Self-insurer Self-audit Program

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1 External Guideline #6 Self-insurer Self-audit Program Part I Occupational health and safety management system requirements Version 20 1 April 2015 Page 1 of 50

2 Contents 1 Overview Step 1 Request for exemption (if eligible) Exemption Exemption request due to timing of renewal audit Exemption request due to certification of OHSMS Approval of exemption request Step 2 Self-audit planning Self-audit methodology Self-audit approach Audit standard Audit ratings Self-audit scope Self-insurer initiatives (optional) Self-audit criteria selection Site selection Self-audit duration Auditors OHSMS auditors Planning meeting (optional) WorkSafe participation in self-audit Observation of the self-audit Conduct a component of the self-audit (optional) Step 3 Self-audit proposal and approval Self-audit proposal Annual self-audit proposal Forecast self-audit proposal (optional) Submission of self-audit proposal Approval of self-audit proposal Approval of annual self-audit proposal Approval in principle of forecast self-audit proposal (if submitted) Late submission of self-audit proposal Step 4 Self-audit conduct Step 5 Self-audit reporting Overview Self-audit findings report Summary of self-audit results Remedial action plan Self-audit certification Page 2 of 50

3 6.5.1 Director certification Auditor certification Lodgement of reporting Step 6 WorkSafe response WorkSafe reporting to the self-insurer How does WorkSafe use self-audit findings? Education and communication Step 7 Close-out of remedial action Further information Appendices...24 Appendix A(1) Exemption request...25 Appendix A(2) Notification of WorkSafe nominated criteria Category Appendix A(3) Self-audit proposal...28 Appendix A(4) Guide to sampling of audit criteria by topic...38 Appendix A(5) Self-audit proposal variation...40 Appendix A(6) Self-audit reporting...41 Appendix A(7) Remedial action plan...46 Appendix A(8) Director certification...47 Appendix A(9) Auditor certification...48 Page 3 of 50

4 Executive summary Pursuant to clause 4.5 of the Ministerial Order made under subsection 380(3) of the Workplace Injury Rehabilitation and Compensation Act 2013 (WIRC Act), it is a term and condition of self-insurance approval that a self-insurer participate in a Self-insurer Self-audit Program (SISAP) approved by (WorkSafe). The SISAP is reviewed by WorkSafe annually to ensure the program is aligned with current injury management practices and to incorporate legislative amendments (where applicable) and any changes to WorkSafe s policies, industry standards and related requirements. Objectives The objectives of the SISAP are to: ensure the safety of the working conditions for workers employed by the selfinsurer ensure the fair and equitable treatment of injured workers ensure compliance with the WIRC Act, Accident Compensation Act 1985 (ACA), Regulations, Ministerial Orders, and any terms and conditions of approval ensure continuous improvement in self-insurer s performance by providing a consistent method for measuring performance; and inform whether an employer is and continues to be fit and proper to be a selfinsurer. Underpinning principles The underpinning principles guiding the approach taken under the SISAP are to: ensure claims management practices do not disadvantage injured workers provide a collaborative and flexible approach, which is tailored to match a selfinsurer s risk profile and performance inform continuous performance improvement and compliance; and reduce, wherever possible, administrative burden. Program structure The SISAP comprises of the following two components: and Part II Claims management, rehabilitation services and other requirements. Page 4 of 50

5 1 Overview A self-insurer is required to participate in the SISAP on an annual basis. The steps that must be followed by a self-insurer when auditing the occupational health and safety management system (OHSMS) requirements of the SISAP are shown in Figure 1. The timeframes for key deliverables within each step of the SISAP are shown in Figure 2 on the next page. Figure 1: SISAP steps Step 1 (If eligible) Request for exemption and WorkSafe decision Step 2 Self-audit planning (where full exemption not granted) Step 3 Self-audit proposal and approval (where full exemption not granted) Step 4 Self-audit conduct Step 5 Self-audit reporting Step 6 WorkSafe response Step 7 Close-out of remedial action/s Page 5 of 50

6 Figure 2: Schedule of key deliverables and timeframes within each SISAP step Submit request for exemption (if eligible) As soon as practicable after 1 April 2015* WorkSafe decision Within 2 weeks of request receipt Self-audit planning (no full exemption) Any time from 1 April 2015 Prepare self-audit proposal Any time from 1 April 2015 Self-insurer advised of Category 3 criteria By 1 July 2015 Finalise & submit self-audit proposal By 14 March 2016** Approval of self-audit proposal By 29 March 2016*** Self-audit conduct Timeframe in self-audit proposal Self-audit reporting to WorkSafe By 31 August 2016**** WorkSafe response to self-insurer September / October 2016 Close out of remedial action/s Time frame in remedial action plan * Date of release of the SISAP Category 3 WorkSafe nominated criteria will be provided to self-insurers by 1 July ** A self-insurer may submit a self-audit proposal at any time prior to 12 March 2016 so long as, for those self-insurers not exempt from the SISAP (OHSMS requirements), submission is after the date the self-insurer has received WorkSafe s response to the findings of the self-insurer s self-audit report. A self-insurer s self-audit report from the previous year must be considered by the self-insurer when completing a self-audit proposal. A self-insurer with a previous exemption due to timing of the renewal audit may consider the results of WorkSafe renewal audit in planning their self-audit. *** The timeframe for approval may not apply if WorkSafe requests a self-insurer to re-submit its self-audit proposal with modification or requests additional information. WorkSafe will notify the self-insurer in writing of the nature of the proposed modification, reasons for the modification and timeframe for re-submitting the revised self-audit proposal. WorkSafe will evaluate a resubmitted self-audit proposal within two weeks of receipt. **** If a self-insurer is exempt from the self-audit due to OHSMS certification, the self-insurer must submit to the WorkSafe all certification/re-certification/surveillance CAB audit reports as well as copies of Certificates of Conformity (or equivalent certification documents) by 31 August Page 6 of 50

