and suppliers and methods employed to ensure compliance
with OHS requirements and specifications. Processes used to select
suppliers of goods, services and human resources shall include (but not
limited to):
the identification of applicable OHS requirements in tender
documentation;
submitted tenderer evaluation for OHS requirement compliance;
ensuring OHS requirements are clearly stated in contractual
documentation;
evaluation of OHS documentation submitted by the successful
tenderer prior to commencement where services are provided.
Where contractors or suppliers of labour hire employees or human
resources are engaged, provision shall be made to develop and implement
compatible site specific safety management plans or safe work procedures.
This shall include provision for OHS induction and training relevant to the
work activities and contractual arrangements between the organisation and
contractor or supplier.
Where goods are procured such as materials, plant and equipment,
procedures for compiling detailed OHS specifications shall be implemented
and shall include any compliance requirements such as those required by
standards, legislation or organisational OHS requirements.
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Procedures for verifying OHS compliance requirements shall be established
and non-conformance addressed prior to the admission of goods to the
workplace. The type and extent of OHS control exercised by management
shall be dependent upon OHS risk factors and evidence of the suppliers
previously demonstrated capacity and performance. Verification procedures
shall be implemented to ensure purchased goods and services conform to
specified requirements.
Responsibilities
Personnel responsible for establishing OHS specifications for goods and
services and reviewing purchasing documentation shall be appropriately
skilled and experienced and where required carry the necessary
qualifications. Such skills, experience and/or qualifications shall be defined.
Responsibilities shall be defined in position descriptions or in a format that
is readily accessible by the position holder. The competence of contractors
and suppliers of goods and human resources to meet OHS specifications
shall be assessed by management. Such responsibilities shall be
documented in position descriptions, system planning arrangements,
procedures and instruments (tools and forms).
Documents/Records
An organisation is purchasing documentation shall clearly define the
required OHS specifications for the goods and services being procured.
Where contractors or labour hire employees are to be admitted to site,
documentation shall include (but not limited to):
elements of the OHS System to be implemented;
reference to site specific OHS risk;
provisions for OHS induction;
inspection, test or audit records indicating review of OHS performance
Records of goods and services OHS conformance verification shall be
maintained.
Review and Evaluation
Procedures shall be reviewed regularly. Review procedures shall ensure
relevance and currency of OHS specifications, OHS system requirements
and procedures for identifying the conformance of goods and services to
predetermined OHS specifications. Corrective actions shall be implemented
where identified to ensure continuous improvement.
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OHS Risk
Management
A structured program of OHS risk management shall be implemented and
maintained and the procedures incorporated in such a program shall be
used to facilitate the early identification of foreseeable hazards, assessment
of risk and implementation of control mechanisms in line with workplace
needs and legislative requirements.
OHS Risk Management Program
An OHS risk management program shall be developed and documented.
The implemented program shall provide procedures for the identification of
OHS hazards arising from the conduct of work activities. Procedures for
assessing the risk associated with identified hazards shall be implemented
and the risk eliminated or otherwise controlled and monitored in accordance
with a preferred order of control methods or hierarchy. These documented
procedures will include the processes and tools used to carry out those
activities in the workplace including a mechanism to inform the person/s
who reported the hazard of the control measure implemented.
Where not reasonably practicable to eliminate, control priorities shall be
assigned for all identified hazards commensurate with the assessed level of
risk i.e. potential severity and likelihood of occurrence of injury or illness.
Identified control measures shall be implemented in accordance with risk
priority where most urgent risks are controlled immediately and a planned
schedule of control for all other risks developed.
Circumstances giving rise to emergency situations shall be identified and
the necessary procedures and control mechanisms for managing
emergencies developed, implemented and maintained.
Legislative Obligations
Workplace activities and the processes and tools required to conduct such
activities shall be reviewed to determine compliance with OHS risk
management legislation, national standards and industry codes of practice.
Risk management activities are to be conducted in consultation with
employees.
Processes shall be implemented to ensure that applicable legislation and
advisory material such as codes of practice and national standards are
appropriately referred to in the identification of hazards and in the
assessment and control of risks. Such processes shall be sufficient to allow
referenced material to be incorporated into the development of safe working
procedures, as required.
