Management Systems Review

SYSTEM REVIEW AND IMPROVEMENT

5.1 MANAGEMENT SYSTEMS REVIEW PROCESS

5.1.1 Full review

The University’s executive management ensure that a review of the HSW management system (which includes

Injury Management) is undertaken to determine its continuing suitability and effectiveness.

This review involves:

 an examination of the previous Management Systems Review Report findings to determine if outcomes have been used as a basis for future system development;

 a review of the HSW Policy scope, content and supporting processes within the HSW Handbook;

 an assessment of the level of achievement against documented objectives, targets and performance indicators outlined in planning arrangements (e.g. Action Plan, Training Needs Analysis);

 a review of findings from internal/external audits and surveys, including the previous WorkCover validation reports;

 a review of legislative changes which impact on our processes;

 a review of any changes in the organisational structure of the University which may impact on safety.

Frequency

The review will be conducted at an appropriate time within each third calendar year (as a minimum), but may be conducted at more frequent intervals if determined by the executive management that the effectiveness of the current systems are not meeting the needs of the University. (See 5.1.2)

System review format

The format and scope of the review will be determined by Manager, HSW. As a minimum the review must meet the requirements of Standard 5 of the WorkCover Self-Insurance Performance Standards and this HSW

Handbook chapter. The auditor (internal or external) may use any Legislative, Workcover, Australian Standards auditing tools/templates to assist in this process (i.e. to provide structure) as agreed.

Who will co-ordinate and conduct the review?

The review will be co-ordinated by the Manager, HSW. This may involve an independent auditor.

Who will take part in the review?

The review will be completed in consultation with relevant stakeholders. This may include employees, title holders, volunteers, students, visitors or third parties engaged by the University (e.g. contractors) and/or a staff member of a controlled entity. Consultation may be achieved through scheduled meetings and/or email advice and/or any other communication which enables review and feedback.

Findings and recommendations

The findings and recommendations from the review will be presented to the Director (Human Resources) and tabled at the University Health and Safety Committee by the Manager HSW for consideration and action where agreed.

HSW Handbook Management Systems Review

Authorised by Manager, Health Safety and Wellbeing

Warning

Effective Date:

Review Date:

19 October 2012

31 July 2015

This process is uncontrolled when printed. The current version of this document is available on the HSW Website.

Version 2.1

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SYSTEM REVIEW AND IMPROVEMENT

5.1 MANAGEMENT SYSTEMS REVIEW (Continued)

5.1.2

5.1.3

Adhoc/interim system reviews

Where the Manager, HSW identifies:

 a gap in the University’s system or program or inter-dependant programs; or

 an emerging incident/injury trend then an adhoc/interim system review may be conducted. (i.e. Before the full review.)

The adhoc/interim review will:

 analyse the level of achievement of documented objectives, targets and performance indicators to promote continuous improvement; and

 be identified or added into the University’s HSW Action Plan.

The findings and recommendations from the adhoc reviews will be tabled at the UHSC on completion.

The reports will be provided to the internal/external auditor conducting the 3 yearly review and findings, recommendations and actions taken will be included in the full review report where applicable.

The adhoc/interim systems review is to be recorded using the template in Appendix B or where appropriate a paper to the UHSC stating the reasons for needing the Interim review.

The matrix in Appendix C will be used to identify which HSW programs may require review.

Reporting – Monitoring and evaluation of the HSW Management Systems Performance

5.1.4

The following HSW reports are collated as indicated in consultation with a number of committees and personnel.

(Please also refer to Appendix A. The flowchart depicts the HSW information which is monitored and the flow of information from the School/Branch level to the University’s Executive/Senior management/Health and Safety

Committees and the University Council.)

Corrective Actions/continuous improvement activities

When endorsed by the UHSC all actions arising from Systems reviews will be entered into RMSS ensuring that the timeframes are determined using the Corrective Actions Information Sheet “Determining timeframes for

HSW Strategy Actions” contained in the HSW Operations manual. Completion of actions will be monitored via the RMSS Action report.

