- Governing Policy
- Context of the University
- Leadership and Staff Participation
5.1 Leadership and Commitment
5.2 Work Health and Safety, and Wellbeing Policy
5.3 Organisational Roles, Responsibilities and Authorities
5.4 Consultation and Participation of Staff and Others
6.1 Hazard Identification and Assessment of Risks and Opportunities
6.2 Assessing WHS Opportunities
6.3 Determining Legal and Other Requirements
6.4 Planning Action
7.3 Awareness and Communications
7.4 Documented Information
8.1 Operation Planning and Control
8.2 Eliminating Hazards and Reducing WHS Risks
8.3 Managing Change
8.7 Emergency Preparedness and Responses
- Performance Evaluation
9.2 Internal Audit
9.3 Management Review
- Improving the WHSMS
10.1 Incident, Non-Conformity and Treatments (Corrective Actions)
10.2 Continual Improvement
- Revisions made to this Procedure
- Further Assistance
This procedure is governed by the Work Health and Safety, and Wellbeing (WHS&W) Policy.
This procedure applies to all staff, staff representatives, students, visitors, volunteers and contractors, and all of the working and learning activities which the University manages and influences.
The University is committed to implementing and continuously improving its Work Health and Safety Management System (WHSMS or framework) and the management of WHS risks that are associated with the working and learning activities it manages and influences.
ACU prioritise aligning its WHSMS with its existing frameworks, processes, and relevant legal and other requirements.
This procedure was developed to provide guidance to staff and others about the core elements of the University’s WHSMS, which are aligned with International Standard ISO 45001. The WHSMS Implementation Procedures also describes the University’s processes for maintaining and continuously improving the framework to facilitate reductions in WHS risks and strengthening of WHS governance.
The inaugural assessment of the University’s context was scheduled for late 2019 and will be reviewed as part of a bi-annual review of its WHSMS.During this assessment process, Human Resources staff will support the University’s Senior Executive and Executive, including the WHS Management Committee, to determine the external issues and internal factors that are relevant to its mission, values and vision and impact upon its capabilities to implement, maintain and continuously improve its WHSMS.
The WHSMS Planning Procedure also specifies that that these factors will be assessed:
- The key internal and external stakeholders influenced by ACU’s WHSMS and their expectations;
- The scope of the WHSMS e.g. expectations of significant stakeholders that will inform WHSMS; and
- Compliance and the range of University activities the framework will apply to.
The University implements and maintains its WHSMS in compliance with relevant standards, including ASNZ 4801 and ISO 45001, and its legal and other requirements.
The WHSMS Roles and Responsibilities Procedure outlines that the Senior Executive andExecutive staff demonstrate safety leadership, are committed to ‘zero harm’, and are accountable for preventing working and learning, related injuries and illnesses and maintaining safe working and learning spaces by ensuring that significant WHS risks are identified and managed.They also engage Nominated Supervisors and Managers about the benefits of promoting consulting with the ACU community about contributing to the WHSMS.
They also demonstrate safety commitment by:
- Ensuring WHS objectives and targets are developed and achieved, and these performance measures and the WHSMS are aligned with business processes;
- Developing, leading and promoting the WHSMS by motivating and communicating with staff and others about reporting and resolving hazards, near misses, incidents and injuries, and contributing to WHSMS improvement opportunities and to the management of WHS risk;
- Allocating adequate resources to facilitate continuous improvements to the WHSMS; and
- Ensuring local WHS Committees and other consultative forums are effective.
The University’s Work Health and Safety, and Wellbeing (WHS&W) Policy is reviewed annually and informs the University’s priorities for implementing and continuously improving its WHSMS, and managing WHS risk and governance obligations. The policy also communicates ACU’s commitment to zero harm, achieving its WHS objectives and targets and continuously improving its WHSMS.
The WHSMS Roles and Responsibilities Procedure and staff Position Descriptions communicate many of the WHS responsibilities that are assigned to staff members, including their role in contributing to the WHSMS and achieving WHS objectives and targets.
The following WHSMS documents define roles and responsibilities for specialist WHS positions that are mainly performed by staff members:
WHS Specialist Roles
Guidance is Provided by
First Aid Officer
First Aid Procedure
WHSMS Roles and Responsibilities Procedure
WHS Committee Members and Health and Safety Representatives (HSR)
WHS Committee Procedure
The Senior Executive have overall responsibility and authority for the WHSMS and have assigned operational responsibility for the WHSMS to the Director, Human Resources. The Director, Properties and Facilities has also been assigned responsibility for many aspects of the framework, including emergency management and contractor management.