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Records
Records shall be kept of identified hazards and the measures implemented
to control such hazards commensurate with the assessed risk. An OHS
Risk Register/s shall be kept that lists all identified risks in the workplace.
Documents produced as a requirement of this element shall be controlled
and maintained in accordance with OHS system requirements.
Responsibility
Responsibility, authority and accountability for OHS risk management shall
be assigned and defined in position descriptions, system planning
arrangements, procedures or instruments (tools and forms). This shall
include responsibility for formal risk management processes as well as
those responsibilities associated with the identification and reporting of risk
identified in the conduct of everyday business activities.
Review and Evaluation
Documented procedures to review and evaluate the risk management
program shall be developed and implemented. Review and evaluation shall
be conducted in consultation with employees at appropriately identified
intervals. All implemented risk management procedures shall be reviewed
and revised where necessary to ensure relevance and compliance to OHS
system requirements. The process shall include review and evaluation of
the:
hazard identification, risk assessment and risk control process;
effectiveness of implemented control measures to prevent illness
and injury.
Corrective actions shall be implemented where necessary to bring about
improvement in the risk management process, procedures or control
measures.
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Process Control
Process control ensures OHS activities, especially those associated with
risk management, are conducted in a planned and systematic manner
through the implementation of documented procedures to ensure the proper
control of workplace activities. Process procedures shall be documented to
ensure uniform communication and application.
Process Control Procedures
Documented procedures shall be implemented and maintained to ensure
the proper control of workplace activities directly impacting on workplace
health and safety. Process control documentation shall include (but not
limited to):
risk management activities including hazard identification, risk
assessment, risk control, monitoring and review of control measures;
activities carrying OHS risk (including those stated in legislative
requirements, for example work premises, working environment,
hazardous substances and processes and construction work);
safe work procedures for all activities where the absence of such
instruction would adversely affect OHS performance;
emergency procedures;
mechanisms for the approval of processes and equipment;
certification of personnel to work on certain equipment or
involved in the conduct of certain processes;
reporting mechanisms including accident, injury reporting and
investigation;
record maintenance.
Safe work procedures shall be documented in a manner ensuring that those
involved or exposed to a process are equipped to conduct work activities in
a safe and healthy manner. Safe work procedures shall include (but are not
limited to):
a description of the activity or process;
the person or position that has supervisory responsibility for the
activity or process;
a clear explanation in sequential order of the steps or stages
comprising the procedure or process
potential hazards
safety controls to minimise potential risk fro any identified hazard
health and safety precautions to be exercised in the course of carrying
out work activities.
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Legislative Obligations
The provisions of OHS legislation including Acts and Regulations as well as
advisory material such as standards and codes of practice shall be
incorporated in relevant process control documentation.
Records
Documents produced as a requirement of this element shall be controlled
and maintained in accordance with OHS system requirements. A register
identifying all OHS process control documentation relevant to the
organisation shall be maintained.
The register shall also be used to identify review dates of process control
documentation.
Responsibilities
Responsibility, authority and accountability for OHS process control shall be
assigned and defined in position descriptions, system planning
arrangements, procedures, instruments (tools and forms).
This shall include responsibility for developing and maintaining a system of
documentation to support risk management activities in the workplace.
Review and Evaluation
Process control documentation shall be reviewed regularly to ensure
relevance and compliance to OHS system requirements. The effectiveness
of implemented procedures to mitigate risk shall be evaluated corrective
actions shall be implemented where identified to ensure continuous
improvement.
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Inspection and
Testing
A planned system of inspection and testing ensures the working
environment, plant, equipment and/or procedures used in the conduct of
work, conform to predetermined standards, legislative requirements and/or
specifications. The testing and inspection plan implemented in the
workplace shall meet internal requirements for testing and inspection as
well as those required by legislation and authorities or bodies external to the
organisation such as government agencies, industry associations and/or
industry codes.
