Health and Safety Improvement Program (Continuous Self- Assessment) CSA Guidelines October, 2014 Contents 1 Executive Summary... 2 2 More information... 2 3 Context... 2 3.1 Continuous Self-Assessment (CSA) process... 2 3.2 Continuous Self Assessment (CSA) audit tool... 3 3.3 University of Tasmania-wide and Organisational Unit Criteria... 3 3.4 Scoring the Self-Assessment... 4 3.5 Risk Register... 4 3.6 WHS Management Plan... 4 3.7 Timing... 5 3.8 Program management and support... 5 3.9 Verification... 6 3.10 Review and Evaluation... 6 3.11 Responsibility... 6 4 Glossary... 7 5 Versioning... 7 Responsible Officer Executive Officer Human Resources Approved by Executive Officer Human Resources Approved and commenced October, 2014 Review by October, 2017 Responsible Organisational Unit Work Health and Safety Unit (October, 2014) Page 1
1 Executive Summary The objective of the University of Tasmania Health and Safety Improvement Program is to continually test and challenge the University s WHS systems and processes, to identify opportunities for improvement and to lock in agreed actions. The Continuous Self - Assessment (CSA) tool has been developed to help the University assess and improve its WHS management and performance. The program is aligned with the University's business planning cycle, with management plans being implemented and monitored over the ensuing year. This is a continuous improvement cycle and the goal is to move all Organisational Units and the University to a level where all elements are rated as 'permanent or better practice'. As part of the University-wide internal audit strategy administered by Risk Management and Audit Assurance (RMAA), the University has committed to all Organisational Units undertaking the WHS Control Self-Assessment (CSA) annually. 2 More information For further information, contact the Work Health Safety Unit 3 Context Email : health.safety@utas.edu.au The health and safety improvement program supports the University s Open to Talent goals and objectives. 3.1 Continuous Self-Assessment (CSA) process The following steps form the basis of the CSA process: (October, 2014) Page 2
Each Organisational Unit participates through completing an on-line selfassessment. This self-assessment provides a maturity rating (Appendix 1) for each of 11 work health and safety elements and their sub-elements (Appendix 2). Once Assessors have completed this step, the head of the Organisational Unit reviews the assessment report, confirms the ratings, sets the Organisational Unit s priorities and approves a management plan for the next cycle. Heads of Faculties and Divisions review the Organisational Unit assessment reports, management plans and budgets, then prioritise and allocate resources to complete this phase of the improvement cycle. (Appendix 3). Heads of Organisational Units implement the improvement program, monitor management plan completion and review performance in preparation for the next improvement cycle. 3.2 Continuous Self Assessment (CSA) audit tool The Work Health and Safety (WHS) Continuous Self-Assessment (CSA) audit tool has been developed to assist the University in assessing and improving its WHS management controls. The content and structure of the tool gives consideration to AS/NZS 4801, Safe Work Australia Act and Regulations, National Self Insurers OHS Audit Tool, SafetyMap, together with University policies and guidance documents. It also incorporates feedback from interviews held with the executive, members of Organisational Units and University Work Health and Safety. The CSA tool utilises the Deloitte ControlTrack system. The tool is reviewed annually by the WHS Unit, with Deloitte providing an independent assessment to ensure the rigor of the instrument is maintained. 3.3 University-wide and Organisational Unit Criteria Two sets of criteria apply across all the key elements and supporting sub-elements of the CSA tool. The University-wide criteria: (October, 2014) Page 3
measure the University s organisational-wide WHS system development, implementation, compliance and continual improvement; are the responsibility of University -WHS, Human Resources (HR), Senior Management Team (SMT), Commercial Services Development (CSD), RMAA and other University wide entities; are assessed and reviewed by the University WHS Unit; provide the basis for the development of the University -wide CSA report and WHS management plan. The Organisational Unit criteria: measure the Organisational Unit s Work Health Safety systems development, implementation, compliance and continual improvement with reference to the University-wide criteria; are the responsibility of Organisational Unit managers, and staff; are assessed and reviewed by the Organisational Unit; provide the basis for development of the Organisational Unit CSA report and Organisational Unit Work Health Safety management plan. 3.4 Scoring the Self-Assessment The following scoring process applies when completing the self-assessment: all criteria for a particular maturity stage must be satisfied for the sub-element to be assessed at that maturity stage; where any one of the criteria for a particular stage of maturity cannot be satisfied, the assessment on that sub-element will be assessed at the previous maturity stage; where the criteria for Framework stage is applicable, but cannot be met, the maturity assessment rating will be one (1) or unrated ; where the sub-element does not apply to any of the operations of the Organisational Unit, it will be excluded from the assessment and be rated Not Applicable. 3.5 Risk Register Risk Management and Audit (RMAA) require that each Organisational Unit maintain a risk register. These risk registers are administered centrally by RMAA. Work health and safety risks are reviewed by the Organisational Unit during the CSA process. Risk Registers are updated at least annually to ensure they accurately reflect the status of each of the Organisational Unit s WHS risks. 3.6 WHS Management Plan The CSA process requires that each Organisational Unit develop and implement a documented WHS management plan. The WHS management plan: reflects the actions identified through the CSA self-assessment process; (October, 2014) Page 4