7 2 Step 1 Request for exemption (if eligible) 2.1 Exemption A self-insurer may request an exemption from all or part of the SISAP in the circumstances outlined in the paragraphs below. A self-insurer must use the form in Appendix A(1) to request an exemption. An exemption request should be submitted to WorkSafe as soon as practicable after the release of the SISAP If the exemption request deviates from the requirements outlined in the paragraphs below, the self-insurer must submit to WorkSafe the reasons for the deviation and any supporting information (if applicable) together with the exemption request Exemption request due to timing of renewal audit Where WorkSafe is scheduled to undertake a renewal audit during or close to the period captured by the SISAP , a self-insurer may request an exemption from all or part of the SISAP (OHSMS requirements). Example: A self-insurer may request an exemption from some of the requirements of SISAP due to the timing of its renewal audit, but the self-insurer may elect to conduct a reduced scope self-audit that includes only Category 3 WorkSafe nominated criteria Exemption request due to certification of OHSMS a. Certification to the NAT Where a self-insurer has an OHSMS certified by a JAS-ANZ conformity assessment body (CAB) to the NAT a self-insurer may request an exemption from all or part of the SISAP. Only Victorian sites that have a certified OHSMS may be included within the exemption request; those sites that do not have a certified OHSMS must be included within the SISAP. The self-insurer must provide evidence of the current OHSMS certification with any exemption request. b. Certification to AS/NZS 4801 or equivalent standard Where the self-insurer has an OHSMS certified by a CAB to AS/NZS 4801 or equivalent standard, the self-insurer may seek an exemption from all or part of the SISAP. The selfinsurer must provide evidence of the scope of CAB certification/re-certification/surveillance audits to be undertaken during the period with its exemption request. Only Victorian sites that have a certified OHSMS may be included within the exemption request; those sites that do not have a certified OHSMS must be included within the SISAP. The self-insurer must provide evidence of the current OHSMS certification with any exemption request. Page 7 of 50

8 2.1.3 Approval of exemption request WorkSafe will review the exemption request and either: approve the exemption request approve the exemption request with modifications, or not approve the exemption request. If WorkSafe intends to approve the exemption request with modifications, WorkSafe will advise the self-insurer of the proposed modifications and the reasons for proposing them and request the self-insurer to provide any additional information that could be taken into consideration. WorkSafe will consider any additional information provided by the selfinsurer before determining whether to approve the exemption request. If a self-insurer requests a full exemption from the SISAP, WorkSafe may decide to approve a full exemption or a partial exemption if it considers that to be more appropriate. Where a self-insurer has been granted an exemption from conducting a self-audit, the selfinsurer must complete the Director certification provided in Appendix A(8) of this document. The duly completed Director certification must be received by WorkSafe no later than 31 August Example: WorkSafe may propose to approve an exemption request subject to the inclusion of Category 1 WorkSafe nominated criteria within the scope of the CAB certification/re-certification/surveillance audits. Where WorkSafe requires a modification to the exemption request, WorkSafe will advise the self-insurer: - of the nature of the changes e.g. include Category 1 WorkSafe nominated criteria within scope of the CAB certification/re-certification/surveillance audits - reasons for the proposed modification e.g. Category 1 criteria have been identified as non-conformance in previous audit results at the self-insurer and close out of remedial actions have not been verified by an independent auditor. The self-insurer will have the opportunity to respond and provide additional information. For example, the self-insurer may have evidence of an independent verification of remedial action close-out. WorkSafe will consider this additional information before determining whether to approve the exemption request or approve the exemption request with modification. If WorkSafe intends not to approve the exemption request, WorkSafe will advise the selfinsurer of reasons for the proposed decision and give the self-insurer an opportunity to provide any additional information that could be taken into consideration. WorkSafe will consider any additional information provided by the self-insurer before making a final decision and notifying the self-insurer in writing whether the exemption request has been approved. Unless an exemption has been approved, the self-insurer must follow the steps required in this SISAP. Page 8 of 50