Note – Interim/short term corrective actions pending the formal HSW Handbook chapter review

Where the UHSC accept the recommendations from an adhoc/interim system review and short term measures are required to ensure Legislative compliance or reflect current work practices, then the Manager HSW will authorise the interim arrangements to be implemented. The changes will be noted on the relevant HSW

Handbook chapter web page under “Roles, Responsibilities and Actions”. The recommendations will then be incorporated in the next chapter review.

Authorised by Manager, HSW _________Original signed_____________________________ 19 October 2012

NG AND EVALUATION OF THE HSW MANAGEMENT SYSTEMS PERFORMANCE

REPORTING – MONITORING AND EVALUATION OF THE HSW MANAGEMENT SYSTEMS PERFORMANCE

HSW Handbook Management Systems Review

Authorised by Manager, Health Safety and Wellbeing

Warning

Effective Date:

Review Date:

19 October 2012

31 July 2015


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Report type

University

Council

Report format http://www.adelaide.edu.au/governance/word_templates/

Generally includes:

 Key HSW achievements (milestones) mapped against the University’s Strategic

Plan (e.g. Healthy University strategies)

Vice-Chancellor’s

Report

(VCAC) http://www.adelaide.edu.au/governance/word_templates/

Generally includes:





 Reports required as part of the HSW Handbook including:

 Annual HSW Consolidated Audit Report (4.1)

 Full review of the HSW Management System (5.1) and

Adhoc/interim reviews as determined by the Manager, HSW

Major incidents (i.e. Notifiables, Dangerous Occurrences)

HSW Strategic activities on the HSW Agenda or conducted since last report

(e.g. WorkCover updates, major changes to Legislation)

Frequency https://www.adelaide.edu.au/governance/council/

Statutes of the University. Chapter 2.1(a).

No less than eight occasions in any calendar year.

Intervals not greater than 3 months.

Usually monthly, but not prescribed.

Responsibility

Vice-President (Services and Resources)

Director, HR

(in consultation with the

Manager, HSW)

HSW Handbook

Authorised by

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Management Systems Review

Manager, Health Safety and Wellbeing

Effective Date:

Review Date:

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31 July 2015


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REPORTING – MONITORING AND EVALUATION OF THE HSW MANAGEMENT SYSTEMS PERFORMANCE (Continued)

Report type

Audit,

Compliance and

Risk Committee

Report

UHSC – HSW

Manager’s

Performance

Report

Report format http://www.adelaide.edu.au/governance/word_templates/

Generally includes standard reports on:

 Key events and incidents (i.e. Notifiables, Dangerous Occurrences) and action taken to prevent a recurrence.

 Performance indicators (Graphs, short analysis/synopsis)

 Injury and near miss trends

 Lost time injury frequency rate graph (LTIFR)

 Lost time (LTI, days, average time lost)

 Workers compensation claims

 Workers compensation claims breakdown by event

 Workers compensation costs

 Workers compensation claims liability

 Key HSW Strategic activities on the agenda/conducted since last report. (Note – check items reported through VCC applicable to this committee.)

 Key findings from the Performance Report

(i.e. incident/injury trends)

 3 highest mechanisms of injury and Div/Fac

 3 highest nature of injury and Div/Fac

 3 highest agency of injury

 3 highest events leading to workers compensation claims

 3 highest events leading to lost time

 UHSC Consolidated Report

 Any unresolved issues requiring resolution/consultation buy the UHSC

 Traffic Light report (emerging issues, trends)

 Corrective actions report (summary of activity)

 Developments and initiatives (highlights)

 Key events and incidents (e.g. summary of any Notifiables, major incidents since last UHSC)

 WorkCover (key dates, activities)

 Other items of interest or impact

Frequency

At least 4 times per year unless otherwise determined by the Chair or as directed by the Council. http://www.adelaide.edu.au/governance/council/committe es/audit_committee/

Quarterly March, June, September and December. http://www.adelaide.edu.au/hr/ohs/committees/

(Completed reports are included in the UHSC minutes)

Responsibility

Director, HR

(in consultation with the

Manager, HSW)