Staff, staff representatives, students, visitors, volunteers and contractors are responsible for their own and other people’s safety, and confidently apply WHSMS processes and procedures. Staff and students should also report hazards, near misses, and injuries within riskware, and visitors, volunteers and contractors engage staff members to log reports on their behalf.
Staff and others also participate or facilitate WHS risk management and emergency management processes, including conducting formal WHS risk assessments and documenting treatments within riskware Action Plans. Staff members participate or facilitate improvement opportunities such as conducting a Job Safety Analysis, WHS Inspections and completing the WHS Workstation Ergonomics Checklist. Refer to the WHS Risk Management Procedure for more information.
The University engages staff members, students, staff and student representatives – such as WHS Committees and Health and Safety Representatives (HSR), visitors, volunteers and contractors about contributing to the success of the WHSMS and the management of WHS risk.
The WHS&W Policy and WHS Communication and Consultation Procedure reinforces the University prioritised two-way communications and consultations about its WHSMS, performance measures, WHS risk assessments, relevant proposed changes and other issues. ACU also prioritises giving staff, students and contractors significant notice about WHS information so that informed feedback is received and help inform the WHSMS.
The WHS Risk Management Procedure specifies that every work area is required to identify and manage the significant risks that are associated with the working and learning activities they manage and influence.
The University publishes or subscribes to the following WHS assessment and management tools, to support work areas to conduct formal WHS risk assessments, which informs many of the treatments (controls), including Safe Work Method Statements/safe work instructions, which are selected to manage WHS risk. These treatments should be developed in collaboration with subject matter experts, impacted staff members and others, including contractors.
WHS Risk Assessment and Management Tools
WHS Risk Assessment Form
Assessing hazards and associated risks, which inform the development of treatments for managing the safety of working and learning activities.
Job Safety Analysis Form
Assessing hazards and associated risks that are associated with specific tasks. These assessments inform the development of treatments.
WHS Risk Management Module, Chemwatch
Assessing Hazards and associated risks, which inform the development of treatments to manage specific, hazardous chemicals.
Safe Work Method Statement (Appendix B)
Developing instructions that support staff, students and others to perform a process safely.
Work areas are required to identify opportunities for improvement by conducting regular WHS Inspections, performing job safety analysis, completing ergonomic checklists, identifying gaps in compliance and so on.
A minimum of the top five WHS risks, which impact each work area, should be placed on organisational risk registers by the end of the first quarter, each year, and these WHS risks inform some of the planning actions within the WHS section of Organisational Unit Plans. The Risk Management Procedure and WHS Risk Management Procedure specify that risk registers should include information about the likely impacts of risks, causes, risk rating and the treatment strategies that are used to manage and minimise these identified risks.
The University’s risk register is informed by the Audit and Risk Committee’s determinations about which risks impact upon the whole University.
The University has established and implements a process, which is outlined in the WHSMS Planning Procedure, to assess University wide opportunities to enhance the WHSMS, WHS performance, eliminate hazards and reduce risks, including WHS governance.
The University publishes a WHS Register of Compliance Obligations that supports staff to easily access compliance resources and comply with the legal and other requirements that are associated with the University’s most significant hazards and associated risks, working and learning activities and its WHSMS. The register is reviewed for currency by the Human Resource Employment Relations and Safety staff in January and July, each year.
The WHS Action Plan will communicate ACU’s WHS objectives and targets and include actions for realising these performance measures, improving emergency responses and mandatory requirements for Organisational Unit Plans. These compliance requirements will support organisational units to implement the WHSMS within working and learning spaces and contribute to the realisation of the WHS objectives and targets.
6.4.1 WHS Action Plan
The WHS Action Plan outlines the University’s WHS focus over the next two years and includes a minimum of three WHS objectives and three WHS targets (measurable). These performance measures will be informed by hazard and incident trends, risk profiles of Faculties, organisational units, contractors and suppliers.
The plan also:
- Includes actions that will support organisational units to realise the WHS objectives and targets;
- Specifies that opportunities for improvement should be identified;
- Informs the WHS section of organisational unit plans;
- Includes actions, which are aligned with existing business processes and the WHSMS, which will support the University to achieve its WHS objectives andtargets;
- Includes mandatory requirements that must be implemented by organisationalunits to ensure that the WHSMS is implemented within their work areas;
- Contributes to continuous improvements in the WHSMS; and
- Incorporates actions that will support ACU to respond to emergencies.
