COR Toolkit: An Employer Guide to COR Certification. Certificate of Recognition (COR) Program.

Transcription

1 COR Toolkit: An Employer Guide to COR Certification Certificate of Recognition (COR) Program Suite 450, One Bentall Centre 505 Burrard Street, P.O. Box 59 Vancouver, BC V7X 1M3 Tel Fax

2 Table of Contents Introduction... 3 Overview of the COR Program... 4 Benefits of COR certification... 5 Implementation and Maintenance of a Safety Management System... 5 Importance of Communication... 6 Effective Supervision... 6 Safety Culture... 7 COR Process and Continual Improvement... 7 Element 1: Management and Leadership Commitment... 8 Element 2: Hazard Identification and Control Element 3: Safe Work Procedures and Written Instruction Element 4: Inspection of Premises, Equipment, Workplaces and Work Practices Element 5: Investigation of Incidents/Accidents Element 6: Training and Instruction of Employees Element 7: Program Administration Element 8: Joint Occupational Health and Safety Committee Element 9: Injury Management/Return to Work Programs Appendices COR Toolkit: An Employer Guide to COR Certification Page 2 of 71

3 Introduction The purpose of this document is to help employers understand the Certificate of Recognition (COR) process, giving an overview of what is needed to succeed, providing detailed explanations of the audit tool s questions and giving practical examples of forms, policies and procedures that companies can use or modify based on their specific needs. By following this manual, companies can expect to improve their safety performance and reduce costs. Common themes running through this manual include the importance of: a formal safety management system (SMS), as opposed to a random collection of safety activities open communication across all levels of an organization effective, fair, documented supervision that does not swamp a supervisor with paperwork an effective safety culture that helps all employees buy into the SMS promoting safety as an integral part of the business for all employees, rather than something only a safety person does. The manual is divided into three main sections: this introduction, which summarizes setting up an SMS; detailed explanations of each of the nine elements of the COR process, with tips and resources to help interpret the audit tool; and a final section that collects the various forms and templates that employers can use or modify. Of the nine elements, eight pertain to the Occupational Health & Safety (OHS) audit, and the ninth deals with the Injury Management/Return to Work (IM/RTW) audit. Each of these sections contains: an overview of the element and its importance in ensuring a safe and healthy workplace relevant links to the OHS Regulation or the Workers Compensation Act a list of resources supporting the element such as booklets, brochures, posters, web sites (go2, WorkSafeBC, and other reliable sources) topic-relevant external training options for employers a list of questions from the audit tool for each element with a clear description of what an auditor looks for in each question a list of any relevant documentation required, as well as sample resources, such as policies, checklists, forms, etc. best practices from leading employers on effective and practical approaches to safety, focusing on the approaches auditors look for when on site. COR Toolkit: An Employer Guide to COR Certification Page 3 of 71

4 Overview of the COR Program The COR Program is a voluntary incentive program for employers in BC. Employers enrolled in the COR program develop management systems in OHS and RTW. By implementing these systems and verifying them through audits, employers can earn rebates up to 15 per cent of their WorkSafeBC premiums. The COR program consists of two elements: the Occupational Health and Safety Certificate of Recognition (OHS COR) the Injury Management/Return-to-Work Certificate of Recognition (IM/RTW COR), which may be earned at the same time as the OHS COR, or subsequently. The OHS COR recognizes that an employer has implemented an OHS management system that exceeds regulatory requirements, and ensures that there are comprehensive management systems in place to provide a safe work environment. This is the foundation of the COR Program. The IM/RTW COR is awarded to employers who have built injury management/return-to-work programs into their health and safety management systems. Return-to-work programs are a proactive way for employers to help injured workers stay at work or return to productive and safe employment as soon as physically possible. These programs are based on the fact that many injured workers can safely perform productive work during the process of recovery. Returning to work is part of the workers therapy and recovery, and workers who participate in a return-to-work program have better long-term health outcomes than those who don t. When the company believes it is ready to proceed with the certification audit, it selects an external auditor. Auditors are experienced in the industry and in safety culture. Through the on-site audit process they develop a comprehensive picture of the situation and can provide meaningful recommendations to help a company improve further. The auditor measures the entire company s performance using the go2 COR audit tool. For any topic that does not meet the standard, the auditor writes a clear recommendation to the company to help meet the requirements. If the company achieves 80 per cent, overall, and 50 per cent in each element of the audit, it is awarded COR certification. If the company is not successful the first time, it can use the auditor s recommendations to improve its system and try again until it is successful. On the first and second anniversaries of certification, the company performs a maintenance audit using the same audit tool. This audit is usually performed by a certified internal auditor, a designated employee who acts as the company s safety champion. In the third year after certification, an external auditor is again selected to perform a full external audit. This audit cycle repeats in subsequent years. A key thing to remember is that there is a full audit every calendar year. COR Toolkit: An Employer Guide to COR Certification Page 4 of 71