9 If a self-insurer is granted an exemption from carrying out a self-audit due to certification of the OHSMS, WorkSafe will require the self-insurer to submit all CAB certification/recertification/surveillance audit reports and any associated remedial action plans for the period to WorkSafe as well as copies of the Certificates of Conformity (or equivalent certification documents). Notes: Where a self-insurer has been granted an exemption from conducting a self-audit due to certification of its OHSMS to the NAT, WorkSafe requires sufficient evidence be included in CAB audit reports to support criteria ratings. Where a self-insurer has been granted an exemption from conducting a self-audit due to certification of its OHSMS to AS/NZS 4801 or equivalent standard, the CAB report must include: - sufficient information with respect to the audit scope and findings to enable WorkSafe to use this information in the manner described in paragraph 7.2 of this program and - sufficient evidence to support the conclusions of the auditor. 3 Step 2 Self-audit planning 3.1 Self-audit methodology Self-audit approach A self-insurer must determine how it will conduct its self-audit and provide a description of the proposed approach within its self-audit proposal (refer to Appendix A(3)). The self-audit must include a review of OHSMS documentation and must test the effectiveness and implementation of the OHSMS. WorkSafe recommends an audit approach which is consistent with the comprehensive auditing methodology provided in AS/NZS ISO 19011:2014 Guidelines for auditing management systems. This approach includes the following activities: Page 9 of 50 conduct of a pre-audit meeting Stage 1: OHSMS document review (through pre-reading and onsite document review) Stage 2: Verify implementation and effectiveness of OHSMS (onsite review, interviews, observation) evaluate audit evidence generate audit findings prepare audit conclusions conduct of closing meeting prepare a remedial action plan; and close of remedial actions.

10 3.1.2 Audit standard The standard for the self-audit is the National self-insurer OHS management system audit tool (NAT), version 3. In conducting the self-audit, auditors are required to assess the selfinsurer against this standard Audit ratings Auditors must report and rate self-audit results in accordance with the requirements of the NAT. The NAT incorporates a rating system as shown in the table below. Conformance (C) Non-conformance (NC) Not able to be verified (NAV) Not applicable (NA) A judgment made by an auditor that the activities undertaken and the results achieved fulfil the specified requirements of the audit criteria. While further improvements may still be possible, the minimum requirements are being met. A judgment made by an auditor that the activities undertaken and the results achieved do not fulfil the specified requirements of the audit criterion. This may be caused by the absence or inadequate implementation of a system or part of a system, documented systems or procedures not being followed or a minor or isolated lapse in a system or procedure. A situation where a relevant system procedure has been developed, but because of the infrequent need to use the system procedure there are no recent records or other form of verification available. A judgment made by an auditor that the requirements of a particular audit criterion do not need to be met, because of the nature of the client organisation s operations. 3.2 Self-audit scope A self-insurer must determine the self-audit scope in accordance with the requirements outlined in this paragraph. Details of the proposed self-audit scope must be provided in the template provided in Appendix A(3). If WorkSafe requires modification to the self-audit scope, the process described in paragraph 4.3 below will be followed Self-insurer initiatives (optional) Although not formally part of the self-audit scope, this section provides an opportunity for the self-insurer to provide details of its work program for the relevant period. The self-insurer may elect to provide supporting information on any of the following: internal OHSMS audit/assurance program initiatives to improve OHSMS performance; or other relevant information. This information may be used by the self-insurer to support criteria and site selection as well as to illustrate continuous improvement in OHSMS performance. Page 10 of 50

11 If the self-insurer elects to include detail of its initiatives, WorkSafe may use this information to monitor and promote continuous improvement in OHSMS performance (refer to paragraph 7.2) Self-audit criteria selection There are two components to self-audit criteria selection, these are: WorkSafe nominated criteria WorkSafe nominated criteria* will consist of up to 15 criteria that a self-insurer** must include within the scope of its self-audit. These criteria will consist of: Category 1: Category 2: Category 3: 5 criteria (selected from the key criteria) that will be included in the annual SISAP and will apply to all self-insurers up to 5 additional criteria which will apply to all selfinsurers (these criteria will be reviewed annually); and up to 5 criteria that will be specific to an individual self-insurer (these criteria will be reviewed annually). The self-insurer may select the sites to audit these criteria against on a sample basis (refer to guidance on site selection in paragraph below). Details of the current WorkSafe nominated criteria Categories 1 & 2 are included in Appendix A(3). WorkSafe will advise individual selfinsurers of their specific Category 3 criteria by 1 July 2015 using the form in Appendix A(2). * WorkSafe nominated criteria will be selected to support continuous improvement in OHSMS and will be determined using trends in audit results, incident and injury trends and WorkSafe initiatives. **Unless the self-insurer has been granted an exemption under Step 1 from some or all of these WorkSafe nominated NAT criteria. Page 11 of 50