The University’s progress in achieving its WHS targets and achievements is monitored through the University’s Traffic Light Report (for the WHS Action Plan) that is managed by OPSM.
6.4.2 WHS Section of Organisational Unit Plans
The WHS sections of organisational unit plans will be pre-populated, each year,with actions that will support organisational units to implement the WHSMS within working and learning areas and realise the University’s WHS objectives and targets. These plans are also informed by the identification of a minimum of the Top Five organisational unit WHS risks and the treatments that are developed to manage these threats.
The University identifies and allocates financial and physical resources, during its annual budget planning process, to facilitate continuous improvements in its WHSMS. These resources are allocated to Human Resources, Properties and Facilities, and other organisational units.Resource allocations, which are assigned for implementing and continuously improving the WHSMS, are reviewed during the bi-annual review of the WHSMS.
The WHS Training and Development Procedure, which was scheduled for release in late 2019, was informed by the Capability Development Framework (CDF), and associated processes for developing Performance Review Plans. The procedure and the CDF support staff members, including Nominated Supervisors and Managers, to identify and develop the necessary competencies of staff to contribute to the implementation and continuous improvements of the WHSMS and perform specialist WHS roles such as First Aid Officers and Health and Safety Representatives (HSR).
The identification of core WHS competencies, within position descriptions, also support the University to identify and recruit staff that have the competencies to contribute to the implementation of the WHSMS, consultation processes and manage WHS risk.
Staff and their representatives are informed of the University’s WHS&W Policy and WHS objectives and targets. They are briefed about their role in contributing to the WHSMS and improving safety performance. The WHSMS Roles and Responsibilities Procedure also provides guidance to staff about how they contribute to the framework.
They are also made aware of:
- The risks to health and safety of not complying with the WHSMS;
- Incidents and outcomes of investigations that are relevant to them;
- How they contribute to the WHSMS and safety leadership;
- Hazards, WHS risks and opportunities, and treatments that impact upon them; and
- The need to remove themselves from working situations that present an imminent danger.
The WHS Communication and Consultation Procedure helps inform the University’s decision making about what is communicated, the timing of this engagement and the target audience.
These and other mediums are used to communicate with internal stakeholders:
- WHS Website, including Quarterly WHS Reports;
- On-line and face to face WHS inductions;
- Online and face to face contractor WHS inductions;
- Contacting HR by visiting Service Central;
- WHS Committee Minutes; and
- Safety signage.
The University should consider the diverse range ofcommunication needs of staff members, and internal and external interested parties e.g. gender, language, culture and literacy. Documented evidence of these communications should be retained and provided during audits.
7.3.1 External Communications
The University communicates relevant information, about the WHSMS, to external audiences via the ACU website and other mediums.
The University retains documentation, in alignment with AS NZS 4801 and ISO 45001, and maintains others documents crucial to its WHSMS. The different types of records are listed within the University’s WHSMS Records Registers and the records maintained by organisational units should be listed within their register (informed by the University’s register).
Whenever documents are created and updated:
- These documents should comply with the naming convention, outlined in the WHSMS Records and Document Management Procedure e.g. titles should be unique, meaningfuland consistent;
- The format is appropriate (e.g. software version, graphics) and medium (hard copy, digital);
- They should be reviewed for suitability and adequacy, and authorised;
- They should be maintained for the periods that are specified within the WHSMS Records; and Register (Appendix A: WHSMS Records and Document Management Procedure).
TheWHS Records and Document Management Procedure provides more detailed information about the processes for controlling, maintaining and protecting records.
The WHSMS Planning Procedure describes how the University undertakes planning and implements and controls the processes associated with its WHSMS.
The University has implemented and maintains processes, which are documented in the WHS Risk Management Procedure, for eliminating hazards and reducing WHS risks. The treatments that are selected to manage risks are informed by the Hierarchy of Controls (treatments). Significant WHS are placed on organisational unit and University’s risk registers.
These policies and procedures also support staff to manage specific types of risks:
- Alcohol and Other Drugs
- ACU Tobacco Free Policy
- Chemical Management Procedure
- Children of Staff and Students on University Premises
- Driver Safety
- Fieldwork Safety
- Laboratory Safety Guidelines
- Injury and Rehabilitation Policy
- Pandemic Diseases
- Workplace Ergonomics
The WHS Risk Management Procedure and the Incident and Hazard Reporting, Investigations and Corrective Actions Procedure specify that hazards and associated risks should be reassessed whenever planned temporary or permanent changes may impact upon the management of risk.