Inspection and Testing Program and Legal Obligation
An inspection, testing and monitoring program shall be implemented and
maintained to ensure workplace operations and the processes and
equipment used to effect those operations proceed safely, correctly and in
accordance with any internal, regulatory or other requirement identified as
relevant to the workplace. The program shall specify:
the inspection, testing and monitoring procedures and provisions
necessary to meet identified OHS needs and statutory requirements
relevant to the workplace;
personnel involved in inspection, testing and monitoring;
record keeping provisions for OHS inspection, testing and monitoring;
the use of suitable testing equipment and procedures to ensure OHS
standards are maintained;
procedures for actioning corrective measures when OHS
nonconformance is identified.
Inspection, testing and monitoring procedures shall be planned and
implemented at key times in the operational cycle and according to
procedural requirements. For example, materials procurement, routine
maintenance, plant installation and commissioning, standard operating
procedures.
Testing and Inspection Responsibilities
Testing and inspection responsibilities and authorities shall be defined and
designated to suitably skilled, qualified and/or trained personnel.
These skills, qualifications and/or training shall be defined. Responsibilities
shall include development of testing and inspection procedures, conduct of
tests and inspections, conformance verification, identification of nonconformance and/or tasks associated with rectifying non-conformance.
Where required, a procedure for training employees in relevant testing,
inspection and monitoring responsibilities shall be implemented
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Testing and Inspection Records
Records of OHS inspection, testing and monitoring shall be maintained and
made available to relevant management, employees and contractors.
Persons responsible for the keeping of testing and inspection records shall
be identified and responsibilities defined.
Review and Evaluation
The test and inspection system planning arrangements, procedures,
instruments (tools and forms) shall be reviewed regularly to ensure ongoing
relevance and maintenance in accordance with OHS system requirements.
Procedures for the review of testing and inspection records shall be
implemented to ensure conformance verification and identify corrective
actions where non-conformance is recorded.
Corrective actions shall be implemented where identified to ensure
continuous improvement.
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Corrective
Action
Corrective action ensures that the outcomes of inspection and testing,
audits, accident, incident and hazard reporting procedures are reviewed
and appropriate procedures implemented to rectify nonconformance and
prevent its recurrence. Procedures for corrective action shall be
implemented to identify risk and implement control provisions before it
causes illness or injury in the workplace.
Commitment
Management shall ensure workplace activities and the tools required to
carry out such activities are assessed for potential risks to health and safety
before incidents occur. Procedures and practices to reduce risk shall be
implemented to prevent illness and injury.
Corrective Action Procedures
The organisation shall establish, document and maintain procedures for
corrective action. This shall include (but not limited to):
hazard reporting;
accidents and incidents reported and their subsequent investigation;
analysing all OHS system processes, work operations, records,
service. reports and complaints to detect and eliminate potential
causes of nonconforming system;
implementing procedures for identifying nonconforming product prior
to purchase or admittance to the workplace;
implementing screening procedures for contractors, service providers
and/or labour hire employees to ensure conformance to standards
(internally and/or externally set);
implementing corrective action procedures to deal with prioritised OHS
system failure;
applying controls to ensure corrective actions are undertaken;
establishing procedures for assessing the non-conformances and the
effectiveness of implemented control measures;
implementing a procedure for recording changes in OHS system
resulting from corrective actions.
the mechanism of consultation with relevant employees.
the mechanism to inform the person/s who reported the
nonconformance of the corrective action undertaken.
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Corrective Action Responsibilities
Corrective action responsibilities shall be designated to competent persons
and statements of responsibility, authority and accountability established.
Responsibilities shall include development and implementation of corrective
action procedures, review processes and follow through on identified nonconformances.
Management shall ensure through implemented processes of review that
corrective action responsibilities are met and that procedural outcomes are
properly actioned and followed through.
Corrective Action Records
Procedures ensuring corrective actions are recorded and maintained in
accordance with legislative requirements and for purposes of OHS
improvement, shall be implemented. A procedure for reviewing records and
facilitating OHS system improvements to prevent recurrence of
nonconformance shall be established and maintained
Review and Evaluation
Corrective action control measures shall be reviewed for their effectiveness
and appropriate action undertaken. Corrective action procedures shall be
reviewed for their relevance and compliance to OHS system requirements.
Conformance requirements and procedures for controlling nonconformance
shall be reviewed and modified to meet ongoing needs, changes in
workplace conditions and system, and to promote continuous improvement
in OHS.