5 Benefits of COR certification There are three main reasons to seek COR certification: annual financial incentives paid by WorkSafeBC reduced assessment payments as a result of improved safety performance and experience rating indirect financial benefits of the program achieved through higher productivity, lower turnover rate, and overall reduction in physical and human operating cost. Financial incentives are provided to employers who achieve COR certification and who are in good standing with WorkSafeBC. Employers earning the OHS COR receive rebates of 10 percent of their WorkSafeBC base assessment. Employers earning the IM/RTW COR can receive additional rebates of five percent of their WorkSafeBC base assessment. Even more significant than financial incentives associated with certification, however, are the costs avoided by preventing workplace injury and illness, which in turn directly results in lower claim costs and reduced WorkSafeBC assessment premiums. A safe company can achieve up to a 50 per cent discount on the base assessment rate, compared to a 100 per cent surcharge on the base rate assessed on a company with poor safety performance. This means a top-level safety performer would only pay one quarter the annual assessment of the worst performers. Savings of this level can be substantial. The successful implementation of the OHS and the IM/RTW systems also contributes to a change in business culture. When employers recognize that health and safety are just as important as other critical business factors (production, quality and profit, etc.), a safer workplace will result. Safer workplaces lead to lower employee turnover and higher employee morale, and these factors in turn lead to higher customer satisfaction. Implementation and Maintenance of a Safety Management System Safety management systems are no more difficult to set up and maintain than any other system, be they accounting, maintenance or human resources. This resource manual is designed to help companies with even minimal safety experience achieve COR certification in a timely and efficient manner. Reviewing this material is an important early step in the process. go2 is available to help companies, both by direct consultation and by providing training to each company s safety champions. A company can achieve success in five steps. The first step is for all senior managers to make an unconditional commitment to safety. They must not only say, but actually believe, that all injuries are preventable and that excellence in safety is necessary for excellence in business. Actions must always support these beliefs. The second step is for managers and supervisors to be personally involved in safety activities, such as meetings, inspections and giving feedback when observing workers. This is the main component of the safety system, but cannot occur in isolation. Safety champions frequently set up easy tools for supervisors to use for this purpose. COR Toolkit: An Employer Guide to COR Certification Page 5 of 71

6 The third step involves empowering employees to have a substantial voice in safety actions. They must hold themselves and others accountable for actions and take pride in achievements. If a company responds negatively to employee concerns, this step quickly fails. Fourth, an objective evaluation of actions is needed to encourage positive behaviour and reduce the negative. These systems must be fairly and consistently applied every time. This is a key that leads to continual improvement. Finally, there must be established an effective reporting system that employees can and will use. It must focus on correcting issues and weaknesses before an injury or incident occurs, but also be able to help the company learn from experience when something goes wrong. Importance of Communication There is no single factor more important than communication in a safety management system. The safety champion could build the world s best SMS, but if management and workers never know about it, it will be useless. As with all systems, management needs to communicate expectations to workers, coach them and train them. Workers need to be engaged in the company, communicating not only when things are wrong (unsafe, unusual, unexpected or unknown) but when things are going well. The communication needs to be open and without fear of reprisal. Management needs to close the loop with workers and let them know how their issue is being handled. The most common and effective method is simple informal talk, either one-on-one or in small groups. Signs, posters and message boards are semi-formal methods. Written policies, procedures and forms are the most formal methods of communication. Each company needs a balance of these methods and also needs to establish a system of recording communication when it happens. The manager s notebook, whether paper or electronic, is a very useful tool. Simple, short notes that a particular worker was observed doing something (right, neutral or wrong) and that subsequent feedback was given can support more formal evaluation records. For minor issues, these notes may be the only record that anything even happened. They can establish patterns of behaviour by the supervisor or a particular worker that can be vital in investigations. The best communications are not categorized as safety or not safety. Each discussion about how to do a job properly is essentially a mini-safety meeting. Safety is just another part of the overall business, and open communication is critical to its success. Effective Supervision Effective supervision is an absolute key to workplace safety. In this context, supervision means someone who controls, instructs and directs people below them. It is not necessary to have the title of supervisor to be one. Most managers in hospitality are supervisors, as are some lead hands. Supervisors are legally responsible for the health and safety of their workers and are required by regulation to teach, train, inform, coach, watch, correct and even discipline them appropriately. COR Toolkit: An Employer Guide to COR Certification Page 6 of 71

