SYSTEM REVIEW AND IMPROVEMENT

5.1 MANAGEMENT SYSTEMS REVIEW PROCESS

5.1.1 Full review

The Universitys executive management ensure that a review of the HSW management system (which includes
Injury Management) is undertaken to determine its continuing suitability and effectiveness.

This review involves:

an examination of the previous Management Systems Review Report findings to determine if outcomes
have been used as a basis for future system development;
a review of the HSW Policy scope, content and supporting processes within the HSW Handbook;
an assessment of the level of achievement against documented objectives, targets and performance
indicators outlined in planning arrangements (e.g. Action Plan, Training Needs Analysis);
a review of findings from internal/external audits and surveys, including the previous WorkCover validation
reports;
a review of legislative changes which impact on our processes;
a review of any changes in the organisational structure of the University which may impact on safety.

Frequency

The review will be conducted at an appropriate time within each third calendar year (as a minimum), but may be
conducted at more frequent intervals if determined by the executive management that the effectiveness of the
current systems are not meeting the needs of the University. (See 5.1.2)

System review format

The format and scope of the review will be determined by Manager, HSW. As a minimum the review must meet
the requirements of Standard 5 of the WorkCover Self-Insurance Performance Standards and this HSW
Handbook chapter. The auditor (internal or external) may use any Legislative, Workcover, Australian Standards
auditing tools/templates to assist in this process (i.e. to provide structure) as agreed.

Who will co-ordinate and conduct the review?

The review will be co-ordinated by the Manager, HSW. This may involve an independent auditor.

Who will take part in the review?

The review will be completed in consultation with relevant stakeholders. This may include employees, title
holders, volunteers, students, visitors or third parties engaged by the University (e.g. contractors) and/or a staff
member of a controlled entity. Consultation may be achieved through scheduled meetings and/or email advice
and/or any other communication which enables review and feedback.

Findings and recommendations

The findings and recommendations from the review will be presented to the Director (Human Resources) and
tabled at the University Health and Safety Committee by the Manager HSW for consideration and action where
agreed.

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SYSTEM REVIEW AND IMPROVEMENT

5.1 MANAGEMENT SYSTEMS REVIEW (Continued)

5.1.2 Adhoc/interim system reviews

Where the Manager, HSW identifies:

a gap in the Universitys system or program or inter-dependant programs; or
an emerging incident/injury trend
then an adhoc/interim system review may be conducted. (i.e. Before the full review.)
The adhoc/interim review will:
analyse the level of achievement of documented objectives, targets and performance indicators to promote
continuous improvement; and
be identified or added into the Universitys HSW Action Plan.

The findings and recommendations from the adhoc reviews will be tabled at the UHSC on completion.
The reports will be provided to the internal/external auditor conducting the 3 yearly review and findings,
recommendations and actions taken will be included in the full review report where applicable.
The adhoc/interim systems review is to be recorded using the template in Appendix B or where appropriate a
paper to the UHSC stating the reasons for needing the Interim review.
The matrix in Appendix C will be used to identify which HSW programs may require review.

5.1.3 Reporting Monitoring and evaluation of the HSW Management Systems Performance
The following HSW reports are collated as indicated in consultation with a number of committees and
personnel.
(Please also refer to Appendix A. The flowchart depicts the HSW information which is monitored and the flow
of information from the School/Branch level to the Universitys Executive/Senior management/Health and Safety
Committees and the University Council.)

5.1.4 Corrective Actions/continuous improvement activities

When endorsed by the UHSC all actions arising from Systems reviews will be entered into RMSS ensuring that
the timeframes are determined using the Corrective Actions Information Sheet Determining timeframes for
HSW Strategy Actions contained in the HSW Operations manual. Completion of actions will be monitored via
the RMSS Action report.

Note Interim/short term corrective actions pending the formal HSW Handbook chapter review
Where the UHSC accept the recommendations from an adhoc/interim system review and short term measures
are required to ensure Legislative compliance or reflect current work practices, then the Manager HSW will
authorise the interim arrangements to be implemented. The changes will be noted on the relevant HSW
Handbook chapter web page under Roles, Responsibilities and Actions. The recommendations will then be
incorporated in the next chapter review.

Authorised by Manager, HSW _________Original signed_____________________________ 19 October 2012

NG AND EVALUATION OF THE HSW MANAGEMENT SYSTEMS PERFORMANCE
REPORTING MONITORING AND EVALUATION OF THE HSW MANAGEMENT SYSTEMS PERFORMANCE

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 REPORTING MONITORING AND EVALUATION OF THE HSW MANAGEMENT SYSTEMS PERFORMANCE

Report type Report format Frequency Responsibility

University http://www.adelaide.edu.au/governance/word_templates/ https://www.adelaide.edu.au/governance/council/ Vice-President (Services
Council Generally includes: and Resources)
Key HSW achievements (milestones) mapped against the Universitys Strategic Statutes of the University. Chapter 2.1(a).
Plan (e.g. Healthy University strategies) No less than eight occasions in any calendar year.
Intervals not greater than 3 months.