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OHS Records
Records provide evidence of compliance. This shall include compliance with
the record keeping provisions of WorkCover licensing conditions,
requirements of the organisation’s OHS management system and that
required by standards, codes of practice and/or legislation. Records also
provide a valuable data source against which OHS performance can be
reviewed and evaluated and plans for continuous improvement
implemented.
Procedures
Procedures shall be established and maintained for the identification,
collection, indexing, filing, storage, maintenance and disposal of OHS
records. OHS records shall be identified and maintained in accordance with
the elements of the WorkCover Self Insurer OHS Model to demonstrate
achievement of the required standards of OHS and the effective operation
of the OHS system.
Records pertaining to the engagement of contractors and their compliance
with OHS requirements as well as those records associated with supplier
compliance including suppliers of goods, services and labour hire shall be
maintained. The privacy of individuals and confidentiality of records shall be
accounted for in the procedures implemented for the indexing, filing,
storage and retrieval of records. Procedures shall be developed for
obtaining access and/or releasing individuals confidential records.
Typical OHS Records
Some examples of records that shall be kept by an organisation are listed
below:
qualifications, skills, knowledge, competency and certifications;
induction and training;
inspection and test reports;
audit reports;
internal review reports;
incident reports/accident reports and investigations;
minutes of OHS meetings, including OHS executive meetings relating
to OHS management system reviews;
statistical analysis of OHS data;
minutes of management review;
OHS action plans;
safety equipment records;
hazardous substances and dangerous goods;
design review;
risk management documentation.
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Responsibility for OHS Records
Responsibility for the identification of record keeping compliance
requirements and record keeping provisions shall be documented in
position descriptions, system planning arrangements, procedures or
instruments (tools and forms).
Review and Evaluation
Procedures for the identification, collection, indexing, filing, storage,
maintenance and disposal of OHS records shall be reviewed at appropriate
intervals. Records shall be used to review and evaluate the effectiveness of
the OHS system to prevent injury and illness in the workplace. The
outcomes of review processes shall be used to implement performance
improvement strategies.
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OHS Audits
OHS audits shall be conducted in order to measure the effectiveness of the
implemented OHS system and provisions thereof to prevent injury and
illness in the workplace. Audit provisions assist an organisation to identify
gaps in system planning arrangements, procedures or instruments (tools
and forms) and to implement illness and injury prevention strategies in
response.
Audit Program
Management shall carry out a comprehensive system of planned and
documented internal OHS audits to verify the established OHS system:
effectively meets organisational OHS policy as well as objectives and
targets for injury/illness prevention and continuous improvement;
conforms to the provisions of the Self Insurer OHS Model and any
legislative and/or industry codes of practice or standards;
has been properly implemented and maintained.
Audit procedures shall be developed and audits conducted in line with
procedural guidelines. Such procedures shall cover:
the scope of audit activities;
frequency with which audits are conducted;
methodologies for conducting audits;
assessment of OHS importance of activities audited;
OHS performance outcomes;
a statement of auditor (lead & member) competency requirements
(See Self Insurer Audit and Report Guidelines, P35 – 37 and Self
Insurer Audit Program, page 34).
Audit results shall be documented and communicated to personnel,
including employees in the area where the audit was undertaken.
Contingencies for performance improvement strategies shall be developed
in consultation with employees and/or their OHS representatives.
Management for the area shall instigate and follow through on appropriate
actions to rectify identified deficiencies.
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Responsibilities
Responsibility for the conduct of OHS Audits must include an auditor who is
suitably qualified. Any team member/s must be either suitably experienced,
skilled and /or qualified.
Auditor competency requirements are to be documented. Responsibilities
shall be defined and documented in position descriptions, system planning
arrangements, procedures or instruments (tools and forms).
Management shall be informed of the system performance and identified
deficiencies. Management shall be responsible for interpreting the
outcomes of audits and managing performance improvement strategies.
Review and Evaluation
Audit procedures shall be reviewed for relevance and compliance to OHS
system requirements at appropriate intervals.
The outcomes of audits shall be recorded and those records analysed to
identify and address system deficiencies through the implementation of
documented performance improvement strategies.