7 The number one trait of effective supervision is integrity. The supervisor needs always to act above the standards they are asking of their workers. They need to follow every safety rule to the letter, or better, and always have every required piece of personal protective equipment not only on but in good condition. Safety Culture Formally, a company s safety culture is its shared beliefs, values, behaviour and attitudes. It is what the employees will do or say when they know no one is watching or listening. It is the consistent belief at all levels that all injuries are preventable and that incidents cannot simply be blamed on worker negligence by default. It is the belief that safe, happy employees have a positive impact on business. Safety is not a cost-benefit calculation, but always a benefit. There can be no cutting corners, and the job must be done right the first time, every time. Safety culture is something anyone without much industry experience can quickly spot, but even specialists struggle to define exactly what it is and how to measure it. People in the industry can usually tell within minutes of stepping onto company property if a business is running a tight ship. It shows in the little things, like housekeeping details in less public areas, crisp uniforms on maintenance staff, and everything put away in back-of-the-house areas. Tight companies are safer, have a lower environmental impact, lower costs and higher profitability, lower employee turnover, and higher employer loyalty and morale. New hires quickly adopt the culture of the organization, and they rarely consciously realize what aspects of the culture have had a subtle but crucial impact on them. COR Process and Continual Improvement One of the principles of COR is continual improvement. The 80 per cent minimum standard for COR certification is only the start of the next phase of the safety journey. The company needs to make a commitment that the only acceptable outcome is ultimately preventing any workplace injury or illness. This very lofty goal can only be approached slowly and systematically, dealing with all remaining issues identified in audits or by other company methods. Many companies manage to address half the deficiencies from each audit before the next. Each year, whittling away half the remaining issues results in getting closer and closer to the final goal. Usually, after several years of certification, companies realize there are safety issues they should address that are not covered in the audit. These companies then add the extra issues to their ongoing to-do safety issue list (otherwise known as a Corrective Action Log, or CAL). Continual Improvement also applies to the COR system itself. Companies are actively invited to give feedback on the COR system, the audit, auditor performance, this manual and any other COR issue. COR Toolkit: An Employer Guide to COR Certification Page 7 of 71

8 Element 1: Management and Leadership Commitment Overview An effective occupational health and safety (OHS) program must demonstrate effective management leadership, a firm commitment to the program and a willingness to improve the workplace safety culture. Companies with good results in safety (or any other area) have leadership that will not allow a substandard result. While cooperation and consensus are very important in getting employee buy-in to programs, ultimately it is the leadership and commitment from management that drives the process. The audit will measure the level of leadership and commitment toward health and safety within the organization by assessing the following items: a current, written health and safety policy that clearly states the employer s aims; the responsibilities of the employer, managers, supervisors and workers; and awareness of these individual responsibilities at all levels of the organization a system for accountability of health and safety roles and responsibilities at all levels of the company. This is often one of the toughest areas for any company what to do when a valued employee is not following the system. the levels of senior and middle management and worker involvement in the program (where those levels exist in the company) the levels of knowledge and awareness of applicable legislation appropriate to an employee s needs. the allocation of sufficient resources for health and safety the level of commitment from senior management (CEO or most senior management) toward improving the workplace safety culture. This is a key performance indicator whether the senior people walk the talk. This element has only one key document: the safety policy. Some companies may have safety as part of an overall mission statement or may have responsibilities for safety outside of the policy. The rest of the element is about showing that the policy is actually followed. Key Concepts and Implementation Tips In order to meet the above objectives, the audit determines whether: The employer has an established safety policy that fits what the company does and how it is organized. Employees are aware of the safety policy and their responsibilities. Supervisors and managers are aware of the applicable legal, regulatory and other requirements of their area. Senior management fully supports the safety program with real resources and makes a clear commitment through their actions. COR Toolkit: An Employer Guide to COR Certification Page 8 of 71

9 The company tracks safety statistics and develops plans based on how those statistics are trending. Examples include: o injury rate o number of safety inspections done each month o percentage of first aid cases with an appropriate investigation o percentage of people on each safety inspection who are wearing the required personal protective equipment (PPE). SUPPORTING RESOURCES: How to Safety Policy Guide to Writing an OHS Policy (CCOHS) grams/osh_policy.html How to prepare OHS Policy (Min. of Labour) s/pubs/ohsa/ohsag_appa.php How to Roles and Responsibilities Safety on the Job is Everyone s Business (WorkSafeBC) ns/health_and_safety/by_topic/assets/ pdf/safetyonthejob.pdf 20 Powerful H&S Motivation Actions for Senior Management (WorkSafeNB) Securing Commitment (HSA) s/securing.htm COR Toolkit: An Employer Guide to COR Certification Page 9 of 71

10 Supervising for Safety (WorkSafeBC) How to Due Diligence Due Diligence Checklist (WorkSafeBC) mmon/due_dil_checklist.pdf Effective Health and Safety Programs (WorkSafeBC) ns/health_and_safety/by_topic/assets/ pdf/ph33.pdf Due Diligence (CCOHS) /diligence.html How to Safety Performance Tracking Business Planning Toolkit (WorkSafeBC) TRAINING OPTIONS: Training Management Responsibility for Safety Employers Advisers Office WorkSafeBC database of training providers COR Toolkit: An Employer Guide to COR Certification Page 10 of 71

