health and safety improvement program

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Health and Safety Improvement Program (Continuous Self-Assessment) – CSA Guidelines

Health and Safety Improvement Program (Continuous Self-

Assessment) – CSA Guidelines

October, 2014

Contents

1 Executive Summary .................................................................................................... 22 More information ......................................................................................................... 23 Context ....................................................................................................................... 23.1 Continuous Self-Assessment (CSA) process .............................................................. 23.2 Continuous Self – Assessment (CSA) audit tool ........................................................ 33.3 University of Tasmania-wide and Organisational Unit Criteria ..................................... 33.4 Scoring the Self-Assessment ...................................................................................... 4

3 5 Risk Register 4


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3 5 Risk Register 4


1 Executive Summary

The objective of the University of Tasmania Health and Safety Improvement Programis to continually test and challenge the University’s WHS systems and processes, toidentify opportunities for improvement and to lock in agreed actions.

The Continuous Self - Assessment (CSA) tool has been developed to help theUniversity assess and improve its WHS management and performance.

The program is aligned with the University's business planning cycle, withmanagement plans being implemented and monitored over the ensuing year.

This is a continuous improvement cycle and the goal is to move all OrganisationalUnits and the University to a level where all elements are rated as 'permanent or betterpractice'.

As part of the University-wide internal audit strategy administered by RiskManagement and Audit Assurance (RMAA), the University has committed to allOrganisational Units undertaking the WHS Control Self-Assessment (CSA) annually.

2 More information

For further information, contact the Work Health Safety Unit

Email : [email protected]

3 Context

The health and safety improvement program supports the University’s Open to Talent

goals and objectives

mailto:[email protected]:[email protected]:[email protected]:[email protected]


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• Each Organisational Unit participates through completing an on-line self-assessment. This self-assessment provides a maturity rating (Appendix 1) for

each of 11 work health and safety elements and their sub-elements (Appendix2).

• Once Assessors have completed this step, the head of the Organisational Unitreviews the assessment report, confirms the ratings, sets the OrganisationalUnit’s priorities and approves a management plan for the next cycle.

• Heads of Faculties and Divisions review the Organisational Unit assessmentreports, management plans and budgets, then prioritise and allocate resourcesto complete this phase of the improvement cycle. (Appendix 3).

• Heads of Organisational Units implement the improvement program, monitormanagement plan completion and review performance in preparation for thenext improvement cycle.


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• measure the University’s organisational-wide WHS system development,implementation, compliance and continual improvement;

• are the responsibility of University -WHS, Human Resources (HR), SeniorManagement Team (SMT), Commercial Services Development (CSD), RMAAand 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 andWHS management plan.

The Organisational Unit criteria:

• measure the Organisational Unit’s Work Health Safety systems development,implementation, compliance and continual improvement with reference to theUniversity-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 andOrganisational 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-elementto be assessed at that maturity stage;

• where any one of the criteria for a particular stage of maturity cannot besatisfied, the assessment on that sub-element will be assessed at the previous

maturity stage;


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• may be integrated with other WHS related actions identified elsewhere, forexample 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 plancompletion;

• is endorsed by the reviewer and the Organisational Unit head.

The Organisational Unit WHS management plan is then submitted to the relevantFaculty or Divisional head for review, prioritising, allocation of resources and approval.

Following approval and confirmation of resource allocation the Organisational Unithead is responsible for implementing the WHS management plan and for monitoringperformance against plan objectives and budget.

3.7 Timing

The CSA program (Appendix 4: Plan on a Page) is aligned with the University’sacademic and business calendars to:

• maximise flexibility in undertaking the self-assessment, recognising thatOrganisational Units have differing time and resourcing constraints;

• co-ordinate with the University’s business planning cycle so that WHSresourcing and budgetary issues can be considered within the broader planningprocess.

The timing of the CSA program is:

Organisational Unit assessment mid October to the end of February


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• reporting annually to RMAA (for RAC) and the WHS Committee onOrganisational Unit and University-wide performance.

3.9 Verification

A verification audit is conducted annually by Deloitte as part of the University-wideinternal audit strategy administered by Risk Management and Audit Assurance(RMAA).

The verification audit assesses a representative sample of Organisational Units toconfirm the accuracy of self-assessment scores and the status of WHS management

plans.

On completion, Deloitte provide a Work Health and Safety self-assessment verificationreport 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 keystakeholders including Organisational Unit assessors and reviewers, RMAA andservice provider Deloitte.