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OHS Training
A structured system of training ensures individuals receive appropriate and
relevant health and safety information, instruction and supervision, and are
assessed as competent by an appropriately qualified or experienced person
before they are expected to carry out the responsibilities of their job.
Training Commitment and Legal Obligations
A commitment to OHS training shall be stated in the Company OHS Policy.
This shall drive the development and implementation of training programs to
meet duty of care obligations and the health & safety skills & knowledge
requirements of employees.
Knowledge, Skills and Training Requirements
The health and safety skills and knowledge base (competencies) of the
organisation shall be identified and documented as a competency profile for
all employees or positions including senior management, line
managers/supervisors, operations personnel, those with specific
responsibilities such as first aiders, fire wardens and safety representatives.
Any contractors, labour hire employees or visitors to site shall also be
assessed. The identified competencies shall take into account the work
activities of the organisation and any risk associated with the conduct of
such activities. Persons are to be competent to safely conduct the duties
that they perform.
A training needs analysis shall be undertaken to facilitate this process. The
organisation shall establish an OHS competency profile needed to perform
each position or role within the organisation. The OHS competence of
persons shall be reviewed. Training requirements shall be at a minimum,
the gap between the training need for the position and the establish
competency of the individual to safety perform the position.
A written training plan/s based on the outcomes of the training needs
analysis shall be developed and implemented. Provisions for the delivery of
training at certain key times in an operational cycle such as induction,
following risk assessment, on transfer of employees to new jobs and
change to work processes, plant, technology, materials or substances shall
be identified and performed.
Training Programs
OHS Training programs shall be developed and implemented in accordance
with the training plan. The training program acknowledges the information
and training necessary to close the skill gap, (this includes third party
qualification and/or legislative requirement). Training tools, materials and/or
learning experiences that support competency based outcomes are
included in training programs as are differences in learning, language,
literacy and numeracy skills of trainees. Learning modes may include, (but
not limited to) health and safety manuals, safe work procedures, specialist
instruction, computer assisted learning, toolbox talks, on-the-job
demonstration and supervision or other resources or techniques essential to
achieving skills and knowledge competency.
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Training and Assessment Responsibilities
Training and assessment responsibilities shall be designated to competent
persons and statements of responsibility, authority and accountability
established. Responsibilities shall include training delivery, supervision,
assessment and/or verification tasks.
Assessment of Competency
Competence requirements to perform OHS training and assessment shall
be documented. The competence of employees including any contractors,
labour hire employees or visitors to site, shall be assessed prior to their
being expected to carry out the tasks associated with their position
responsibilities.
Training Records
Record keeping requirements for training (including confidentiality
requirements) shall be established and implemented. Persons responsible
for the keeping of training records shall be identified and responsibilities
defined. A system of maintenance shall be developed to ensure
completeness and currency of records.
Training Review and Evaluation
Procedures for the review of training and assessment shall be implemented
to ensure the effectiveness of programs to meet skills and knowledge
requirements of the workplace. Review outcomes shall be used to update
competency profiles, program requirements, resources and strategies to
maintain relevance, currency and continuous improvement.
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Statistical
Techniques
Statistical techniques shall be used as a means to analyse incident,
injury/disease and workers compensation data to establish objective
measures of OHS performance and ascertain the effectiveness of the
implemented OHS system. The outcomes of statistical analysis shall be
used to support requirements for the implementation of appropriate
performance improvement strategies and to prevent adverse health and
safety trends.
Commitment
The organisation shall ensure that objective assessment of recorded data is
undertaken. Provision for OHS system improvement in response to
statistical review outcomes shall be ensured.
Procedures
Management shall establish and maintain procedures for the use of
statistical techniques to:
monitor and evaluate the performance of the OHS system;
monitor and evaluate OHS performance outcomes as a function of the
organisation's OHS system provisions;
compile and analyse injury and disease data relevant to the
organisation is own workplace and its performance relative to that of
the industry sector to which it belongs;
compile and analyse workers compensation claims relevant to the
organisation’s own workplace and its performance relative to that of
the industry sector to which it belongs.