Vice-Chancellors http://www.adelaide.edu.au/governance/word_templates/
Report Generally includes:
Major incidents (i.e. Notifiables, Dangerous Occurrences) Usually monthly, but not prescribed. Director, HR
(VCAC) HSW Strategic activities on the HSW Agenda or conducted since last report (in consultation with the
(e.g. WorkCover updates, major changes to Legislation) Manager, HSW)
Reports required as part of the HSW Handbook including:
Annual HSW Consolidated Audit Report (4.1)
Full review of the HSW Management System (5.1) and
Adhoc/interim reviews as determined by the Manager, HSW

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 REPORTING MONITORING AND EVALUATION OF THE HSW MANAGEMENT SYSTEMS PERFORMANCE (Continued)

Report type Report format Frequency Responsibility

Audit, http://www.adelaide.edu.au/governance/word_templates/ At least 4 times per year unless otherwise determined by Director, HR
Compliance and Generally includes standard reports on: the Chair or as directed by the Council. (in consultation with the
Risk Committee Key events and incidents (i.e. Notifiables, Dangerous Occurrences) and action http://www.adelaide.edu.au/governance/council/committe Manager, HSW)
Report taken to prevent a recurrence. es/audit_committee/
Performance indicators (Graphs, short analysis/synopsis)
Injury and near miss trends
Lost time injury frequency rate graph (LTIFR)
Lost time (LTI, days, average time lost)
Workers compensation claims
Workers compensation claims breakdown by event
Workers compensation costs
Workers compensation claims liability
Key HSW Strategic activities on the agenda/conducted since last report. (Note
check items reported through VCC applicable to this committee.)

UHSC HSW Key findings from the Performance Report Quarterly March, June, September and December. Manager, HSW
Managers (i.e. incident/injury trends) http://www.adelaide.edu.au/hr/ohs/committees/
Performance 3 highest mechanisms of injury and Div/Fac
Report 3 highest nature of injury and Div/Fac (Completed reports are included in the UHSC minutes)
3 highest agency of injury
3 highest events leading to workers compensation claims
3 highest events leading to lost time
UHSC Consolidated Report
Any unresolved issues requiring resolution/consultation buy the UHSC
Traffic Light report (emerging issues, trends)
Corrective actions report (summary of activity)
Developments and initiatives (highlights)
Key events and incidents (e.g. summary of any Notifiables, major incidents since
last UHSC)
WorkCover (key dates, activities)
Other items of interest or impact

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 REPORTING MONITORING AND EVALUATION OF THE HSW MANAGEMENT SYSTEMS PERFORMANCE (Continued)

Report type Report format Frequency Responsibility

Division/Faculty Unresolved HSW and Injury management issues requiring resolution/consultation Quarterly Executive Dean/Vice
Consolidated with the UHSC Template for the Div/Fac Consolidated report is available President/Deputy Vice
HSW report Corrective Actions Report at Chancellor in consultation
2 Issues of highest safety concerns at the time of the report http://www.adelaide.edu.au/hr/ohs/committees/ with the Division/Faculty
Details of HSW News, development, proactive initiatives undertaken since last HSW Committee Secretary
UHSC
Workplace inspections (trends)
School/Branch Traffic Light Reports against defined criteria.

UHSC Consolidation of Div/Fac reports as indicated above. Quarterly UHSC Secretary

Consolidated Div/Fac Performance tracking (%) charts and graphs Template for the Div/Fac Consolidated report is available
HSW report at http://www.adelaide.edu.au/hr/ohs/committees/
Completed report is available in the UHSC minutes.

UHSC Status Traffic light report Quarterly Senior HSW Consultant

against the HSW (Policy and Liaison)
Action Plan(s) Completed report is available in the UHSC minutes.

Schedule of Division/Faculty/School/Branch Traffic light report Quarterly Executive Dean/Vice

Programmable President/Deputy Vice
Events (Completed reports are available in the Div/Fac/School/Branch Health and Safety Chancellor in consultation
Committee minutes.) with the Division/Faculty
and HSW Committee

Training Needs School/Branch HSW

Analysis Committees (or equivalent)
or Head of School/Branch

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 REPORTING MONITORING AND EVALUATION OF THE HSW MANAGEMENT SYSTEMS PERFORMANCE

Report type Report format Frequency Responsibility

Corrective Actions arising from internal audits, external audits, As per the time-frames specified on the Registered Health and Safety Committees
Actions workplace inspections, risk assessments, exercises RMSS Action report or database.
entered into RMSS; or Head of School/Branch in consultation with the person responsible
Other authorised databases for the action.
(e.g. Maintenance Service Job Requests) where there
is a system for recording, assigning of actions,
monitoring, follow-up and completion within
designated time-frames.