may be integrated with other WHS related actions identified elsewhere, for example through workplace inspections, monitoring, hazard reporting and incident investigation; sets objectives and target completion dates, assigns responsibilities and identifies those resources, including human and financial, required for plan completion; is endorsed by the reviewer and the Organisational Unit head. The Organisational Unit WHS management plan is then submitted to the relevant Faculty or Divisional head for review, prioritising, allocation of resources and approval. Following approval and confirmation of resource allocation the Organisational Unit head is responsible for implementing the WHS management plan and for monitoring performance against plan objectives and budget. 3.7 Timing The CSA program (Appendix 4: Plan on a Page) is aligned with the University s academic and business calendars to: maximise flexibility in undertaking the self-assessment, recognising that Organisational Units have differing time and resourcing constraints; co-ordinate with the University s business planning cycle so that WHS resourcing and budgetary issues can be considered within the broader planning process. The timing of the CSA program is: Organisational Unit assessment - mid October to the end of February Organisational Unit review March and April Faculty/Divisional review May 3.8 Program management and support The WHS Unit is responsible for: consulting with RMAA regarding the continuous self-assessment program and its delivery; engaging with key stakeholders to explain the CSA process including its purpose, implementation and improvement opportunities; supporting Organisational Units through the assessment and review stages, including developing and scheduling of assessor training; advising on the review of risk registers and the development of WHS management plans; coordinating external verification and other audits through RMAA and with service provider Deloitte; locally administering the CSA related software (Deloitte ControlTrack); reviewing the program and CSA audit tool in response to changes within the University and to legislation and in response to stakeholder feedback; providing support services and information through a health and safety improvement web page; consulting with key stakeholders to continually improve the CSA process, assessment tools and support services; (October, 2014) Page 5
reporting annually to RMAA (for RAC) and the WHS Committee on Organisational Unit and University-wide performance. 3.9 Verification A verification audit is conducted annually by Deloitte as part of the University-wide internal audit strategy administered by Risk Management and Audit Assurance (RMAA). The verification audit assesses a representative sample of Organisational Units to confirm the accuracy of self-assessment scores and the status of WHS management plans. On completion, Deloitte provide a Work Health and Safety self-assessment verification report which is provided to RMAA for submission to the Risk and Audit Committee (RAC). 3.10 Review and Evaluation The University supports continual improvement in WHS at both the Organisational Unit and University-wide level. The WHS Unit reviews the CSA program annually in consultation with key stakeholders including Organisational Unit assessors and reviewers, RMAA and service provider Deloitte. The purpose is to: identify opportunities for improvement in the CSA program and its delivery, the self-assessment tool and supporting documentation; update the CSA tool and support materials in line with changes to the University, legislative requirements and industry standards. The WHS Unit submits a report to the Work Health and Safety Committee and RMAA. The Work Health and Safety Committee review the report and recommend objectives and targets for the next assessment period to the Senior Management Team. The Senior Management Team set the University s WHS strategic direction and confirm the CSA minimum standard to be achieved by the University and each of its Organisational Units. 3.11 Responsibility Assessor Head of Faculty/Division Complete the CSA self-assessment within program time frames. Participate in the self-assessment review process as required. Undertake auditor/assessor training. Undertake a management review of the Organisational Units CSA reports for the Faculty/Division, including management plans, risk registers. Prioritise management actions, allocate resources and budget. (October, 2014) Page 6