Procedures for reporting statistical analysis outcomes to management and
employees shall be established and maintained. Fundamental to procedural
requirements is the development and implementation of initiatives
established in consultation with employees to improve OHS performance
and prevent adverse trends.
Statistical Techniques Responsibilities
Responsibility for the use and implementation of statistical techniques shall
be designated to appropriate management personnel and the
responsibilities defined in position descriptions, system planning
arrangements, procedures or instruments (tools and forms).
Senior management shall be responsible for interpreting the results of
statistical analysis and ensuring initiatives to promote performance
improvement and prevention of adverse trends are established and
implemented.
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Records
Records documenting the outcomes of statistical analysis and performance
improvement initiatives arising as a consequence, shall be established and
an appropriate process of maintenance implemented.
Review and Evaluation
The techniques and procedures employed to statistically analyse OHS
injury/disease and workers compensation data shall be reviewed regularly
to ensure relevance and compliance to OHS system requirements.
The analysis of data and trends shall be used to direct OHS system
improvement opportunities. The cause of adverse trends shall be analysed
and OHS program priorities revised to ensure adequate resources and
processes to reverse such trends.
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Implementing the
Self Insurer Model
Self Insurer organisations are required to implement OHS management
system, which includes the standards laid down in the Model. The
implementation of the thirteen elements of the Model require the
organisation to develop procedures commensurate with the Model and the
OHS needs of the organisation arising from the conduct of business
activities. Some implementation strategies are provided below.
Strategic
Framework
Develop a strategic framework. This provides the mechanisms through
which policy is made, procedures are developed and decisions actioned.
Unless OHS strategies are supported by a structured system, then
implementation will be fragmented and there will be no consistency or
uniformity in the administration of OHS within the organisation. To develop
a strategic framework you will need to:
gain senior management commitment;
agree OHS objectives;
devise policy;
review policy;
establish OHS priorities;
implement benchmarking and review best practice;
devise implementation strategies;
action implementation strategies.
Consultative
Framework
If everyone in the organisation is provided with opportunity to contribute to
the OHS system and its implementation and action in the workplace, then
people are more likely to embrace health and safety initiatives and work
towards continuous improvement. This can only be achieved if a framework
for consultation is established. Think about:
identifying the broader team/key players;
defining roles and responsibilities;
determining the activities/tasks to be undertaken by those with
designated responsibility;
preparing a consultative framework plan;
implementing appropriate consultative arrangements;
evaluate consultative mechanisms regularly to ensure ongoing
relevance and effectiveness.
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Information
System
Information empowers employees to make appropriate decisions about
injury/illness prevention and to carry out the requirements of their job in a
manner safeguarding health and safety. However, the information can only
be used to the benefit of the organisation if it is readily accessible.
When developing an information system:
define performance requirements;
review the current system and identify gaps;
tailor the system or develop a new system as appropriate;
review the information system regularly to ensure ongoing relevance
and currency.
Training &
Education
Strategy
Training needs to be structured if the skills and knowledge underpinning
business activities are to be identified and training and education provisions
commensurate with skills and knowledge requirements are to be adequately
provided for. A training and education strategy requires:
identification of key personnel and target groups;
development of an appropriate training plan to identify competency
requirements, training needs and gaps in the skills and knowledge
base;
development of programs;
implementation of programs;
development and implementation of assessment provisions;
evaluation.
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Self Insurers
Audit Program
The audit process verifies the effectiveness of the OHS system to prevent
injury and illness. For this reason, Self Insurers should be conducting audits
that comply with recognised audit protocols on a regular basis. Persons
charged with responsibility for the conduct of audits in particular, persons
leading the audit (lead auditor) shall be suitably qualified. When establishing
an audit program, Self Insurers should consider:
establishing an appropriately qualified and experienced audit team in
accordance with section 7.4.1, AS/NZS ISO 19011-2003;
defining audit objectives;
defining auditor responsibility and tasks;
initiating audit by determining audit scope, frequency and review
process;
preparing audits by formulating an audit plan, audit team assignment
and working documents;
executing audits;
submitting audit results to WorkCover using audit guidelines and
agreed audit plan;
determining any corrective action to address non-conformance.