11 RELEVANT REGULATION AND LEGISLATION: Workers Compensation Act (BC Gov t) ns/ohsregulation/workerscompensatio nact.asp#sectionnumber:part3division1 Section 115, 116, 117 General Duties of Employers, Supervisors, and Workers Guidelines for Using the COR Audit Tool QUESTION 1.1 Does the business have a written health and safety policy? Auditor Guideline: Review documentation to ensure there is a health and safety policy. Employer Guideline: This can be a mission statement or a corporate health and safety policy that outlines the company s goals. For companies that are branches of a large corporation, either a company or a corporate policy is acceptable. Types of Documentation to Review: Mission statement, corporate health and safety policy QUESTION 1.2 Are the aims of the health and safety policy clearly stated? Auditor Guideline: Review documentation (health and safety policy). It must clearly state the aims of the occupational health and safety program which must be consistent with the objectives of: o creating a culture of health and safety in the workplace o preventing workplace injury and disease. Employer Guideline: The policy must include the objectives listed in the auditor guideline. This must be in the policy itself, not in any supplemental documentation. Types of Documentation to Review: Mission statement, corporate health and safety policy QUESTION 1.3 Does the health and safety policy clearly outline the responsibilities of the Employer, Managers, Supervisors, and Workers? Auditor Guideline: Review documentation (the health and safety policy) and ensure it clearly outlines the responsibilities for the Employer, Managers, Supervisors, and Workers. Employer Guideline: COR Toolkit: An Employer Guide to COR Certification Page 11 of 71

12 Often companies list the responsibilities separately, but this question requires the key points to be spelled out in the actual policy for all levels listed: employer, manager, supervisor and worker. If the company does not have supervisors, or all managers are the employer, then the extraneous levels could be omitted. Synonyms, such as using the term associate instead of worker, are acceptable but should match the terms used by the company. When outlining policies, try to distill them down to a couple of key points for each level, so that the policy can be an easily displayed one-page document. Types of Documentation to Review: Mission statement, corporate health and safety policy QUESTION 1.4 Does the Employer inform Employees about the policy? Auditor Guideline: Interview Employees to verify they are aware of the policy. Employer Guideline: Because the interview asks employees to cite the key points in the corporate policy, having a clear and concise policy can help workers remember the key points. The auditor doesn t expect employees to recall the policy word for word but wants to see that they understand the general themes. QUESTION 1.5 Does senior management ensure that ongoing resources are allocated to implement and maintain the health and safety program? Auditor Guideline: Interview Workers, Supervisors, and Managers. Resources could include health and safety committee, employee training, communications and meetings, hazard controls, budget allocations, or scheduling concessions. Employer Guideline: The question asks the employees for examples of how senior management supports the program. This could include the resources listed in the auditor guidelines, plus incentive programs, health and safety coordinator positions, and/or PPE availability and the right equipment required for the job. The auditor needs to provide detailed evidence to support the score awarded for this very large point allocation in the audit. QUESTION 1.6 Are the following aware of their safety responsibilities: 1. Managers 2. Supervisors 3. Workers Auditor Guideline: Interview Managers, Supervisors and Workers. COR Toolkit: An Employer Guide to COR Certification Page 12 of 71

13 Employer Guideline: Employees at each level are asked for examples of their responsibilities. Managers should be able to provide more exact details than supervisors, and workers the least amount of detail. The outlines of these responsibilities should not contradict the stated company program; legislated and regulatory requirements, especially for workers, are not expected to be a full listing of all responsibilities. QUESTION 1.7 Are health and safety responsibilities carried out? Auditor Guideline: Interview Managers, Supervisors and Workers to ensure health and safety responsibilities are carried out. Determine if their involvement is appropriate to their level in the organization. Employer Guideline: This is designed to see whether supervisors and managers are providing training and guidance to workers, and whether workers are performing the appropriate level of work or are performing supervisory jobs as well. QUESTION 1.8 Is there an effective system to ensure accountability for safety roles and responsibilities? Auditor Guideline: Review documentation to demonstrate that there is an effective system to ensure accountability (e.g. performance evaluations, log books, training records, KPIs, etc. Employer Guideline: There needs to be a system that holds everyone accountable for their jobs. This can be done with a spreadsheet that tracks inspections, evaluations, meetings, and investigations. There needs to be regular review showing there is an appropriate response when something is not being completed on time. Supervisors need to demonstrate that they are performing their jobs, while managers should have a documented record of how their supervisors are performing. Training records, journals, and logbooks can be used as well to show that there is follow-up being done for individual issues, but the pattern of issues needs to be tracked and understood by senior leadership. There needs to be documentation showing that senior leadership is meeting their legal and company requirements; this can be demonstrated through their journal notes, appearance in meeting minutes, co-signing of documents, etc. In the guideline, the phrase KPI refers to Key Performance Indicators important items that the company monitors over time. Each company will develop its own set of useful KPIs. Types of Documentation to Review: Performance evaluations (workers, supervisors and managers), machine log books, training records, training matrix, management meetings and reports, annual reports, s, memos, journal notes, documented observations of worker practices by COR Toolkit: An Employer Guide to COR Certification Page 13 of 71