The purpose is to:

• identify opportunities for improvement in the CSA program and its delivery, the

self assessment tool and supporting documentation;


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Head ofOrganisational Unit

Assign assessor(s) to undertake the self-assessmentprocess.

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 theOrganisational Unit’s routine business reviews.Report management plan status against targets.

WHS Unit Administer the delivery of the CSA self-assessmentprogram.

Report performance to the Work Health and SafetyCommitteeManage the assessment and review of the University-WHSsection of the CSA program.

Reviewer Review the assessment conducted by the OrganisationalUnit Assessor

Risk Managementand Audit

Assurance

Manage the engagement and scope of work of serviceprovider – Deloitte.

Report continuous self-assessment outcomes to the Auditand Risk Committee (ARC).

4 Glossary

Term/Acronym Definition

OrganisationalUnit

Faculty, School, Centre, University Institute, other UniversityEntity, Division, Section or University Business Enterprise.

CSA C ti S lf A t dit t l


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Appendix 1: Maturity Model

The audit tool has been structured in the form of a maturity model across ten key elementsand a number of supporting sub-elements.

The maturity model considers five stages as detailed below:

Maturitylevel

Unrated Framework Implementation Compliance Consolidation

‘The elementis not inplace’

‘Theelement isin place’

‘The element isin operation’

‘The elementis effective’

‘The elementispermanent/better practice’

Score 1 2 3 4 5

Stagedefinition

The element isapplicable.However,there is noevidence of adocumented

framework andsupportingprocesseshaving beendeveloped

There isevidence ofadocumentedframework

andsupportingprocessesdevelopedto addressthe risksidentified byUTAS that

There is evidenceof thedocumentedframework andsupportingprocesses having

beenimplemented

There isevidence thatpersonnelcomply withrequirementsof the

framework andsupportingprocesses

There isevidence thatthe frameworkand supportingprocesses areembedded and

are beingreviewed toencouragecontinuousimprovement


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Health and Safety Improvement Program (Continuous Self-Assessment – CSA) Guidelines

Appendix 2 WHS Elements and Sub-elements

1. Management Responsib ili ty

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 induct ion

2.1 Induction for staff

2.2 Student, contractor and volunteerinduction and visitor instruction

2.3 Training

2.4 Leadership training

3. WHS consul tation andcommunication

3.1 WHS committees and HSRs

3.2 Team meetings

3 3 P f ti

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 anddangerous 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 W ki f h


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Health and Safety Improvement Program (Continuous Self-Assessment – CSA) Guidelines

Health and Safety Improvement Program (Continuous Self-Assessment) – CSA Guidelines (October, 2014) Page 10

Appendix 3: Con tinuous Self-Assessmen t Process


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Health and Safety Improvement Program (Continuous Self-Assessment) – CSA Guidelines (October, 2014) Page 11

Appendi x 4: Plan on a PageJan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Academicand

BusinessYear

ContinuousSelf

Assessment

The Opportunities:

• Build flexibility to conduct the CSA within OU businessprogram.

• 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, Riskand Audit and OUs to deliver an effective businessoutcome and support role clarity and accountability.

• Adopt the UTAS Assessor/ auditor training and process tosupport the CSA

• Build target setting and action plan progress into the OU’sroutine business reviews.

Acti on Pl an:

• Review the CSA tool and update to reflect theopportunities identified in the previous review, includingreference to risk registers.

• Adjust the assessment, review and verification process tobetter fit the business cycle, including the budget process.

• Consult with key stakeholders to explain CSA purposeand process and enhance understanding of OUrequirements.

• Review the UTAS Assessor/ auditor training program forsuitability in supporting the “broader objectives”

• Consider appropriate targets, and the opportunity tointroduce trend reporting.

Semester 1 (25 Feb – 30 May) Semester 2 (14 Jul – 17 Oct)

Business Plans and Budget Prep

Study &

Semester 3 (1 Jan - 23 Feb) Semester 4 (31 May – 13

Assessment

Study &

Semester 5 (18 Oct – 31 Dec)

Assessment Assessmen

t Review

OUManagement

Review

FacultyManagement

Review

WHS Action planning WHS Resourcing/B ud et

Ali gn ing and In tegr atin g the Con tinuo us Sel f Assessment wi ththe People, Business and Academic Years and the Bu siness

UTAS Risk & AuditObjectives

Org UnitHealth SafetyObjectives

UTAS WHSStrategy and

Objectives

Open to Talent

Goals andobjectives

External Verification

Open to Talent Through the judicious

alignment of ourpeople,

infrastructure,resources and

health and safety improvement program

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