Manager, HSW

HSW Handbook

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Review Date:

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31 July 2015


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REPORTING – MONITORING AND EVALUATION OF THE HSW MANAGEMENT SYSTEMS PERFORMANCE (Continued)

Report type

Division/Faculty

Consolidated

HSW report

UHSC

Consolidated

HSW report

 Traffic light report

Report format

 Unresolved HSW and Injury management issues requiring resolution/consultation with the UHSC

 Corrective Actions Report

 2 Issues of highest safety concerns at the time of the report

 Details of HSW News, development, proactive initiatives undertaken since last

UHSC

 Workplace inspections (trends)

 School/Branch Traffic Light Reports against defined criteria.

 Consolidation of Div/Fac reports as indicated above.

 Div/Fac Performance tracking (%) charts and graphs

Quarterly

Template for the Div/Fac Consolidated report is available at http://www.adelaide.edu.au/hr/ohs/committees/

Quarterly

Frequency

Template for the Div/Fac Consolidated report is available at http://www.adelaide.edu.au/hr/ohs/committees/

Completed report is available in the UHSC minutes.

Quarterly

Completed report is available in the UHSC minutes.

UHSC Status against the HSW

Action Plan(s)

Schedule of

Programmable

Events and

Training Needs

Analysis

 Division/Faculty/School/Branch Traffic light report

(Completed reports are available in the Div/Fac/School/Branch Health and Safety

Committee minutes.)

Quarterly

Responsibility

Executive Dean/Vice

President/Deputy Vice

Chancellor in consultation with the Division/Faculty

HSW Committee Secretary

UHSC Secretary

Senior HSW Consultant

(Policy and Liaison)

Executive Dean/Vice

President/Deputy Vice

Chancellor in consultation with the Division/Faculty

HSW Committee

School/Branch HSW

Committees (or equivalent) or Head of School/Branch

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Report type

Corrective

Actions

Report format

 Actions arising from internal audits, external audits, workplace inspections, risk assessments, exercises entered into RMSS; or

 Other authorised databases

(e.g. Maintenance Service Job Requests) where there is a system for recording, assigning of actions, monitoring, follow-up and completion within designated time-frames.

 Accident, Incident, Near miss reports

Frequency

As per the time-frames specified on the

RMSS Action report or database.

Data is entered in RMSS within 5 working days from the date of the incident, and in the case of Field trips, within 5 days of return to the University.

Escalations are automatically generated via

RMSS to personnel responsible or involved in follow-up/corrective action. (i.e. Heads of

School/Branch, HSOs, HSRs, HSW Team.)

Quarterly Injury

Management

(Work and non work related illness and injury)

 Injury Management Register (database)

Work and Non-work related injuries/illnesses reported to the relevant Heads of School/Branch or Executive.

 Open Claims Weekly

Responsibility

Registered Health and Safety Committees

Head of School/Branch in consultation with the person responsible for the action.

Registered Health and Safety Committees, HSW Team

Heads of School/Branch

Health and Safety Officers

Health and Safety Reps

 Manager, HSW

 Senior HSW Consultant (Policy and Liaison)

 HSW Specialist (IM and Wellbeing)

 Manager HSW, Senior HSW Consultant (Policy and Liaison),

HSW Specialist (Injury Management and Wellbeing)

 Claims Manager

For complex claims or where there are also issues around employment legislation (e.g. Industrial Relations):

 Director, HR; and

 Vice-President (Services and Resources) and/or

 Executive Deans/Heads of School/Branch where required.

HSW Handbook

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Review Date:

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31 July 2015


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HSW

Management

System

1.

Policy

2.

Planning

3.

Implementation

4.

5.

