Safety Groups Validation Audits

Transcription

1 Safety Groups Validation Audits Carmela Coffa WSIB Safety Group Program Consultant November 25,

2 Agenda Validation Audit Process Background Pre-Audit On Site discussion at start of audit Documentation Review SG Program Requirements & Validation Audit Evidence Year End Achievement & Maintenance Forms Workplace Interviews & Tour Scoring 2012 Validation Audit Summary of Findings 2

3 Background Sponsor coaches firms and ensures firms meet SG program requirements Audit process focuses on 2013 Year End Achievement report and the elements reported as complete as this represents 75% of the score Maintenance Reports are then reviewed and account for max. 25% of validation score Firms are expected to implement standards based on minimum requirements in SG Employer Guidelines, communicate, train, evaluate and acknowledge success and make improvements for each standard/element 3

4 Pre-Audit Process Sponsor notified by from SG Consultant SG Consultant contacts firm by phone or with proposed date based on consideration of travel cost effectiveness. All firms are expected to be prepared for the audit within two weeks of validation audit list being released. Contact will be made with person noted on the Year End Achievement Report. Advise firm that the audit may take up to half a day and includes : Review of all required documentation Interviews Plant/site tour Firms are expected to ensure all required documentation is available at time of audit. Confirm personal protective equipment required for onsite tour. 4

5 On Site: Pre-Audit Review Review audit template that is used by all SG consultants. Explain scoring, noting each element requires the verification of documentation for each of the 5 steps for each element; no part marks for incomplete element. Score is provided after documentation review, interviews and site tour. 60 % is a pass = eligible for group share of rebate In case of failure, firm is advised that sponsor will be contacted ASAP by SG Consultant to provide details. Copy of audit template completed with our notes/comments and score, to be signed by auditor and firm representative. Copy provided to firm prior to leaving premises. Letter summarizing audit score and results to be ed to firm and sponsor copied. 5

6 The Five Steps 6

7 Year End Achievement Report 2013 Pg 65 7

8 The Audit Process : Step 1 Set Standards SG Program Requirement : (Page 11 of SG Guidelines) Written statements outlining expectations, policies, procedures and workplace rules for health and safety. Each program element must have a standard that tells everyone in the workplace what to do, how to do it and when. Validation Audit Evidence Documentation: Compare their standard against program element requirements as noted in Employer Guidelines Standard (and all steps) is dated, current and in writing. Review any specific company expectations set out in their standard; Firms must meet both legislated and their own company requirements Verify implementation of their standard i.e. regular workplace inspections meeting the legislative minimum requirements & their own company expectations. 8

9 The Audit Process: Step 2 - Communication SG Program Requirement: (Page 13 of SG Guidelines) Ensuring that ALL appropriate people have a clear understanding of what is expected of them as employees and what they can expect from others regarding health and safety ALL communication must be completed by December 31 st 2013 Validation Audit Evidence Documentation: Ensure communication was conducted in 2013 either by; Bulletin board postings (i.e. H&S policy) Pay stuffers Newsletters Intranet communications Memos to appropriate staff Meeting, safety talk agenda and minutes 9

10 The Audit Process: Step 3 - Training SG Program Requirement : (Pages of SG Guidelines) Management, supervisors and workers ALL attain the knowledge and skills appropriate for the jobs. For each element, it must be determined who needs what skills and knowledge and how will the training be delivered. ALL training must be completed and/or verified by December 31 st 2013 Validation Audit Evidence Documentation: Review training records including sign off sheets and/or certificates required for every element to ensure ALL appropriate staff have completed training in 2013 Must be able to verify date of training, elements trained, who conducted the training, method of training and list of persons in attendance. All training records for SG elements selected must be viewed and verifiable at time of audit. Firm is responsible to ensure all training records are at worksite agreed upon to conduct audit. Examples of training delivery: Orientation training Classroom Training sessions Demonstrations by supervisors Observing another co-worker (mentoring or buddy system) Safety talks E-learning 10