Triggers for these reassessments:
- Changes to the University’s services and processes or the introduction of new systemsand processes;
- Changes to compliance obligations;
- New knowledge or information about hazards and WHS risks, including incident reports;
- Developments in knowledge and technology.
The consequences of these intended changes are assessed, and treatments should be developed to mitigate any adverse effects.Refer to the WHSMS Planning Procedure for more information.
The University has established, implemented and maintains processes for integrating WHS considerations into the purchase of goods and services, and prioritises the selection of suppliers that maintain Health Safety and Environment Management Systems (HSEMS) and are committed to continuously improving their HSEMS and the management of WHS risk.
These requirements are outlined in the WHSMS Procurement Procedure and are informed by:
- Minimum Requirements for Suppliers of Goods and Services (Sections A.6, A.7, A.11, D.4); and
- Minimum Requirements for Sourcing within ACU.
The University coordinates its procurement processes with its contractors so that relevanthazards and associated WHS risks, which are associated with its maintenance and construction projects, are assessed and controlled.
The University is committed to ensuring that contractors comply with the requirements of the WHSMS and environmental and safety considerations inform the selection of contractors as they are required to address the University’s Four Pillars of Success criteria during formal tender processes.For examples, contractors provide information about their governance processes, safety performance and whether they have a certified Health Safety and Environmental Management System.
Maintenance contractors, performing higher risk activities, are also required to submit Safe Work Method Statements to Facilities Management staff for review, prior to commencing work. Project Managers are assigned to new capital projects who oversee the WHS performance and incident reporting processes.
The University aligns outsourced functions and processes with its WHSMS. Outsourced arrangements should be compliant with legal requirements and other requirements, including safety management system standards and Minimum Requirements for Sourcing within ACU.
The University implements and maintains a process for preparing and responding to emergency situations, including critical incidents and first aid requests.
Some of the activities that prepare staff, students and others for emergencies, include:
- The provision of six-monthly training sessions for building and floor wardens;
- Holding annual evacuation drills;
- Evaluating emergency responses, including evacuation drills;
- Scheduling critical incident debriefings to capture learnings;
- Conducting WHS risk assessments to inform how organisational units and theUniversity’s respond to an emergency/reduce the risk that emergencies will occur;
- Placing emergency equipment and spill kits in laboratories; and
- Briefing staff about their responsibilities in an emergency.
The University communicates and provides information to relevant staff about their emergency response roles, and provides relevant information to its tenants, contractors, volunteers, visitors, emergency services, government authorities and the local community.
ACU considers the needs and capabilities of all relevant stakeholders, such as building tenants and managers, and relevant staff should engage themabout these people about the development and execution of planned emergency responses.
More detailed processes and requirements are outlined in the policies and procedures:
- Emergency Management Manuals for each building;
- In Case of an Emergency poster;
- ACU Critical Incident Management Policy;
- Reporting incidents in riskware;
- First Aid Policy;
- First Aid Procedure;
- Chemical Management Procedure; and
- Laboratory Safety Guidelines.
The Critical Incident Management Procedure was also scheduled to be released by late 2019.
The WHSMS Planning Procedure and WHSMS Performance Measurement, Evaluation and Reporting Procedure outlines the University’s processes for monitoring, measurement, analysing,evaluating and reporting on the performance of the framework.
The components of the WHSMS that are monitored and measured, include these and other requirements:
- An annual review of compliance, conducted by Human Resources, with legal and other requirements;
- The measurement of a range of lag indicators, including Lost Time Injuries and workers compensation costs which are benchmarked across the University sector;
- Lead (proactive) performance indicators that measure those activities ACU initiates to reduce the risk of injuries and illnesses;
- Health and Air Monitoring requirements, which are outlined in the WMSMS Health and Air Monitoring Procedure;
- A review of the effectiveness of the University operational controls, including its procedures;
- An annual review to ensure that the University has identified the significant hazards, risks and opportunities that are associated with working and learning spaces and activities the University influences;
- An assessment of the risks that impact upon the University’s capabilities to achieve the intended outcomes for its WHSMS; and
- Progress toward achieving WHS objectives and targets.
The University conducts internal audits at planned intervals to assess whether the WHSMS conforms to internal requirements, including the WHS&W Policy and WHS objectives and targets.The WHSMS Auditing Procedure outlines that these audits will also assess whether the WHSMS is effectively implemented and maintained by organisational units and contractors. These audits will also identify gaps in compliance and WHSMS opportunities for improvement.