12 Self-insurer nominated criteria The self-insurer nominated criteria will be selected from the remaining NAT criteria (i.e. criteria that have not been included in WorkSafe nominated criteria). The self-insurer must nominate criteria to be included within the scope of its self-audit based on the following principles: the risk profile of the self-insurer previous OHSMS audit results to align with initiatives being undertaken by the self-insurer during the relevant period to align with other audits or assurance activities being undertaken by the self-insurer; and to provide representation of the effectiveness and implementation of all of the NAT elements throughout the approval period. The self-insurer nominated criteria may be selected according to topic. WorkSafe has provided an example grouping by topic in Appendix A(4). A self-insurer may elect to use a different approach; however, details of the alternative approach must be included within the self-insurer s self-audit proposal. WorkSafe recommends that self-insurers include the key criteria* in the scope of the self-audit in the year prior to their renewal audit. *The key criteria are listed in External Guideline #3 Assessment of application for renewal of approval as a self-insurer. Note: In general, WorkSafe expects that at least 90% of all NAT criteria will be audited at least once during the approval period (either within WorkSafe nominated or the self-insurer nominated categories) Site selection Where a self-insurer operates multiple sites, the self-insurer is required to select a sample of sites to be included within the self-audit scope. The following documents should be used as a guide when selecting sites: JAS ANZ Procedure 02 Part 1, Issue 3 Requirements for bodies providing audit and certification of Occupational Health and Safety Management Systems, 18 August 2011 (JAS ANZ Procedure 02 Part 1); and IAF Mandatory Document for the Certification of Multiple Sites Based on Sampling, Issue 1 (IAF MD1:2007). In addition, the site selection must provide a representative coverage of self-insurer operations over the period of approval. The self-insurer should consider the following principles when selecting sites: Page 12 of 50

13 selecting sites which include significant OHS risk activities or are the focus of strategic initiatives selecting a sample of sites which represent all businesses, operations and activities of the self-insurer the complexity of the management of OHS at the site (e.g. multiple small sites with similar management such as retail stores, compared with a large, complex manufacturing site/s with a dedicated OHS manager) the level of existing OHSMS assurance activities (including certification of OHSMS) when the site/s were last audited and whether they had non-conformance/s; and selecting sites to audit WorkSafe nominated criteria where these criteria have not previously been audited. The self-insurer must explain how it has selected the sites it proposes to audit and provide the reasons for site selection in its self-audit proposal. WorkSafe recognises that for some organisations, auditing criteria at a site may not be relevant. In such cases, the self-insurer must provide detail within its proposal on how it defines its approach taken for sampling (i.e. how the self-insurer defines an auditable unit if that auditable unit is not defined by site ). Example: A self-insurer may operate multiple business units (e.g. Administration, Manufacturing) at one location and elect to audit criteria at selected business units. The self-insurer would then define its auditable unit as a business unit. Note: Any reference to the term site within this document can be substituted by the term auditable unit by a self-insurer who defines its auditable unit other than by site. 3.3 Self-audit duration A self-insurer is required to estimate the on-site self-audit duration (in auditor days) for each site included within the self-audit scope and record this estimate within the self-audit proposal. JAS-ANZ Procedure 02 Part 1 may be used to estimate duration for Stage 1 and Stage 2 (or equivalent) of the self-audit. The self-audit duration must be sufficient for adequate assessment of all criteria in scope and for determining whether the relevant OHSMS procedures are implemented and effective. WorkSafe recommends allocating sufficient time for preparing the self-audit findings report to ensure the report will meet the requirements of this program. Page 13 of 50

14 3.4 Auditors Self-audits may be conducted by internal auditors of the self-insurer or by engaging external providers. All auditors must be independent of the sites being audited. The self-insurer must be satisfied with regard to the auditor s independence and qualifications. WorkSafe recommends that an auditor has not worked or consulted at the site being audited for the period relevant to the self-audit period (i.e. two years). The qualifications, training and experience of all auditors to be engaged by the self-insurer are to be included in the self-audit proposal with any potential conflict being declared and addressed OHSMS auditors WorkSafe recommends that auditors have the minimum qualifications, knowledge and experience outlined in AS/NZS ISO 19011:2014 Guidelines for auditing management systems: Lead auditors (internal) can demonstrate: they hold current Exemplar Global certification (or equivalent) OR qualifications in OHS or a related field OHSMS lead auditor training in a nationally recognised course (e.g. registered with Exemplar Global) knowledge of current Victorian OHS and dangerous goods legislation a minimum of five years work experience including at least three years in an OHS role, and experience conducting at least four OHSMS audits totalling not less than 20 days on site within the last three years against the NAT, AS/NZS 4801:2001 or equivalent standard. Auditors (internal) can demonstrate: they hold current Exemplar Global certification (or equivalent) OR qualifications in OHS or a related field OHSMS auditor training in a nationally recognised course (e.g. registered with Exemplar Global) knowledge of current Victorian OHS and dangerous goods legislation a minimum of three years work experience including at least two years in an OHS role; and Page 14 of 50