14 supervisors and managers that show both positive and negative observations and appropriate action plans to correct deficiencies are also acceptable. QUESTION 1.9 Are Managers and Supervisors aware and knowledgeable of the applicable regulations? Auditor Guideline: Interview Managers and Supervisors to determine their awareness of the regulation that applies to the organization and knowledge of regulation that applies to their area of responsibility (ex. BC OHS Regulations, Workers Compensation Act). Employer Guideline: This question looks to verify that managers and supervisors are aware of governing bodies (and the applicable rules from those bodies) they need to be in compliance with outside of the company s rules. This could include, but is not limited to, fire codes, employment standards, WSBC, BC Safety Authority, etc. The scope of this question is intended to be limited to safety-related issues. Non-safety issues (i.e. copyright law) are not germane. The auditor wants to see that managers and supervisors understand how regulations apply to their jobs as well. If interviewees believe they are knowledgeable and in compliance, but evidence elsewhere in the audit indicates noncompliance based on lack of knowledge by managers or supervisors, these are negative findings. QUESTION 1.10 Does senior management demonstrate their level of commitment toward improving the workplace safety culture? Auditor Guideline: Interview the senior management (including the CEO or most senior management in B.C.) to gauge the level of commitment toward improving the workplace safety culture. Employer Guideline: This question calls for a conversation with senior management to determine what kind of initiatives they have implemented to support and improve a safety culture. Are they aware of the programs within their organization?. Managers need to be in touch with the program and have realistic and achievable plans for improvement. Senior management may delegate most of the company s safety activities but still need to be the driving and authorizing force behind the program. Safety champions are often the eyes, ears and hands of the safety program and give advice to senior management, but ultimately senior management makes the large decisions and sets the ultimate direction. COR Toolkit: An Employer Guide to COR Certification Page 14 of 71

15 Element 2: Hazard Identification and Control Overview A method to identify and control workplace hazards is important in order to eliminate, minimize or prevent unsafe or harmful conditions and work procedures. All jobs, equipment, machinery, worker activities and on-site conditions need to be included in the hazardrecognition process. The audit will measure if the company has implemented: a risk rating system to analyze jobs, equipment and conditions for potential hazards; this should be done once overall when building the system and then partially any time there is a change in a job, a piece of equipment or working conditions. a method to control the workplace hazards by o engineering controls proper use of controls, such as power machinery instead of manual lifting by workers, and availability of standardized engineering controls o administrative controls including having workers follow written safe work procedures for hazardous jobs, plus management enforcement of these practices o personal protective equipment (PPE) controls including availability, training and maintenance of PPE (such as gloves) and enforcement of its use, where appropriate a method to communicate the risk assessment and the control procedures to workers and ensure that the controls are used. Key Concepts and Implementation Tips In order to meet the above objectives, the audit checks whether: The employer performs hazard/risk assessments at the worksite. Employees participate in the hazard/risk assessment, since they are the ones most affected by hazards and risks. People assessing the risk are adequately qualified to do so. A qualified individual is someone who is knowledgeable about the work, the hazards involved and the means to control the hazards. This qualification can be earned through education, training or experience, or a combination of these things. Once hazards have been identified, they are prioritized and controls put in place to manage them. There is a process to review the effectiveness of the controls once they have been put in place. When operations change or new procedures are added, an assessment of the change is performed. Supervisors check that workers follow the safety procedures, providing coaching and corrective feedback where necessary. The employer has a written discipline policy when coaching and correction are not working. COR Toolkit: An Employer Guide to COR Certification Page 15 of 71

16 Employees have a method of reporting unsafe conditions, hazards or problematic activities and understand the process for refusing unsafe work. Employees are trained in the hazards and controls that affect them and how to report problems. Training is documented. SUPPORTING RESOURCES: How to - Hazard Identification and Risk Assessment What is Risk Assessment? (go2) Risk Assessment Tool for Accommodation (go2) Risk assessment (CCOHS) rams/risk_assessment.html How to - Safe Work Procedures Sample Hospitality Safe Work Procedures (WorkSafeBC) osp_smbiz/add_res/online- Sample_Procedures1.pdf How to - Reporting Unsafe Conditions/ Refusal of Unsafe Work The Right to Refuse Unsafe Work poster (WorkSafeBC) /health_and_safety/posters/assets/pdf/ri ght_refuse.pdf COR Toolkit: An Employer Guide to COR Certification Page 16 of 71

17 Worker Rights and Responsibilities (WorkSafeBC) ngworker/apprenticeprograms/culinarya rts/rights_student.pdf Getting a Job? Ask Questions about Safety (WorkSafeBC) ngworker/getting_job.pdf How to - Personal Protective Equipment PPE (WorkSafeBC) E/Home.asp PPE (CCOHS) tion/ppe/ TRAINING OPTIONS: Training - Risk Assessment Employers Advisers Office WorkSafeBC database of training providers CCOHS Training - Safe Work Practices WorkSafeBC database of training providers Training - Refusal of Unsafe Work WorkSafeBC database of training providers COR Toolkit: An Employer Guide to COR Certification Page 17 of 71