Accident, Incident, Near miss reports Data is entered in RMSS within 5 working Registered Health and Safety Committees, HSW Team
days from the date of the incident, and in Heads of School/Branch
the case of Field trips, within 5 days of Health and Safety Officers
return to the University. Health and Safety Reps
Escalations are automatically generated via
RMSS to personnel responsible or involved
in follow-up/corrective action. (i.e. Heads of
School/Branch, HSOs, HSRs, HSW Team.)

Injury Injury Management Register (database) Quarterly Manager, HSW

Management Work and Non-work related injuries/illnesses reported Senior HSW Consultant (Policy and Liaison)
(Work and non to the relevant Heads of School/Branch or Executive. HSW Specialist (IM and Wellbeing)
work related
illness and injury)

Open Claims Weekly Manager HSW, Senior HSW Consultant (Policy and Liaison),
HSW Specialist (Injury Management and Wellbeing)
Claims Manager
For complex claims or where there are also issues around
employment legislation (e.g. Industrial Relations):
Director, HR; and
Vice-President (Services and Resources) and/or
Executive Deans/Heads of School/Branch where required.

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 Reporting Monitoring and Evaluation of the HSW Management system APPENDIX A
University Division/Faculty
University Health and UHSC Convenor reports
University Council Audit, Compliance and Safety Committee, to the VC&P
Report on the University Risk Committee Quarterly meetings, Senior Exec plus staff
Strategic Plan representatives

Unresolved HSW issues requiring

Vice Chancellors Audit, Compliance and Consolidated HSW report Faculty/Division University UHSC Committee
Committee (VCC) Risk Committee, HSW Report Status against Corporate Action Executives sign off Actions against CAR
Plan 2 Highest safety concerns for each
Manager HSW Performance Fac/Div
report HSW news and Developments
Statistics (Incident, claims), Traffic Light reports
trends Workplace Insecptions
HSW Report Director Human Resources UHSC reporting template Risk Management
(Division/Faculty Reports (Quarterly) TNA and SPE review

School/Branch Division/Faculty Other Boards and

Consolidated Traffic Light HSW Committees Committees
Manager, HSW and Report by each
HSW Team

School/Branch HSW report authorised Unresolved HSW issues requiring

HSW by the Head of School/Branch University UHSC Committee
Management HSW Div/Fac Managers Actions against CAR
System Monitor/verify Traffic Light reports 2 Highest safety concerns for each
and report on activities Fac/Div
1. Policy University HSW and IM Plan HSW news and Developments
2. Planning Schedule of Programmable Events Traffic Light reports
3. Implementation Training Needs Analysis Training Plan Workplace Insecptions
4. Monitoring and Corrective Action Register Risk Management
Review Traffic Light reports (report on selected TNA and SPE review
5. Management activities within the HSW Handbook)
Systems review

Branch/School Health and Safety Committees (If no

Heads of School/Branch,
RMSS committee Head of School/Branch)
HSO & HSRs
Accident, Incident, Near Miss
Internal Audits
Traffic Light Report Training Needs Analysis
Risk assessments
External Audit Reports Inspections
Enter RMSS (via Manager, HSW) Reports to Management
as Corrective Actions Corrective Actions Register Schedule of Programmable
Events

Legend = Monitoring forums, personnel = HSW Reports, documents, tools used to collate HSW information

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 Appendix B
MANAGEMENT SYSTEMS REVIEW
(Standard 5 WorkCover Performance Standards)

Name of Process/System Date

Review undertaken by Name: Position

Element 1: Policy
Ref Criteria Objective Evidence/Findings Compliance
1.1 The scope and content Enter if Compliant (C)
of the process has been
reviewed in or
consultation with Non-Compliant (C)
employees (or their
representatives) to
ensure continued
suitability and
effectiveness.

Effectiveness

Recommendations

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Element 2: Objectives, targets and performance indicators

Ref Criteria Objective Evidence/Findings Compliance

2.1.1 The level of Objectives (e.g. as outlined in the HSW Handbook process, Action Plans, University objectives)
achievement against
documented objectives
has been analysed.

Effectiveness

Recommendations

2.1.2 The level of Performance Indicators and targets (if applicable) (e.g. as outlined in the HSW Handbook process or other monitoring criteria)
achievement against
documented targets and
performance indicators
has been analysed.

Effectiveness

Recommendations

2.2 The organisation must

ensure results are
analysed and used to
determine areas of
success and areas
requiring corrective and
preventive action.

Effectiveness

Recommendations

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Element 3: System review

Ref Criteria Objective Evidence/Findings Compliance

3.1 The organisation must
ensure the system is
reviewed and revised if
required, in line with
current legislation, the
workplace and work
practices.

