OHS Management System Review and Audit Procedure
(MPF1187)
GOVERNING POLICY
This procedure is made under the Occupational Health and Safety Policy.
SCOPE
This procedure applies to all staff, students, contractors and other personnel at workplaces under
the management or control of the University of Melbourne.
This procedure describes the requirements for management reviews and internal and external
audits of the occupational health and safety management system (OHSMS).
PROCEDURE
1. University management review
1.1
The Director, OHS and Injury Management must review the University’s Occupational
health and safety policy and strategic objectives every three years, and as required by the OHS
documents procedure.
1.2
Once a year, the Director, OHS and Injury Management must review:
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1.3
University operational objectives and associated KPIs
University operational targets and associated KPIs
responsibilities documented in the OHS procedures and other documents
other elements of the OHS system identified as requiring a review.
Reviews must take into account:
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internal audit annual reports (see section 4)
results of external audits (see section 5)
accident/incident data
changes in legislation
changes within the University (for example, structure, activities or campuses)
relevance, practicability and readability of documents under review.
1.4
Following each review, the Director, OHS and Injury Management will report to the OHS
Committee on the review outcomes and any resulting recommended changes to the OHSMS.
Following OHS Committee approval, revised documents will then be forwarded to the
Administrative and Business Advisory Group (ABAG) for review and approval by the Senior VicePrincipal.
1.5
The Director, OHS and Injury Management is responsible for communicating changes to
the OHSMS to all relevant areas of the University.
2. Budget division management review
2.1
Heads of budget division must ensure the following are reviewed once a year:
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2.2
budget division operational objectives and associated KPIs
budget division operational targets and associated KPIs
assigned responsibilities (for example, those documented in position descriptions)
other elements of the OHS system identified as requiring review.
Reviews must take into account:
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results of internal OHSMS audits (see section 4)
results of external OHSMS audits (see section 5)
accident/incident data
changes in legislation
relevant changes in the budget division (for example, structure, activities or campuses)
relevance, practicability and readability of documents reviewed.
2.3
Heads of budget division must ensure that review outcomes are reported to the budget
division OHS committee. The committee must discuss the review and make any changes
necessary to maintain the relevance of the system and ensure its continual improvement.
Authorisation of changes must be sought from relevant parties.
2.4
Heads of budget division must ensure changes made to the system as a result of a review
are implemented.
2.5
The budget division OHS committee is responsible for communicating changes to all
relevant parts of the budget division and to the OHS and Injury Management department where
appropriate.
3. Monitoring implementation of changes
3.1
Local OHS practice experts must develop strategies to promulgate and track adoption of
revised University and local OHS management system.
4. Internal audits
4.1
The Director, Internal Audit, in consultation with the Director, OHS and Injury
Management and heads of budget division, must develop an annual internal OHS audit schedule.
4.2
The Director, Internal Audit must ensure:
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the internal audit schedule is based on previous audit results, and the level of OHS risk
associated with the activities and operations of the division or local area to be audited
for OHSMS audits, each budget division and controlled entity is audited at least once
over a four-year cycle
internal auditors are sufficiently qualified, competent and experienced to perform OHS
audits, or else supported by other experts to enable them to perform audits competently
internal auditors are independent of the direct management control of the budget division
or controlled entity that they are auditing.
4.3
The University will audit its OHSMS to the requirements of the National Self-Insurer OHS
Audit Tool.
4.4
The Director, Internal Audit, in consultation with the Director, OHS and Injury
Management, will develop, publish and maintain the Internal OHS audit methodology. The
methodology must include:
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definitions for internal audit findings
scope of internal audits
opening meeting requirements
audit process requirements
closing meeting requirements
audit report requirements.
4.5
The Director, Internal Audit must ensure that an internal audit report consistent with the
Internal OHS audit methodology is provided to the head of budget division four weeks from the
internal audit closing meeting. The report must include a corrective action report for each nonconformance and requires correction finding.
4.6
Within four weeks of receiving the report, the head of budget division must ensure that a
corrective action plan is provided to the Director, Internal Audit, for each non-conformance finding
and requires correction finding. Corrective action plans must include:
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audit criterion
audit result
audit finding description (from audit report)
proposed corrective action to address adverse audit finding(s)
timeframe or date and priority by which planned corrective action(s) should be completed
responsible officer for ensuring planned corrective action(s) are completed.
4.7
The head of budget division must ensure that the budget division’s audit reports are
tabled at the budget division’s OHS committee meetings.
4.8
The Director, Internal Audit must report OHS internal audit results annually to the OHS
Committee, Risk Management Committee, Risk Committee and the Senior Executive.
5. External audits
5.1
The Director, Internal Audit will select competent and qualified external auditors to certify
the University's OHSMS to the standards of the National Self-Insurer OHS Audit Tool.
5.2
The Director, Internal Audit and the Director, OHS and Injury Management will advise
certification auditors on the planning, scheduling and scope of audits.
5.3
The Director, Internal Audit will advise heads of budget division of the certification
auditor's proposed audit schedule.
5.4
The Director, OHS and Injury Management and the Director, Internal Audit will distribute
relevant sections from certification audit reports to heads of budget division that have been
subject to certification audits.
5.5
The head of budget division will ensure that the audit reports are tabled at budget division
OHS committee meetings.
5.6
The Director, Internal Audit will report external audit results annually to the OHS
Committee, Risk Management Committee, Risk Committee and the Administrative and Business
Advisory Group.
RELATED DOCUMENTS
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AS/NZS 4801: Occupational health and safety management systems – Specifications
with guidance for use
National Self-Insurer OHS Audit Tool 2.0
JAS-ANZ, Procedure Number 2.0, Issue No 2: Requirements for bodies providing audit
and certification of occupational health and safety management systems
OHS audit budget incentives
University of Melbourne internal OHS audit methodology
OHS Documents Procedure
DEFINITIONS
Term
Audit
Corrective action plan
External audit
Internal audit
Key performance
indicator (KPI)
Occupational health
and safety
management system
(OHSMS)
Definition
A systematic examination against defined criteria to determine whether
activities and related results conform to planned arrangements. The audit
will determine whether these arrangements are implemented effectively
and are suitable in achieving the organisation's policy and objectives. (AS
4801)
A plan completed by the auditee to address deficiencies identified in the
audit report (AS 4801).
An audit conducted by a third party for the purpose of certification to a
recognised standard and/or self insurance compliance. (AS 4801)
An audit conducted by a University staff member or contractor for the
purpose of (a) reviewing conformance to the management system, (b)
reviewing compliance with legal obligations, (c) preparation for external
audits, (d) identification of continuous improvement opportunities, (e)
maintaining compliance with conditions of a self insurance licence. (AS
4801)
Quantitative or qualitative measurement that gives an indication of
progress against a specific OHS objective or target.
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 risks associated with the business of the organisation. (AS 4801)
RESPONSIBLE OFFICER
The Director, OHS and Injury Management is responsible for the development, compliance
monitoring and review of this procedure and any associated guidelines.
IMPLEMENTATION OFFICER
The Director, OHS and Injury Management is responsible for the promulgation and
implementation of this procedure in accordance with the scope outlined above. Enquiries about
interpretation of this procedure should be directed to the Implementation Officer.
REVIEW
This procedure is to be reviewed by 30 June 2015.
VERSION HISTORY
Version
-
Authorised by
OHSC
Approval Date
9 May 2012
Effective Date
18 June 2012
Sections modified
 Revised form
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Senior Vice Principal
28 June 2012
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