The WHSMS Planning Procedures specifies that the Senior Executive and Executive, including the WHS Management Committee, will conduct a bi-annual management review of:
- The status of actions from previous reviews;
- Assessments and reviews of the context of the University;
- Changes in internal and external issues which will impact upon the WHSMS;
- Significant stakeholders and their expectations, including which of their needs will help inform the WHSMS;
- The scope of the WHSMS;
- The extent to which WHS Policy and targets and objectives have been met;
- WHS performance data;
- WHS risks, including the risks that could impact upon the University’s intended outcomes for the WHSMS, and opportunities;
- The adequacy of resources for maintaining an effective WHSMS;
- A review of the suitability, adequacy and effectiveness of the WHSMS;
- The effectiveness of communications and consultations with interested stakeholders, including staff; and
- Opportunities for continuously improving the WHSMS.
The results of the review, including any recommendations for improvement, will be documented and communicated to staff and their representatives and will help inform the WHS Strategy Plan and the WHS Section of Organisational Unit Plans.
Opportunities for improving the WHSMS will be identified during annual and bi-annual reviews of the WHSMS. The framework will also be strengthened by organisational units identifying improvement opportunities; identifying and implementing corrective actions, actioning non-conformances and other actions.
The Incident and Hazard Reporting, Investigation and Corrective Actions Procedure describes the process for investigating hazards, near misses, incidents and injuries; developing treatments and reporting on actions that were taken to manage incidents, which should be documented within riskware Action Plans. Non-conformities are also actioned and reported on.
Whenever an incident and non-conformity occurs, organisational units should take timely actions to control and manage this issue and identify any contributing factors. Relevant Nominated Supervisors and Managers should evaluate the relevant risk with staff and others and consult about any proposed corrective actions.
Human Resources staff will assess whether similar incidents or non-conformities are occurring on a broader scale across the University and facilitate actions to manage these risks. The logging of riskware reports can also trigger reviews of existing assessments of risks, the application of treatments and changes to the WHSMS.
The treatments, which are selected to manage reports of hazards, near misses, injuries and hazards (logged in riskware), are assigned a risk rating (to determine their effectiveness) and documented within riskware Action Plans. Actions taken to address WHSMS non-conformities should also be documented, within riskware Action Plans (logged as reports of hazards), by organisational units. Staff and their representatives, including WHS Committees, HSR and the ACU Consultative Committee, are updated about the actions that are taken to manage the risks identified by incident and hazard reports, audits and other non-conformities.
The WHSMS Planning Procedure outlines how the University also continuously improves the WHSMS by:
- Determining the suitability, adequacy and effectiveness of the WHSMS during bi-annual reviews;
- Enhancing the safety of working and learning spaces, and the activities which the University influences;
- Promoting a culture that supports a robust WHSMS;
- Engaging staff about implementing actions that will lead to continuous improvements in the WHSMS;
- Informing staff about improvements to the framework; and
- Documenting these continuous improvements.
Major, Minor or Editorial
The University may make changes to this procedure from time to time to improve its effectiveness. If any staff member wishes to make any comments about this procedure, they should forward their suggestions to Human Resources.
Any staff member who requires assistance in understanding this procedure should first consult their Nominated Supervisor or Manager who is responsible for applying the University’s WHSMS within their work area. Should further information or advice be required staff should visit Service Central.
- WHSMS Implementation Procedure (Policy, PDF File, 310.2 KB)
|Policy applies to||
All Staff And Students
|Policy Status||New Policy|
|Approval Authority||Vice-Chancellor And President|
|Governing Authority||Chief Operating Officer|
|Responsible Officer||Director, Human Resources|
|Date of Last Revision||20/01/2020|
|Effective Date of Last Revision||20/01/2020|
* Unless otherwise indicated, this policy will still apply beyond the review date.
Related Policies, Procedures, Guidelines and Local Protocols
- Model Work Health and Safety Act/Regulation
- Occupational Health and Safety Act/Regulation (VIC)
- Work Health and Safety, and Wellbeing (WHS&W) Policy
- WHS Risk Management Procedure
- WHS Risk Assessment Form
- Incident and Hazard Reporting, Investigations and Corrective Actions Procedure
- WHS Communication and Consultation Procedure
- ISO 45001: Occupational health and management system – Requirements with guidance for use
- AS/NZS 4801: Occupational health and safety management systems – specification with guidance for use
- ACU Planning Framework
- Capability Development Framework
Page last updated: 2020-02-19
Short url: https://policies.acu.edu.au/2340336