18 RELEVANT REGULATION AND LEGISLATION: Occupational Health and Safety Regulation (WorkSafeBC) Workers Compensation Act (BC Gov t) publications/ohsregulation/h ome.asp Publications/OHSRegulation/W orkerscompensationact.asp#s ectionnumber:part3division1 Section 3.10 Reporting Unsafe Conditions Section 3.12 Refusal of Unsafe Work Part 8 Personal Protective Equipment Section 115, 116, 117 General Duties of Employers, Supervisors, and Workers Guidelines for Using the COR Audit Tool QUESTION 2.1 Is there a process to analyze jobs, equipment, and conditions for hazards according to risk? Auditor Guideline Review documentation to ensure there is a process / policy for identifying and assessing hazards in the workplace. Employer Guideline Provide a written policy and process for hazard identification and risk assessment that identifies the tasks within all departments, then breaks down the tasks for each hazard and then says how it is going to be controlled. Each risk needs to show that it has been analyzed for frequency of exposure, potential consequences and hazard probability. These three combined provide a risk rating (low-, medium- or high-risk and up to multipoint scales). The controls need to use the order of: 1. eliminating the hazard 2. engineered controls 3. administrative controls 4. PPE. Types of Documentation to Review: Hazard identification and risk assessment process or policy QUESTION 2.2 Is the process to analyze risks outlined in Question 2.1 being followed? Auditor Guideline Review documentation (hazard / risk assessments) to determine if the process for identifying and assessing hazards in the workplace is being followed. Employer Guideline Provide documentation that proper hazard/risk assessment is complete for all positions and tasks, according to the method in question 2.1. The documents sampled need to be internally consistent and logical (i.e., sweeping the floor after hours is lower risk than COR Toolkit: An Employer Guide to COR Certification Page 18 of 71

19 dealing with an argumentative, impaired person). Questions 2.7, 2.8 and 2.13 use some of the sampled risk assessments for further examination. Types of Documentation to Review: Job safety breakdowns, completed assessments Possible Secondary Document Source: Area inspections (with risk assessment) QUESTION 2.3 Is there a process for reporting unsafe conditions? Auditor Guideline Review documentation for a formal or informal process (e.g. unsafe conditions report form or verbal reporting). Employer Guideline The process for reporting unsafe conditions is clearly identified in writing in a policy-handbook form that outlines general rules and specific responsibilities. Types of Documentation to Review Policy on reporting, hazard report form, supervisor journal notes Possible Secondary Document Source Corrective action log, maintenance records QUESTION 2.4 Do Workers report unsafe conditions? Auditor Guideline Interview a representative number of Workers to determine their understanding of the process. Employer Guideline This question aims to verify that workers understand the procedure or policy that guides their actions when reporting an unsafe condition. Do they know what to do? There is no audit requirement for workers to fill out a form unless the company policy directs them to do so. QUESTION 2.5 Do qualified individuals participate in the hazard identification process? Auditor Guideline Review documentation to confirm qualified individuals participate in hazard identification process. Interview Supervisors and Workers to verify qualified individuals participate in the hazard identification process. COR Toolkit: An Employer Guide to COR Certification Page 19 of 71

20 Employer Guideline Employees involved in hazard/risk analysis must have received training in the process. This could be demonstrated by a certificate or some other record of training. Training can be done in house, but proof of completed training is still required. The questions posed to supervisors and workers are intended to show whether the people doing the risk assessments have received training to perform them adequately. Types of Documentation to Review Training records or certificates compared to people listed on Hazard Identification Forms, Possible Secondary Document Source Joint Occupational Health & Safety Committee (JOHSC) minutes QUESTION 2.6 Are the hazard identifications, assessments and controls reviewed regularly? Auditor Guideline Review documentation (hazard identification process / policy) to ensure hazards are reviewed as per the process / policy. Interview a representative number of Supervisors and Managers to determine if the process is reviewed. Employer Guideline This question requires a policy outlining how often risk assessments are reviewed, and proof that the policy has been followed. This can be proven with creation and revision dates on the risk assessments, JOHSC meeting minutes showing a review of the risk assessments, a safety schedule showing when the review is to be done and the resulting changes. To count positively in the audit, documents must be dated within the past two years (or more recently if the company policy requires more frequent review); undated documents count as negative. The interview is looking to verify that the hazards are reviewed at least every two years or when there is a change in processes, equipment or jobs, etc. The interview evidence can still be fully positive even if there is no documentation evidence within this question. Types of Documentation to Review: Policy manual, work area inspections (with risk assessments), job safety breakdowns, job safety analysis, JOHSC minutes, crew safety meeting minutes COR Toolkit: An Employer Guide to COR Certification Page 20 of 71