Monitoring and

Review

Management

Systems review

University Council

Report on the University

Strategic Plan

Vice Chancellor’s

Committee (VCC)

HSW Report

Reporting – Monitoring and Evaluation of the HSW Management system

University

Audit, Compliance and

Risk Committee

Division/Faculty

University Health and

Safety Committee,

Quarterly meetings, Senior Exec plus staff representatives

Audit, Compliance and

Risk Committee, HSW Report

Director Human Resources









Consolidated HSW report

Status against Corporate Action

Plan

Manager HSW Performance report

Statistics (Incident, claims), trends

Faculty/Division

Executives sign off

UHSC reporting template

(Division/Faculty Reports (Quarterly)











Manager, HSW and

HSW Team

University HSW and IM Plan

Schedule of Programmable Events

Training Needs Analysis – Training Plan

Corrective Action Register

Traffic Light reports (report on selected activities within the HSW Handbook)

School/Branch

Consolidated Traffic Light

Report by each

HSW Div/Fac Managers

Monitor/verify Traffic Light reports and report on activities

Division/Faculty

HSW Committees

School/Branch HSW report authorised by the Head of School/Branch

APPENDIX A

UHSC Convenor reports to the VC&P

































Unresolved HSW issues requiring

University UHSC Committee

Actions against CAR

2 Highest safety concerns for each

Fac/Div

HSW news and Developments

Traffic Light reports

Workplace Insecptions

Risk Management

TNA and SPE review

Other Boards and

Committees

Unresolved HSW issues requiring

University UHSC Committee

Actions against CAR

2 Highest safety concerns for each

Fac/Div

HSW news and Developments

Traffic Light reports

Workplace Insecptions

Risk Management

TNA and SPE review

Legend

RMSS

External Audit Reports

Enter RMSS (via Manager, HSW) as Corrective Actions









Accident, Incident, Near Miss

Internal Audits

Risk assessments

Inspections

= Monitoring forums, personnel

Heads of School/Branch,

HSO & HSRs

Reports to Management

Branch/School Health and Safety Committees (If no committee Head of School/Branch)

Traffic Light Report

Corrective Actions Register

= HSW Reports, documents, tools used to collate HSW information

HSW Handbook

Authorised by

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Effective Date:

Review Date:

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31 July 2015


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Training Needs Analysis

Schedule of Programmable

Events

Name of Process/System

Review undertaken by

Element 1: Policy

Ref

1.1

Criteria

The scope and content of the process has been reviewed in consultation with employees (or their representatives) to ensure continued suitability and effectiveness.

Effectiveness

Recommendations

Name:

HSW Handbook

Authorised by

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Effective Date:

Review Date:

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31 July 2015


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Appendix B

MANAGEMENT SYSTEMS REVIEW

(Standard 5 – WorkCover Performance Standards)

Date

Position

Objective Evidence/Findings Compliance

Enter if Compliant (C) or

Non-Compliant (C)

Element 2: Objectives, targets and performance indicators

Ref Criteria

2.1.1 The level of achievement against documented objectives

Objective Evidence/Findings

Objectives (e.g. as outlined in the HSW Handbook process, Action Plans, University objectives) has been analysed.

Effectiveness

Recommendations

2.1.2 The level of achievement against documented targets and performance indicators has been analysed.

2.2

Effectiveness

Recommendations

The organisation must ensure results are analysed and used to determine areas of success and areas requiring corrective and preventive action.

Effectiveness

Recommendations

Performance Indicators and targets (if applicable) (e.g. as outlined in the HSW Handbook process or other monitoring criteria)

HSW Handbook

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Compliance

Element 3: System review

Ref

3.1

3.2

Criteria

The organisation must ensure the system is reviewed and revised if required, in line with current legislation, the workplace and work practices.

Effectiveness

Recommendations

The organisation must ensure the system’s measurement outcomes are used as a basis for future system development.

Effectiveness

Recommendations

Objective Evidence/Findings

HSW Handbook

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Review Date:

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Compliance



3

The Manager, HSW will review the following criteria once in each calendar year to determine if any adhoc/interim systems reviews are to be conducted. Report/Review date / /

The template will be populated on an ongoing basis by the Senior HSW Consultants (i.e. Operations and Policy & Liaison).

1

An “X” indicates an area of concern. The number of adhoc/interim systems reviews will be based on the number of identified areas of concern and/or the severity of the risk to the University.