Effectiveness

Recommendations

3.2 The organisation must

ensure the systems
measurement outcomes
are used as a basis for
future system
development.

Effectiveness

Recommendations

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 Appendix C (Page 1 of 2)
MANAGEMENT SYSTEMS REVIEW
(Standard 5 WorkCover Performance Standards)

The Manager, HSW will review the following criteria once in each calendar year to determine if any adhoc/interim systems reviews are to be conducted. Report/Review date / /
The template will be populated on an ongoing basis by the Senior HSW Consultants (i.e. Operations and Policy & Liaison).
An X indicates an area of concern. The number of adhoc/interim systems reviews will be based on the number of identified areas of concern and/or the severity of the risk to the University.
The recommendations will be tabled at the UHSC by the Manager, HSW as part of the Performance Report. The completed reviews will be saved electronically in Section 5.1 of the HSW Handbook.

Policy/Process Significant Identified as an Identified as a Traffic light Notifiable Incident Issue/trend Adhoc feedback provided
HSW Programs due for review legislative emerging issue contributing report, low has been reported identified during by HSW Managers, HSOs
changes will or trend during factor in performance last calendar year the Internal Audit other stakeholders
impact on this incident Workers trend last and a gap in the process last that a HSW program is
program/ investigations or Comp last calendar year system/process was calendar year not effective in its current
process data calendar year a contributing factor format.
1 Policy
1.1 HSW Policy 1/12/13
Planning
2.1 HSW Action Planning 30/6/13
2.2 Schedule of Programmable Events 11/2/13
2.3 HSW Training Needs Analysis and Training Plan 11/2/13
2.4 Corrective Actions 11/2/13
3 Implementation of HSW Activities & Hazard Management
3.1 HSW Training 11/2/13
3.2 Induction 11/2/13
3.3 Travel Safety 11/2/13
3.4 Emergency Management 11/2/13
3.5 Hazard Management 11/2/13
3.6 Workplace Inspections 11/2/13
3.7 Plant/Equipment Safety Management 9/8/13
3.8 First Aid 4/7/14
3.9 Drugs and Alcohol 11/2/13
3.10 Boating Operations 31/12/14
3.11 Diving (Under Development) NBA
3.12 Field Work 11/2/13
3.13 Smoke Free University 9/2/15
3.14 Biological Safety Management 9/8/13
3.15 Children on Campus 11/2/13
3.16 Confined Spaces 16/4/15
3.17 Work at Heights and Prevention of Falls 31/12/14
3.18 Hot Work (Heat or Spark Producing Activities) 18/11/14

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 Appendix C (Page 2 of 2)
MANAGEMENT SYSTEMS REVIEW
(Standard 5 WorkCover Performance Standards)

HSW Programs Policy/Process Significant Identified as Identified as a Traffic light report, Notifiable Incident Issue/trend Adhoc feedback
due for review legislative an emerging contributing low performance has been reported identified during provided by HSW
changes will issue or trend factor in trend last last calendar year the Internal Audit Managers, HSOs
impact on this during Workers Comp calendar year and a gap in the process last other stakeholders
program/ incident last calendar system/process was calendar year that a HSW
process investigations year a contributing factor program is not
or data effective in its
current format.
3.18 Hot Work (Heat or Spark Producing Activities) 18/11/14
3.19 Chemical Safety Management 11/2/13
3.20 Basic Laboratory and Workshop Safety 30/8/13
3.21 Contractor Safety Management 11/2/13
3.22 Events Safety Management 19/3/15
3.23 Asbestos Management 11/2/13
3.24 Higher Degree by Research Safety Management Plan 11/2/13
3.25 Personal Protective Equipment 15/7/13
3.26 Temperature Extremes in your Working Environment 11/2/13
3.27 Injury Management (Work Related Injuries/Illness) 11/2/13
3.28 Student Placement 31/12/14
3.29 Incident, Near Miss Reporting and Investigation 11/2/13
3.30 Radiation Safety Management 31/12/14
3.31 Infectious and Communicable Diseases 11/2/13
3.32 Manual Handling (includes Ergonomics) 11/2/13
3.33 Working Hours and Reducing Fatigue 21/10/14
4 Measurement and Evaluation
4.1 Internal Audit 11/2/13
5 System Review and Improvement
5.1 Management System Review 31/7/15
5.2 HSW Policy Review 4/4/15
5.3 Document Control 24/12/12
5.4 Culture and Climate 28/5/15
5.5 Monitoring Performance Exec Engagement 28/5/15
5.6 Travel Safety Exec Engagement 28/5/15

Based on the above findings, the HSW team recommends that Interim systems reviews be conducted on the following HSW Programs

1___________________________________________________ 2.____________________________________________________ 3.____________________________________________________

Endorsed by the Manager, HSW _____________________________________________

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