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Self Insurer Audit and
Reporting Guidelines
The standard licence term for Self Insurers is three years. Self Insurers are
required to conduct self audits of their OHS management system against
the elements of the Model and furnish a report to WorkCover on an annual
basis. Failure to conduct self audits and submit the annual report
contravenes Self Insurer licencing obligations.
The AS/NZS ISO 19011- Guidelines for quality and/or environmental
management systems auditing provides a comprehensive auditing
methodology and is consistent with the quality approach underpinning the
Model.
However, Self Insurers may use any audit methodology, which
demonstrates performance and provides appropriate measurement against
the Model.
Audits shall be conducted regularly by appropriately qualified and
experienced personnel. Various audit training and certification programs are
available.
Self Insurers may engage the services of an independent auditor as part of
their audit procedure to obtain objective verification of conformance to the
elements of the Model.
Procedure
Self Insurers shall carry out a planned audit, on an annual basis or at other
times as deemed necessary.
WorkCover audit must NOT replace the Self Insurer planned audit to be
conducted at least annually.
Step 2: Include OHS audit plan in reporting documentation
The OHS Audit Plan developed by the Self Insurer forms part of the
reporting documentation to be submitted to WorkCover.
Step 3: Determine internal audit criteria/frequency
Self Insurers shall determine audit frequency and the audit selection criteria
so that the audit is representative of the whole organisation and takes into
account the following:
time required to carry out the audit and accounting for the number of
work sites, similarities of activities and geographical locations;
risk associated with the organisation's activities;
workers compensation claims experience;
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the need to cover an appropriate percentage of staff having
regard to occupations;
geographic distribution of organisation;
selection of elements for the audit which may be a sub-set of
the Model.
Step 4: Submit report to WorkCover on an annual basis
Self Insurers shall provide reports and supporting documentation
where necessary in the following form:
the OHS Audit plan; (including a schedule of planned audits to
be carried out over the next 1-3yrs)
audit report summary (see Appendix A: Audit Report
Summary);
a short narrative of each element audited which must include
appropriate descriptive examples;
a report on non-conformance identified in the audit and how it
will / has been addressed.
The Audit Report Summary shall be used by Self Insurers to
summarise audit findings. The table (a bar chart) is used to display
the demonstrated level of implementation of each element in the
Model. Appendix B provides definition of the various performance
levels used in the Audit Report Summary. Self Insurers should
account for the performance criteria when assessing their level of
performance and reporting this to WorkCover. Performance in any
area below the statutory minimum is unacceptable and prompt action
is expected to correct any such failings.
Step 5: Report OHS statistics annually
OHS statistics shall be furnished as part of the Self Insurers annual
report to WorkCover. These must include:
number of prosecutions for breaches under the Occupational
Health and Safety Act and subordinate legislation;
lost time frequency rates;
duration rates.
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WorkCover Audits
WorkCover use the Model as the basis of its scheduled audit of Self
Insurers OHS system. The standard WorkCover audit is conducted
on a 3-year cycle. In some circumstances where audit outcomes
verify non-conformance with the requirements of the Model,
WorkCover may audit a Self Insurer on a more frequent cycle.
Continuing non-conformance may result in action being taken in
respect of the Self Insurer's licence. In regards to applicants for a
new Self Insurer licence, failure to comply with the provisions of the
Model will preclude them from being granted a licence. Depending
on the circumstances, WorkCover may agree to an application
being deferred for a period whilst the applicant is given an
opportunity to rectify deficiencies and demonstrate compliance with
the Model.
The Audit
Process
The WorkCover Authority will carry out audits of Self Insurer
programs on a three year cycle with the option to carry out an audit
at any other time as deemed necessary. The WorkCover Audit
Team will nominate an appointed date/s for the purpose of
conducting the audit. The Self Insurers compliance with the
requirements of the Model and their right to continue as a Self
Insurer shall be verified by the Audit Team via an established
process. New Applicants will be evaluated on their capacity to
implement the provisions of the Model. This involves the following
activities.
1.
The WorkCover Authority will nominate for audit, from the
Model, two elements for existing Self Insurers and three
elements for new applicants.
2.
The Self Insurer will nominate two other elements from the
Model whilst new applicants will nominate three other
elements.