The recommendations will be tabled at the UHSC by the Manager, HSW as part of the Performance Report. The completed reviews will be saved electronically in Section 5.1 of the HSW Handbook.

Policy

1.1

HSW Programs

HSW Policy

Policy/Process due for review

1/12/13

Significant legislative changes will impact on this program/ process

Identified as an emerging issue or trend during incident investigations or data

Identified as a contributing factor in

Workers

Comp last calendar year

Traffic light report, low performance trend last calendar year

Notifiable Incident has been reported last calendar year and a gap in the system/process was a contributing factor

Issue/trend identified during the Internal Audit process last calendar year

Planning

2.1 HSW Action Planning

2.2

2.3

Schedule of Programmable Events

HSW Training Needs Analysis and Training Plan

2.4 Corrective Actions

Implementation of HSW Activities & Hazard Management

3.1

3.2

HSW Training

Induction

3.3

3.4

3.5

3.6

Travel Safety

Emergency Management

Hazard Management

Workplace Inspections

3.7

3.8

Plant/Equipment Safety Management

First Aid

3.9 Drugs and Alcohol

3.10 Boating Operations

3.11 Diving (Under Development)

3.12 Field Work

3.13 Smoke Free University

3.14 Biological Safety Management

3.15 Children on Campus

3.16 Confined Spaces

3.17 Work at Heights and Prevention of Falls

3.18 Hot Work (Heat or Spark Producing Activities)

30/6/13

11/2/13

11/2/13

11/2/13

11/2/13

11/2/13

11/2/13

11/2/13

11/2/13

11/2/13

9/8/13

4/7/14

11/2/13

31/12/14

NBA

11/2/13

9/2/15

9/8/13

11/2/13

16/4/15

31/12/14

18/11/14

Appendix C (Page 1 of 2)

Adhoc feedback provided by HSW Managers, HSOs other stakeholders that a HSW program is not effective in its current

format.

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Review Date:

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HSW Programs Policy/Process due for review

Significant legislative changes will impact on this program/ process

Identified as an emerging issue or trend during incident investigations or data

Identified as a contributing factor in

Workers Comp last calendar year

3.25

3.26

3.27

3.28

3.29

3.30

3.31

3.32

3.33

3.18

3.19

3.20

3.21

3.22

3.23

3.24

Hot Work (Heat or Spark Producing Activities)

Chemical Safety Management

Basic Laboratory and Workshop Safety

Contractor Safety Management

Events Safety Management

Asbestos Management

Higher Degree by Research Safety Management Plan

Personal Protective Equipment

Temperature Extremes in your Working Environment

Injury Management (Work Related Injuries/Illness)

Student Placement

Incident, Near Miss Reporting and Investigation

Radiation Safety Management

Infectious and Communicable Diseases

Manual Handling (includes Ergonomics)

Working Hours and Reducing Fatigue

18/11/14

11/2/13

30/8/13

11/2/13

19/3/15

11/2/13

11/2/13

15/7/13

11/2/13

11/2/13

31/12/14

11/2/13

31/12/14

11/2/13

11/2/13

21/10/14

5

4 Measurement and Evaluation

4.1 Internal Audit

System Review and Improvement

5.1 Management System Review

5.2

5.3

5.4

5.5

HSW Policy Review

Document Control

Culture and Climate

Monitoring Performance – Exec Engagement

11/2/13

31/7/15

4/4/15

24/12/12

28/5/15

28/5/15

5.6 Travel Safety – Exec Engagement 28/5/15

Based on the above findings, the HSW team recommends that Interim systems reviews be conducted on the following HSW Programs

1___________________________________________________

Endorsed by the Manager, HSW

2.____________________________________________________

_____________________________________________

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Traffic light report, low performance trend last calendar year

Notifiable Incident has been reported last calendar year and a gap in the system/process was a contributing factor

Appendix C (Page 2 of 2)

Issue/trend identified during the Internal Audit process last calendar year

3.____________________________________________________

Adhoc feedback provided by HSW

Managers, HSOs other stakeholders that a HSW program is not effective in its

current format.

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