15 experience conducting at least two OHSMS audits against the NAT, AS/NZS 4801:2001 or equivalent standard. External auditors can demonstrate: they hold current Exemplar Global certification (or equivalent) OR qualifications in OHS or a related field OHSMS lead auditor training in a nationally recognised course knowledge of current Victorian OHS and dangerous goods legislation a minimum of five years work experience including at least three years of experience in an OHS role; and experience conducting at least four OHSMS audits totalling not less than 20 days on site within the last three years against the NAT, AS/NZS 4801:2001 or equivalent. Where a self-insurer has selected a lead auditor or auditor who does not meet the requirements outlined above, the self-insurer must provide evidence demonstrating equivalent qualifications, knowledge and experience. Example: An auditor may have 10 years of experience in an OHS role but may have conducted only three OHSMS audits and multiple quality management system audits within the last three years. In this case, the self-insurer may be able to demonstrate equivalent experience. 3.5 Planning meeting (optional) A self-insurer may request a planning meeting with its WorkSafe Lead Auditor (and Portfolio Manager) to discuss the self-audit proposal. The self-insurer must have completed the planning stages outlined in paragraphs 3.1 through to 3.4 above and prepared a draft self-audit proposal (using Appendix A(3)) prior to requesting a planning meeting. If a self-insurer is proposing that WorkSafe conduct a component of the self-audit, the selfinsurer must request a planning meeting to discuss the proposal (refer paragraph below). 3.6 WorkSafe participation in self-audit Observation of the self-audit WorkSafe may elect to observe the conduct of some or all of the OHSMS self-audit. WorkSafe will advise the self-insurer if this is the case by no later than 29 March 2016 or by two weeks after submission of the self-audit proposal, whichever is earlier. Page 15 of 50

16 3.6.2 Conduct a component of the self-audit (optional) The self-insurer may propose that WorkSafe s Lead Auditor conduct a component of the self-audit (no more than five criteria). The self-insurer must also request a planning meeting to discuss the reasons for its proposal. WorkSafe may refuse this proposal but will provide reasons to the self-insurer for refusing the proposal. WorkSafe may propose that WorkSafe s Lead Auditor conduct a component of the selfaudit (but no more than five criteria). Where WorkSafe proposes to conduct a component of the self-audit, the self-insurer may refuse the proposal. Where the self-insurer agrees to WorkSafe conducting a component of the self-audit, the criteria and sites to be audited by WorkSafe will be discussed and agreed at the proposal stage. There may be various reasons for WorkSafe proposing to conduct a component of the SISAP (e.g. aligns with current WorkSafe initiatives). Reasons must be provided in the self-audit proposal if this option is agreed to. Note: Where there is agreement for WorkSafe to conduct a component of the SISAP, WorkSafe will prepare a report in accordance with the requirements of the SISAP for the criteria that WorkSafe has audited and provide it to the self-insurer for inclusion within their self-audit findings report. 4 Step 3 Self-audit proposal and approval 4.1 Self-audit proposal Annual self-audit proposal A self-insurer is required to complete and submit a self-audit proposal in accordance with the format and templates provided in Appendix A(3). The proposal must address the requirements contained in Step 2 of this document and Appendix A(3). If the self-audit proposal deviates from the requirements of the SISAP, the self-insurer must submit to WorkSafe the reasons for the deviation and any supporting information (if applicable) together with the self-audit proposal. A request for an exemption from part or all of the requirements of SISAP may be required (refer Step 1 above). Note: If WorkSafe has previously approved in principle a forecast self-audit proposal for the current SISAP year, the self-insurer may re-submit the forecast self-audit proposal or confirm to WorkSafe that there are no changes to the forecast self-audit proposal in order to meet the requirements of this paragraph and of paragraph 4.2 below. Page 16 of 50

17 4.1.3 Forecast self-audit proposal (optional) The self-audit proposal may include a forecast proposal for the term of approval to selfinsure. A forecast proposal may be approved in principle by WorkSafe if it meets the requirements of this SISAP (refer to paragraph below for process applied to approval in principle of forecast self-audit proposals). 4.2 Submission of self-audit proposal A self-audit proposal must be submitted to WorkSafe no later than 14 March A self-insurer may submit a self-audit proposal at any time prior to 14 March 2016 so long as it is after the date the self-insurer has received WorkSafe s response to the findings of the self-insurer s self-audit report. A self-insurer s self-audit report from the previous year must be considered by the self-insurer when completing a selfaudit proposal. This requirement applies to a self-insurer that is not exempt from the SISAP. If a self-insurer was subject to an OHMS audit undertaken by WorkSafe in , the self-insurer must consider the findings of the audit when completing a self-audit proposal. It is preferred that a self-insurer lodge its self-audit proposal electronically. However, a self-insurer may make alternative arrangements for lodgement of the self-audit proposal in agreement with WorkSafe. 4.3 Approval of self-audit proposal Approval of annual self-audit proposal WorkSafe will evaluate the self-audit proposal by 29 March 2016 or by two weeks after submission of the self-audit proposal, whichever is earlier. WorkSafe will consider the selfaudit proposal to determine whether the requirements of the SISAP have been met including an evaluation of any deviations from the program. WorkSafe will either: approve the self-audit proposal, or require the self-insurer to resubmit the proposal with modification. If the self-insurer is required to modify its self-audit proposal, WorkSafe will notify the self-insurer in writing of the nature of the proposed modification, reasons for the modification and the date agreed to by WorkSafe and the self-insurer for re-submitting the self-audit proposal. WorkSafe may require modification to: the self-audit scope if the principles for criteria and site selection (detailed in paragraphs and respectively) have not been considered, and/or Page 17 of 50