21 QUESTION 2.7 Are engineering controls identified in the hazard identification process available and being used? Auditor Guideline Observe a representative sample of engineering controls from the hazard identification process and verify they are available and being used or other effective controls are in place. Employer Guideline During the documentation review in question 2.2, auditors are looking at the risk assessments for engineering controls that have been put in place to control a hazard. The list is verified during the observation tour. The auditor should select at least three (preferably more) engineering controls that would reasonably be expected to have something observable (i.e., a railing added to a balcony rather than a wiring change inside a sealed electrical panel). The auditor should focus on significant or large controls where possible. There is no defined timeline for when the control was put in place. For example, railings added around a chair-lift cable wheel a decade ago due to a risk assessment when the lift was installed are still positive findings for a current audit if the railings are still present and in use. QUESTION 2.8 Do Workers work according to safe work procedures and job practices? Auditor Guideline Observe Workers engaged in work activities for which safe work practices and job procedures have been developed. Employer Guideline During the documentation review in question 2.2, auditors are looking at the safe work procedures for specific details, such as the PPE required for a certain job, steps for performing jobs safely, etc. During the observation tour, auditors verify that safe work procedures are being followed. QUESTION 2.9 Does the employer have a method to ensure compliance with the rules, safe work practices, and job procedures? Is it being followed? Auditor Guideline Review documentation for a method to ensure compliance. Interview Managers, Supervisors, and Workers to verify the application of compliance procedures. Employer Guideline This question is looking for a progressive discipline policy. Does the organization have a clear policy that shows what will happen if someone is not compliant with the health COR Toolkit: An Employer Guide to COR Certification Page 21 of 71

22 and safety program, and is the policy documented? Typical steps include coaching or education, verbal and written warnings, suspension and ultimately termination of employment. It is acceptable to have a policy where some offenses are more serious than others and have higher disciplinary penalties. The interview seeks to determine if the discipline policy is used consistently. Interview evidence may still be fully positive even if the documentation is negative, provided all interviewees report a standard uniform method of discipline. Interviewees who are not aware of actual discipline having been needed but have a correct expectation that it would be used if necessary, are considered to have provided positive responses. Types of Documentation to Review: Discipline policy NOTE: Actual records of discipline being applied are confidential human resources documents and are NOT to be included in the audit process or report by internal or external auditors. QUESTION 2.10 Are hazards and controls communicated to Workers? Auditor Guideline Interview a representative number of Workers to determine if they have been made aware of the hazards associated with their position. Employer Guideline This question asks workers to identify hazards that are part of their jobs. What kinds of things could hurt them in the course of their work, and do they know how to protect themselves? The auditor needs to have evaluated the hazard/risk assessment for the job(s) applicable to the interview. QUESTION 2.11 Are Employees who use PPE trained? Auditor Guideline Review documentation to verify formal or informal training. Employer Guideline Auditors are looking for current documentation of training that includes use of and care for PPE. Examples of acceptable documentation are training records, a spreadsheet that tracks training and shows that employees have been trained in the proper use of their protective equipment, or records demonstrating that specific PPE requirements have been reviewed in departmental meetings. While training records are preferred for ease of recall in future years, meeting minutes are equally acceptable for this question. Types of Documentation to Review Training records, training spreadsheets, crew safety meeting documentation COR Toolkit: An Employer Guide to COR Certification Page 22 of 71

23 QUESTION 2.12 Is there a system to ensure Employees wear appropriate PPE? Is it being followed? Auditor Guideline Review documentation to determine if there is a system to ensure Employees wear appropriate PPE. Observe use of PPE during site tour. Employer Guideline This question is looking for a policy or procedure that provides guidance to supervisors, managers and workers on their responsibilities regarding PPE training, usage, supply, maintenance and storage. The observation tour is done to see if workers are following the safe work procedure requirements for PPE for the task they are performing. Safety signage can be part of an effective system but cannot be the whole system. A policy or procedure is still needed to support the signage. Types of Documentation to Review PPE policy or manual, documented observations on use of PPE by supervisors and JOHSC Possible Secondary Documentation Signs, journal notes, inspections, log books, worker observations QUESTION 2.13 Is PPE identified in the hazard identification process available and being properly maintained? Auditor Guideline Observe a representative sample of PPE identified in the hazard identification process and verify it is available and being properly maintained. Employer Guideline On the observation tour, the auditor checks to see whether PPE listed in the safe work procedures is available and in good condition. PPE needs to be clean, dry, sanitary and uncontaminated (at least on the side that the employee touches). If gloves or footwear are designed to be non-slip, the grip or traction should not be worn off. Specialized PPE, such as cartridge respirators, fall protection equipment and some emergency response PPE, must have documentation of the correct maintenance when documentation is required by regulation or company policy. COR Toolkit: An Employer Guide to COR Certification Page 23 of 71

