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
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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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REPORTING – MONITORING AND EVALUATION OF THE HSW MANAGEMENT SYSTEMS PERFORMANCE
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
Warning
Management Systems Review
Manager, Health Safety and Wellbeing
Effective Date:
Review Date:
19 October 2012
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
Authorised by
Warning
Management Systems Review
Manager, Health Safety and Wellbeing
Effective Date:
Review Date:
19 October 2012
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
HSW Handbook
Authorised by
Warning
Management Systems Review
Manager, Health Safety and Wellbeing
Effective Date:
Review Date:
19 October 2012
31 July 2015
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REPORTING – MONITORING AND EVALUATION OF THE HSW MANAGEMENT SYSTEMS PERFORMANCE
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
Authorised by
Warning
Management Systems Review
Manager, Health Safety and Wellbeing
Effective Date:
Review Date:
19 October 2012
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
Audit, Compliance and
Risk Committee
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
Warning
Management Systems Review
Manager, Health Safety and Wellbeing
Effective Date:
Review Date:
19 October 2012
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
Warning
Management Systems Review
Manager, Health Safety and Wellbeing
Effective Date:
Review Date:
19 October 2012
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
Authorised by
Warning
Management Systems Review
Manager, Health Safety and Wellbeing
Effective Date:
Review Date:
19 October 2012
31 July 2015
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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
Authorised by
Warning
Management Systems Review
Manager, Health Safety and Wellbeing
Effective Date:
Review Date:
19 October 2012
31 July 2015
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Compliance
MANAGEMENT SYSTEMS REVIEW
(Standard 5 – WorkCover Performance Standards)
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.
HSW Handbook
Authorised by
Warning
Management Systems Review
Manager, Health Safety and Wellbeing
Effective Date:
Review Date:
19 October 2012
31 July 2015
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MANAGEMENT SYSTEMS REVIEW
(Standard 5 – WorkCover Performance Standards)
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.____________________________________________________
_____________________________________________
HSW Handbook
Authorised by
Warning
Management Systems Review
Manager, Health Safety and Wellbeing
Effective Date:
Review Date:
19 October 2012
31 July 2015
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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.