18 the explanation supporting the self-audit scope, if it is not clear how the principles for criteria and site selection have been considered. Where WorkSafe requires such changes to the criteria or site selection or supporting explanation, reasons will be given to the self-insurer. WorkSafe will evaluate the re-submitted self-audit proposal within two weeks of receipt. The self-insurer must not commence conducting the self-audit until WorkSafe has approved the self-insurer s self-audit proposal Approval in principle of forecast self-audit proposal (if submitted) WorkSafe will evaluate the forecast self-audit proposal by 29 March 2016 or by two weeks after submission of the self-audit proposal, whichever is earlier. WorkSafe will consider the self-audit proposal to determine whether the requirements of this SISAP have been met including an evaluation of any deviations from the program. WorkSafe will: approve in principle the forecast self-audit proposal, or require the self-insurer to resubmit the forecast proposal with modification. If the self-insurer is required to modify its forecast self-audit proposal, WorkSafe will notify the self-insurer in writing of the nature of the proposed modification, reasons for the modification and the date agreed to by WorkSafe and the self-insurer for resubmitting the self-audit proposal. WorkSafe will evaluate the re-submitted forecast self-audit proposal within two weeks of receipt. All forecast self-audit proposals will be subject to an annual review and may require modification to account for annual variations, including: any changes to WorkSafe nominated criteria new acquisitions, de-mergers, divestments (etc) changes to the SISAP changes to risk profile audit results, incident data and other relevant performance trends; and new WorkSafe initiatives. WorkSafe will not request modifications to an approved in principal forecast self-audit proposal when conducting its annual review unless the modifications are necessary to enable WorkSafe to use the self-audit findings report for the purposes described in paragraph 7.2. Page 18 of 50

19 Example: Where a self-insurer has had an emerging trend in incidents, WorkSafe may require the inclusion of additional criteria within the forecast self-audit proposal. Additional criteria selected will address the system elements designed to prevent such incidents. 4.4 Late submission of self-audit proposal If a self-audit proposal is received after 14 March 2016, WorkSafe will record the submission as late, unless: WorkSafe requests the self-insurer to modify the self-audit scope of the self-insurer's self-audit proposal WorkSafe revises the date that the modified self-audit proposal is to be submitted to WorkSafe the self-audit proposal is modified by the self-insurer in accordance with WorkSafe 's request, and is received by WorkSafe by the revised due date. In the circumstance where WorkSafe requests that a self-insurer re-submit its self-audit proposal due to the circumstances below, WorkSafe will record the submission of the revised self-audit proposal as late if received after 14 March 2016: an omission, incorrect or incomplete information being furnished, or the self-audit proposal deviates from the requirements of the SISAP without proper explanation as to the reason/s for the deviation. 5 Step 4 Self-audit conduct The self-insurer must conduct the self-audit in accordance with the approved self-audit proposal. If there are unforeseen circumstances that require a variation to the approved self-audit proposal, the self-insurer must advise WorkSafe as soon as is reasonably practicable using the template in Appendix A(5) and seek approval for the variation (e.g. change of auditor, site shut down). 6 Step 5 Self-audit reporting 6.1 Overview Self-audit reporting by the self-insurer to WorkSafe must include the following: self-audit findings report (which meets the requirements of paragraph 6.2. below) summary of self-audit results (using the template in Appendix A(6)) all CAB certification/re-certification/surveillance audit reports as well as copies of the Certificates of Conformity (or equivalent certification documents) (if applicable) where applicable, remedial action plan/s to remedy any identified non-conformance Page 19 of 50

20 certification of the self-audit findings by the responsible officer/s of the self-insurer; and certification of the self-audit findings by the auditor/s appointed by the self-insurer. Incomplete documentation may be returned to the self-insurer to complete or WorkSafe may request further information. This may occur where: the certification is incorrect or incomplete the self-audit findings report does not match the self-audit proposal approved by WorkSafe the self-audit findings report does not meet the requirements of paragraph 6.2 below; and all required documents have not been included. 6.2 Self-audit findings report The self-audit findings report must include sufficient information to enable WorkSafe to confirm any aspect of the self-audit. The template in Appendix A(6) may be used for preparing self-audit findings reports. The self-audit findings report must: provide positive and negative comments relating the effectiveness of the OHSMS include the names and details of the audit team and self-insurer representative/s location/s of where the self-audit has been conducted include specific findings/comments against each criteria in the self-audit scope identify all evidence sources for each criterion Note: The auditor may cite additional evidence other than documentation provided; for example, details of interviews with staff and/or observations made to ensure system components are working and provide clear identification of all audit reference documents, including document title and version and how these support any conclusions assign a rating to each criterion (conformance, non-conformance, not applicable, or not able to be verified) include explanations which support any conclusions including whenever ratings of not applicable or not able to be verified are applied to criterion where relevant, makes a comparison of the performance of the self-insurer to previous year self-audit results; and where applicable, makes recommendations on measures the self-insurer may adopt to improve performance in light of the issues identified. Page 20 of 50