11 The Audit Process: Step - 4 Evaluation SG Program Requirements: (Page of SG Guidelines) Evaluation makes sure the firm is carrying out the standard, the element is properly communicated and effective training has taken place. Checks for up-to-date standards and if it is being followed Evaluation must be completed by March 30, Validation Audit Evidence Documentation: Analysis of observations/inspections/plant or job-site audits Survey of employees/supervisors interviews or questionnaire with summarized results Quizzes of employees/supervisors summarized results and action planning Statistical review and analysis (i.e. WSIB Information) Review and analysis by JHSC (minutes) Management review and analysis Third party assessment and analysis Completion of evaluation plan by March 31,

12 Audit Process: Step 5 - Make Improvements and Acknowledge Success SG Program Requirement: (Page 18 SG Guidelines) Based on results of evaluation, firm to look for opportunities for improvement and create a documented plan or recommendations to implement changes Recognize everyone who contributed to successful incident prevention activities by meeting and surpassing company standards Validation Audit Evidence Documentation of: Review action plan and/or summary of recommendations addressing the gaps identified in their evaluation Review documentation of either: performance evaluations Letter /memo from president, health & safety awards, public recognition for JHSC and/or employees, staff meeting, newsletter article and/or bulletin board display 12

13 Audit Process: Maintenance of Elements SG Program Requirements: (Pgs of SG Guidelines) Firms must demonstrate their method to regularly (annually) check elements implemented in the past to determine that they are maintained in the current year (i.e., the 5-Steps of previous elements) Validation Audit Evidence Documentation: Firm is required to provide documentation that demonstrates that it has completed: an annual review of previous element s standards, and an annual evaluation of previous elements which includes when, by whom and action taken Ensures programs are up to date and being complied with i.e. expired training is identified and addressed 13

14 Year End Maintenance Report pg 67 Program Year 14

15 Workplace Interviews and Tour Introduce our role and the purpose of the interview To verify employee s and/or supervisor s understanding of SG elements Random selection of persons to interview for brief one on one discussion (without management present) Reference to worksite only, not person(s)name. Verify evidence noted from document review ie:h&s board postings, JHSC meeting minutes, workplace inspections, pre-start inspections for forklifts, first aid log book and/or first aid certificates posted. 15

16 Audit Validation Scoring 16

17 Audit Validation Scoring (cont.) Maintenance Elements 1 st year in SG Program No maintenance 2 nd year in SG each element worth 5 % 3 rd year each element worth 2.5% 4 th year each element worth 1.67% 5 th year each element worth 1.25% Maximum Maintenance Score is 25% 17

18 2012 Safety Groups Audits Summary Summary of Reductions and/or Failures: Approximately 50% due to unable to verify training completed in 2012 Approximately 23% due to incomplete standards Approximately 12% due to incomplete evaluations 18

19 Questions 19

20 Safety Group Advantage Program 2013 Validation Audit Process November

21 2012 Advantage Program Audits Summary of Audit Score Reductions Approximately 50% due to Standard, and Continual Improvement Plan requirements Approximately 50% due to Audit, and Work Re-integration requirements 21

22 2013 Advantage Program Audits Step Year-end Report/Checklist Step 2 - Audit list released to Sponsors Step 3 Validation Desk Audit: Document and Record Review Only SGAP Firms selected for audit Step 4 Validation Site Audit: Verification of SGAP Employer Requirements Audit process Audit Closing 22

23 Step Validation Audit List Released Release of validation audit list to Sponsors targeted for February 17, 2014 Two weeks from validation audit list published, firms must be ready for onsite audits. 23

24 Step 3 Validation Desk Audit Supporting documentation audited against the 5 SGAP Employer Requirements: Written Standard - 20% Auditor Training - 20% Completed Audit - 20% WR Policy Review - 20% Continual Improvement Plan - 20% Establishes initial 2013 validation audit score Desk audit scores <60 are not subject to on-site validation audit & become validation audit score 24