24 Element 3: Safe Work Procedures and Written Instruction Overview Making safe work procedures and practices part of standard operating procedure may seem a matter of common sense, but in fact an effective health and safety program for workers is required by the Occupational Health and Safety Regulation Without a written standard to refer to, whether for bed-making or respirator-wearing, there is no consistent guidance for workers or supervisors. Measurement of these items in the audit will include written safe work procedures, practices and/or instructions including: all routine and non-routine expected operations of the company a Workplace Hazardous Materials Information System (WHMIS) instructions that direct the first aid services, supplies and equipment to be provided and how employees receive that service procedures addressing possible emergencies, training of workers in those procedures, testing their effectiveness, and evaluating and revising the procedures based on drills and actual emergencies. The audit also measures whether the procedures are the right ones for the tasks the workers perform. The procedures need to flow from the risk assessments in the previous element of the audit to ensure that the procedures actually address the hazards of the job. As with other sections, communication and supervision are underlying themes. Workers need to be told the procedures, and supervisors need to coach the workers to help ensure that the work is done to right way the first time, every time. Key Concepts and Implementation Tips In order to meet the above objectives, the audit checks whether: The employer has safe work procedures based on the hazard/risk assessments done at the worksite. Employees participate in the hazard/risk assessment, since they are the ones most affected by the hazards or risk. There is a first aid assessment done for each site that the company operates. The company has appropriate first-aid supplies, equipment, rooms and personnel. There is a procedure for workers to follow when they are injured (or observe an injury) and need first aid. There is a set of emergency-response procedures appropriate to the company s activities and risks. Examples of risk factors include: o blood-borne pathogens, fire, injury, fatality, natural disasters. o workplace violence, working alone, wildlife encounters, crisis management, power failure, major equipment failure, major substance spills, robberies, assaults, bomb threats, car accidents, rescue from remote locations, heights or depths, etc. COR Toolkit: An Employer Guide to COR Certification Page 24 of 71

25 Employees know their roles in the first aid and emergency-response plan, whether they are responders, reporters or bystanders. Emergency drills are held annually to test whether the various response plans actually work for the company. The company has a WHMIS program. Training is documented. SUPPORTING RESOURCES: How to - Safe Work Procedures Sample Hospitality Safe Work Procedures (WorkSafeBC) Hosp_SmBiz/add_res/Online- Sample_Procedures1.pdf Safe Work Procedures (Safe Work Manitoba) /bulletins/bltn249(3).pdf How to First Aid Assessment First Aid Assessment (WorkSafeBC) taid/first_aid_assessment_worksheet.p df How to First Aid Procedures First aid (WorkSafeBC) rstaid/home.asp COR Toolkit: An Employer Guide to COR Certification Page 25 of 71

26 How to Emergency Response Plans Emergency Response Plan (WorkSafeBC) ns/health_and_safety/by_topic/assets/ pdf/emergency_response_guide.pdf How to WHMIS WHMIS (WorkSafeBC) HMIS/Home.asp WHMIS at Work (WorkSafeBC) ns/health_and_safety/by_topic/assets/ pdf/whmis.pdf WHMIS (CCOHS) ention/whmis/ Getting WHMIS Program Started (Saskatchewan Labour) TRAINING OPTIONS: Training - Risk Assessment and Safe work procedures Employers Advisers Office WorkSafeBC database of training providers CCOHS Training First Aid COR Toolkit: An Employer Guide to COR Certification Page 26 of 71

27 WorkSafeBC database of training providers Training WHMIS WorkSafeBC database of training providers CCOHS (online) RELEVANT REGULATION AND LEGISLATION: Occupational Health and Safety Regulation (WorkSafeBC) Workers Compensation Act (BC Gov t) /OHSRegulation/Home.asp /OHSRegulation/WorkersCompensationAct.asp#SectionNumber:Part3Division1 Safe Work Procedures Section 3.3 ( c ) First Aid Sections Emergencies and drills Sections WHMIS Section Reporting injuries Section 172 Guidelines for Using the COR Audit Tool QUESTION 3.1 Have safe work practices and job procedures been written for the identified hazards as required? Auditor Guideline Review a representative sample of documentation (safe work practices / job procedures) and compare to hazard identification and assessment. The percentage cannot exceed the percentage scored in Question 2.2 (i.e. If only 50% of the assessments have been completed in Question 2.2, 50% is the maximum that can be scored) Employer Guideline This question looks at the risk assessments completed for the company to see whether there are corresponding safe work procedures. If only a fraction of the risk assessments have been completed, the number of points available for this question is that the same fraction. Without having a risk assessment, the company has no real way to determine whether the safe work procedure it has developed is actually appropriate for the job. It may be, but it might not be. Types of Documentation to Review Safe work practices/job procedures QUESTION 3.2 COR Toolkit: An Employer Guide to COR Certification Page 27 of 71