21 6.3 Summary of self-audit results A summary of the self-audit results must be provided using the template contained within Appendix A(6). The self-insurer must also advise of any deviation from the self-audit duration estimated in the self-audit proposal using this template. 6.4 Remedial action plan The self-insurer must submit a remedial action plan if any criteria have been rated by the auditor as a non-conformance. The template in Appendix A(7) may be used. A remedial action plan must: specify actions, priorities and timeframe for addressing any identified non-conforming criteria specify the person/s responsible for the implementation of specific actions specify the person/s responsible for monitoring the remedial action plan and closing out actions specify how progress of actions is to be measured; and provide detail on how the effectiveness of all actions will be measured. The self-insurer may apply its risk assessment methodology to risk rank the nonconforming criteria and prioritise the remedial actions. If WorkSafe identifies issues with the remedial actions, timeframes or priorities specified by the self-insurer, WorkSafe will raise these issues with the self-insurer to resolve. The selfinsurer will have the final responsibility for determining resolution of these issues including in circumstances where WorkSafe has conducted a component of the self-audit. 6.5 Self-audit certification Director certification The self-audit findings report must be accompanied by a statement, signed by at least one responsible officer of the self-insurer, that: certifies that the self-audit was completed in accordance with the self-insurer s selfaudit proposal approved by WorkSafe and is in accordance with the SISAP confirms that the findings of the self-audit are true and correct; and confirms that appropriate remedial action, if required, will occur within a timeframe as specified in the remedial action plan. The statement signed by the responsible officer/s of the self-insurer is referred to in the SISAP as a Director certification. The responsible officer/s must complete and sign the certification template contained in Appendix A(8). A responsible officer means if the self-insurer is a body corporate, a director or member of the governing body of the self-insurer, or Page 21 of 50

22 if the self-insurer is the Municipal Association of Victoria (MAV), the person occupying the position which is responsible for the day to day operations of the MAV Auditor certification The self-audit findings for the OHSMS component of the self-audit must be accompanied by a completed and signed certification by the self-insurer s auditor in accordance with the template provided in Appendix A(9). If, however, the self-insurer has received an exemption from all requirements of the SISAP (OHSMS requirements) and submitted all CAB certification/re-certification/surveillance audit reports, the certification in Appendix A(9) need not accompany the report. 6.6 Lodgement of reporting The self-audit report accompanied by the duly completed certifications and where applicable a remedial action plan must be received by WorkSafe no later than 31 August It is preferred that a self-insurer lodge its self-audit documentation electronically. However, a self-insurer may make alternative arrangements for lodgement of the required documentation in agreement with WorkSafe. 7 Step 6 WorkSafe response 7.1 WorkSafe reporting to the self-insurer WorkSafe will review a self-insurer s self-audit report and remedial action plan (where applicable) and notify in writing to the self-insurer the outcome of the review. The time taken for WorkSafe to review a self-insurer s self-audit report and remedial action plan (where applicable) will be dependent on issues that may arise during the course of the review. However, subject to full completion of the self-audit report and receipt of all required documentation, WorkSafe will complete its review during the period September October If a self-insurer submits their self-audit report and remedial action plan (where required) earlier than the due date, WorkSafe will endeavour to complete its assessment as soon as possible. The self-insurer s self-audit performance will also be included in the self-insurer s Selfinsurance Performance System (SIPS) report which is sent to the self-insurer annually. 7.2 How does WorkSafe use self-audit findings? WorkSafe will use the self-audit findings reports to: monitor self-insurer compliance with the WIRC Act 1, Regulations and Ministerial Orders monitor and promote continuous improvement in OHSMS performance 1 In certain circumstances, compliance with the ACA may apply. Page 22 of 50

23 inform whether the remedial action plan (where submitted) adequately remedies the non-conformance/s identified in the self-audit report; and assess whether an employer is and continues to be fit and proper to be a selfinsurer. Self-audit findings that identify potential breaches of the WIRC Act 2, OHS, or dangerous goods legislation may be referred to the relevant division of WorkSafe for investigation. A self-insurer may be subject to field inspections by person/s authorised by WorkSafe. 7.3 Education and communication From time-to-time WorkSafe will provide information about any performance trends, criteria interpretation, reporting requirements, remedial action plans or any other matter arising from the SISAP to self-insurers. All education and communication will ensure the confidentiality of self-insurers is maintained. WorkSafe encourages self-insurers and the auditors of self-insurers to approach WorkSafe directly for guidance and clarification on any aspect of the requirements of the SISAP. 8 Step 7 Close-out of remedial action The self-insurer is responsible for verifying the effectiveness of remedial actions and closing out any non-conformances including in circumstances where WorkSafe has conducted a component of the self-audit. It is at the discretion of the self-insurer whether to engage its auditor to assist with the closing out of the non-conformances. WorkSafe may monitor implementation of remedial action/s by requesting progress reports, requesting supporting evidence or by conducting a visit to the workplace of the self-insurer. 9 Further information For further information in relation to the OHSMS component of SISAP, please contact: Manager Management Systems Services Insurance Division 222 Exhibition Street Melbourne VIC 3000 Phone: Freecall: Fax: In certain circumstances, breaches of the ACA may apply. Page 23 of 50