25 Step 3 Validation Desk Audit 1) Written Standard for HSMS Audit Program: i date on standard (originating/review/revise) ii. Reference to audit schedule timeline (at least annually) and procedures iii. Reference to Auditor training qualifications iv. Assignment of roles and responsibilities v. Reference to formal continual improvement plan process 2) Auditor Training: i. Record of Auditor(s) training ii. Does training match qualifications outlined in standard? iii. Date of training does not need to be 2013 iv. Cross-reference with HSMS Audit Review Form document : do names match?, did training precede the audit? v. 3 rd Party Auditor? training verification is applicable 25

26 Step 3 Validation Desk Audit 3) HSMS Audit: i. An approved HSMS Audit is completed all sections ii. iii. iv. Sufficient supporting evidence for each audit requirement Findings/Conclusions of conformance for each requirement Auditor(s) sign-off with date (cross reference to training record) v. Documented evidence of Senior Management Review of completed audit 4) Return to Work: i. As part of the HSMS Audit a documented review of RTW Standards against WSIB WR Policies ii. Same process as outlined above part of the HSMS Review 26

27 Step 3 Validation Desk Audit 5) Continual Improvement Plan: i. Written Continual Improvement Plan submitted ii. Action items addressing ALL non-conformities including RTW non-conformities iii. Action items scheduled to be initiated in 2013 iv. All other non-conformities scheduled to be initiated within 6 months of audit conclusion v. Non-conformity action items planned to resolution vi. Responsibilities assigned and timelines established vii. Documented evidence of Senior Management Review of the developed Continual Improvement Plan and any subsequent revisions 27

28 Step 4 - Site Audit Same contact process as with Safety Group firms Date/time of site audit scheduled with firm Sponsor welcome to attend audit as an observer Conducted by Safety Group Program Consultants Completion of the 5 SGAP Employer Requirements are verified based on sampling of: documents/records/interviews and site observations 28

29 Site Audit 1) Written Standard for HSMS Audit Program: i. Verified during Desk Audit ii. iii. May ask to see Standard within context of H&S Manual Implementation of standard 2) Auditor Training: i. Verified during Desk Audit ii. May ask to interview Auditor(s) 29

30 Site Audit 3) HSMS Audit: i. Desk audit verified the firm completed an approved HSMS Review Audit ii. We do not redo the HSMS Review Audit during our site audit iii. By sampling sections of the selected HSMS Review Audit we verify: the listed evidence is available for review and/or confirmation the audit finding can be supported by the listed evidence may request additional evidence to verify finding 30

31 Site Audit 3) HSMS Audit: iii. Sign-off by Auditor(s) with date may ask to speak with Auditor(s) iv. Documented evidence of Senior Management review of completed audit may ask to speak with Senior Manager 31

32 Site Audit 4) Return to Work: i. Verify documented review of Company RTW Standards against the 6 WSIB Work Reintegration policies ii. Part of the HSMS Audit, therefore, same Validation Audit process applied the listed evidence is available for review and/or confirmation, and the audit finding can be supported by the listed evidence may ask to see additional evidence 32

33 Site Audit 5) Continual Improvement Plan: i. Verify status of action item(s) initiated in 2013 ii. Verify on-going status of remaining action items iii. May ask to interview individuals with assigned responsibilities iv. Verify if timelines are being followed v. Senior Management review of any CIP revisions 33

34 Site Audit Audit Closing: 1. Review validation audit findings with firm may include opportunities for improvement 2. Verify validation audit score 3. Answer any questions 4. Firm acknowledges review and discussion of audit notes and score by signature 5. Copy of validation audit notes offered to firm 6. Advise firm a formal audit letter will be sent within 4 weeks 7. Audit concluded. 34