3.
Four elements in total will be audited for Self Insurers and six
elements in total for new applicants. It is expected that at
each WorkCover audit, different elements will be audited over
a period of time to ensure the provisions of the Model are
functioning effectively within the organisation and that all
aspects of the organisation are given due consideration.
4.
The Self Insurer or new applicant shall forward documentation
supporting the elements to be audited, two weeks prior to the
appointed audit date. The WorkCover Audit Team will review
the support documentation in the interim.
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5.
On the first day of the audit, senior management shall make a
presentation to the WorkCover Audit Team on each element
subject to audit. The WorkCover Audit Team will incorporate their
observations in the final report. The organisation must make time
for any questions raised during the course of the presentation.
6.
The WorkCover Audit Team will conduct a site audit including
questioning of the organisation’s employees.
7.
The Audit Team will compile a report for the Licencing and
Financial Review Branch indicating whether the Self Insurer
meets the minimum acceptable performance standard which will
be taken into account for licence renewal or the granting of a new
licence. Performance levels shall be indicated in line with those
detailed in the Performance Levels (Appendix B) and summarised
as per the Audit Summary Report (Appendix A).
8.
A copy of the audit report shall be submitted to the Self Insurer or
new applicant. Any corrective actions will be noted and the
organisation given two weeks in which to address the issues and
furnish a report back to WorkCover highlighting their intended
strategies and time frame for effecting corrective actions.
9.
Self Insurers exhibiting a poor OHS performance will be targeted
by WorkCover on a case by case basis.
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Policy and/or
Identification
of Needs
Responsibility
and
Accountability
Established
OHS System /
Procedure
Implementation
Comprehensive
System /
Procedure
Implementation
Measurement /
Audit Plan Used
to Plan
Improvements
Demonstrated
Continuous
Improvement
Each performance criteria can be assessed in a quarter scale increment. As an example this means when assessing performance an
Organisation might rank their OHS Risk Management performance in the bottom quartile of performance level: Comprehensive System
Procedure Implementation. When WorkCover conducts its licence verification audit, the same ranking process will be used.
Guide to Assessing Performance
Statistical Techniques
OHS Training
OHS Audits
OHS Records
Corrective Action
Inspection and Testing
Process Control
OHS Risk Management
Purchasing
Document Control
Design Control
OHS System
Management Responsibility
Nothing
Audit Report Summary (Performance Level)
Appendix A
Appendix B
Definition of
Performance
Levels
Nothing
The activity has not been commenced or the element
implementation standard is will below any acceptable,
established or legislative standard.
Policy and/or
Identification of
Needs
A base level of understanding is demonstrated by the
organisation, but no major activities have been
commenced in implementing the requirements of the
Self Insurer OHS Model. Evidence the identification of
general OHS management system requirements
applicable to the organisation and Corporate Policy
supporting this.
Responsibility
and Accountability
Established
Activities have been completed which identify that the
organisation has implemented responsibility and
accountability compliance in system elements. This
identifies system and process ownership by relevant
position holders within the organisation and traceability
to verify that implementation by those persons is
occurring.
OHS System
Procedure
Implemented
A system exposure across all operations of
organisation for the particular element criteria with an
acceptable/evidence for continuation of ongoing
implementation of the requirements.
Comprehensive
System Procedure
Implemented
A system of high level has been implemented. The
organisation is able to demonstrate that their system is
structurally sound. The elemental criteria are carefully
implemented within the organisation.
Measurement
Audit Used to Plan
Improvements
Objectively established procedures are in place and
operational to assess comprehensive system
procedure implementation.
Demonstrated
Continuous
Improvement
A high quality system incorporating objectively
established evaluation procedures with clear indication
of regular improvement and or enhancements. Some
processes may be considered “best practice”
initiatives. The organisation may be undertaking/
participating in research towards OHS best practice
principles or be involved in sponsorship programs of
other industry organisations.
Performance in any area below the statutory minimum is unacceptable and prompt action is expected to
correct any such failings. New Applicants or existing Self Insurers are expected to demonstrate a system
that is operating at no less than “OHS System/Procedure Implementation” performance level.
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