24 10 Appendices Appendix A(1): Appendix A(2): Appendix A(3): Appendix A(4): Appendix A(5): Appendix A(6): Appendix A(7): Template application for an exemption to all or part of the SISAP. Form used by WorkSafe to notify a self-insurer of Category 3 WorkSafe nominated criteria. Template self-audit proposal. Guide to the sampling of audit criteria. Template self-audit proposal variation. Template self-audit results reports. Template remedial action plan. Appendices A(8): Template for director certification of the self-audit, which must accompany the self-audit documentation. Appendix A(9): Template for auditor certification of the self-audit, which must accompany the self-audit documentation. Self-insurers can reproduce and expand or delete the rows and tables in the appendices where necessary. Page 24 of 50

25 Appendix A(1) Exemption request Occupational health and safety management system requirements Request for exemption 1. Contact details Name of self-insurer Name of contact Title of contact Contact number address 2. Exemption request Q1. Are you seeking an exemption from the requirements of the SISAP because WorkSafe is scheduled to undertake a renewal audit proximate to the period captured by the SISAP ? Yes No If yes, proceed to Q6 If no, proceed to Q2. Q2. Are you seeking an exemption from the requirements of the SISAP because all or some of your Victorian sites are currently certified to the NAT (or equivalent standard)? Yes No If yes, please provide details of which sites are certified to the NAT (or equivalent standard) below and proceed to Q3 If no, proceed to Appendix A(3). Details of which sites are certified: Q3. Do you agree to submit all CAB certification/re-certification/surveillance audit reports to WorkSafe for the sites covered by the exemption? Yes No If yes, proceed to Q4 If no, please provide reasons below: Q3 reasons: Page 25 of 50

26 Q4. Have you attached copies of the accredited NAT certification (or equivalent certification) certificates to this self-audit proposal? Yes No If yes, proceed to Q5 If no, please provide reasons below: Q4 reasons: Q5. If your OHSMS is certified to AS/NZS 4801 (or equivalent standard), have you provided evidence of the scope of CAB certification/recertification/surveillance audits to be undertaken during the period? Yes No If yes, proceed to Q6 If no, please provide reasons below: Q5 reasons: Q6. Are you seeking an exemption from all of the requirements of the SISAP or for all your sites? Yes No If yes, see Note (a) below If no, please proceed with completing the proposal template in Appendix A(3) Note (a): WorkSafe will consider your responses to Q1 through to Q6 above and any other supporting information you provide. WorkSafe will advise you whether your exemption request has been: approved (i.e. you are exempt from all or part of the SISAP requirements) approved with modifications (i.e. you are exempt from all or part of the SISAP requirements); or not approved (i.e. you must proceed with submitting a full self-audit proposal and undertake a self-audit in accordance with the approved proposal). Page 26 of 50

27 Appendix A(2) Notification of WorkSafe nominated criteria Category 3 Occupational health and safety management system requirements Category 3 criteria notification WorkSafe will advise the self-insurer of it s SISAP Category 3 criteria by 1 July The self-insurer Portfolio Manager will provide the details to the self-insurer using the following form. Self-insurer Criteria [Self-insurer] Page 27 of 50

28 Appendix A(3) Self-audit proposal Occupational health and safety management system requirements Self-audit proposal Introduction In preparing its OHSMS self-audit proposal, a self-insurer is required to complete this form. The completed form (and any supporting documentation) is to be submitted to WorkSafe no later than 14 March The information provided will be used by WorkSafe to assess the self-audit proposal and approve with or without modifications. If a self-insurer has an approved exemption from all the requirements of the SISAP under Appendix A(1) above, the self-insurer is not required to complete the following form. If a self-insurer has not sought an exemption from the requirements of the SISAP or a selfinsurer has an approved exemption from only some of the requirements of the SISAP, the self-insurer must complete the relevant sections within the form below. The self-insurer has received an exemption from all of the requirements of the SISAP (tick for confirmation). The self-insurer has received an exemption from some of the requirements of the SISAP (tick for confirmation). The self-insurer has not received an exemption from the requirements of the SISAP (tick for confirmation). 2. Self-audit methodology Provide a description of your proposed self-audit methodology (refer paragraph 3.1 of program) Page 28 of 50

29 4. Self-audit scope self-insurer initiatives (optional) Provide details of work program for the relevant period (refer paragraph of program) 5. Self-audit scope site selection Guidance on site selection can be found in JAS-ANZ Procedure 02 Part 1 and IAF MD1:2007. Define auditable unit: Site Other If Other, please provide detail on definition of auditable unit: Total number of sites in Victoria: Total number of sites to be audited: Please explain the methodology/justification used to determine which sites are to be audited and the number of sites to be audited (refer to paragraph of program): Site 1 [Insert business name and address] Site 2 [Insert business name and address] Site 3 [Insert business name and address] etc [Insert business name and address] Describe briefly the activities that occur on site and state which activities are excluded from scope: Estimate self-audit duration (i.e. estimated auditor days on site): Number of employees: Describe briefly the activities that occur on site and state which activities are excluded from scope: Estimate self-audit duration (i.e. estimated auditor days on site): Number of employees: Describe briefly the activities that occur on site and state which activities are excluded from scope: Estimate self-audit duration (i.e. estimated auditor days on site): Number of employees: Describe briefly the activities that occur on site and state which activities are excluded from scope: Estimate self-audit duration (i.e. estimated auditor days on site): Number of employees: Total on-site self-audit duration (estimated in auditor days) Page 29 of 50

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