Head of Organisational Unit WHS Unit Reviewer Risk Management and Audit Assurance Assign assessor(s) to undertake the self-assessment process. Review the CSA assessment report and risk register. Develop the Organisational Unit WHS management plan, including resource and budget requirements. Integrate WHS management plan monitoring into the Organisational Unit s routine business reviews. Report management plan status against targets. Administer the delivery of the CSA self-assessment program. Report performance to the Work Health and Safety Committee Manage the assessment and review of the University-WHS section of the CSA program. Review the assessment conducted by the Organisational Unit Assessor Manage the engagement and scope of work of service provider Deloitte. Report continuous self-assessment outcomes to the Audit and Risk Committee (ARC). 4 Glossary Term/Acronym Organisational Unit CSA Deloitte ControlTrack system RMAA RMC Definition Faculty, School, Centre, University Institute, other University Entity, Division, Section or University Business Enterprise. Continuous Self-Assessment audit tool A support tool for internal audit functions which streamlines the process of communication within the organisation and assists in reporting Risk Management and Audit Assurance Risk Management Committee 5 Versioning Current Version Version 1 Health and Safety Improvement Program Guidelines (current document) ; approved October 2014 (October, 2014) Page 7
Appendix 1: Maturity Model The audit tool has been structured in the form of a maturity model across ten key elements and a number of supporting sub-elements. The maturity model considers five stages as detailed below: Maturity level Unrated Framework Implementation Compliance Consolidation The element is not in place The element is in place The element is in operation The element is effective The element is permanent/be tter practice Score 1 2 3 4 5 Stage definition The element is applicable. However, there is no evidence of a documented framework and supporting processes having been developed There is evidence of a documente d framework and supporting processes developed to address the risks identified by UTAS that are associated with the element There is evidence of the documented framework and supporting processes having been implemented There is evidence that personnel comply with requirements of the framework and supporting processes There is evidence that the framework and supporting processes are embedded and are being reviewed to encourage continuous improvement (October, 2014) Page 8
Health and Safety Improvement Program (Continuous Self-Assessment CSA) Guidelines Appendix 2 WHS Elements and Sub-elements 1. Management Responsibility 1.1 Work Health and Safety (WHS) Policy 1.2 Legislative requirements 1.3 Licences and certificates 1.4 Objectives and targets 1.5 WHS management plans 1.6 Responsibility and accountability 1.7 Resourcing 2. WHS training and induction 2.1 Induction for staff 2.2 Student, contractor and volunteer induction and visitor instruction 2.3 Training 2.4 Leadership training 3. WHS consultation and communication 3.1 WHS committees and HSRs 3.2 Team meetings 3.3 Performance reporting 3.4 Escalation of issues 4. WHS records 4.1 Document control 4.2 Records management 5. WHS incident management 5.1 Incident reporting 5.2 Incident investigation 6. WHS risk management 6.1 Risk management 6.2 Hazard and near miss reporting 6.3 Permit to work 6.4 Workplace inspections 6.5 Standard operating procedures (SOPs) and work instructions 6.6 Corrective actions 6.7 Emergency management 6.8 Contractor management 6.9 First aid 6.10 Hazardous chemicals and dangerous goods 6.11 Purchasing 7. UTAS key risk factors 7.1 Psychosocial 7.2 Driving 7.3 Travel and field activity 7.4 Ergonomic & manual handling 7.5 Noise management 7.6 Marine safety (diving and boating) 7.7 Bio-safety and infection control 7.8 Working from home 8. Inspect, test and monitor 8.1 Plant and equipment 8.2 Health surveillance 9. Audit and Management Review of the WHS management system 9.1 Audits 9.2 Management review 10. Health and Wellbeing 10.1 Health and wellbeing (October, 2014) Page 9
Health and Safety Improvement Program (Continuous Self-Assessment CSA) Guidelines Appendix 3: Continuous Self-Assessment Process (October, 2014) Page 10
Appendix 4: Plan on a Page Academic and Business Year Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Semester 1 (25 Feb 30 May) Study & Semester 2 (14 Jul 17 Oct) E ams Semester 3 (1 Jan - 23 Feb) Semester 4 (31 May 13 Business Plans and Budget Prep Study & Exams Semester 5 (18 Oct 31 Dec) Continuous Self Assessment Assessment Assessmen t Review WHS Action planning OU Management Review Faculty Management Review WHS Resourcing/ Budget Assessment UTAS WHS Strategy and Objectives UTAS Risk & Audit Objectives Aligning and Integrating the Continuous Self Assessment with the People, Business and Academic Years and the Business External Verification Open to Talent Goals and objectives The Opportunities: Build flexibility to conduct the CSA within OU business program. Modify the CSA to reflect the forward planning approach Identify and assess OU critical risks in the process Establish role clarity and accountability in the OUs Build relationships and understanding between WHS, Risk and Audit and OUs to deliver an effective business outcome and support role clarity and accountability. Adopt the UTAS Assessor/ auditor training and process to support the CSA Build target setting and action plan progress into the OU s routine business reviews. Org Unit Health Safety Objectives Open to Talent Through the judicious alignment of our people, infrastructure, resources and processes Action Plan: Review the CSA tool and update to reflect the opportunities identified in the previous review, including reference to risk registers. Adjust the assessment, review and verification process to better fit the business cycle, including the budget process. Consult with key stakeholders to explain CSA purpose and process and enhance understanding of OU requirements. Review the UTAS Assessor/ auditor training program for suitability in supporting the broader objectives Consider appropriate targets, and the opportunity to introduce trend reporting. (October, 2014) Page 11