- Governing Policy
- WHS Section of Organisational Unit Plans
4.1 Top Five, WHS Risks
4.2 Developing the WHS Section of the Organisational Unit Plan
4.3 Minimum Requirements within Organisational Unit Plans
- University WHSMS Planning Processes that Inform the WHS Action Plan
5.1 Bi-Annual Assessments and Reviews
- ACU WHS Action Plan
6.1 Defining WHS Objectives and Targets
6.2 WHS Action Plan
- Ongoing Performance Monitoring of the Framework and WHS Action Plan
7.1 Traffic Light Reporting
7.2 Continuous Improvements in WHSMS
- 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 the working and learning activities the University manages and influences.
This ACU Planning Framework and the WHSMS Planning Procedure are enablers of annual and bi-annual processes for reviewing the Work Health and Safety Management System (WHSMS or framework) and developing the WHS Action Plan that specifies WHS objectives, targets and initiatives which will support the University to achieve these performance measures. This plan also includes a listing of actions which organisational units should action to ensure that the WHSMS is applied to the working and learning activities, which they manage and influence.
These planning and review processes support the University to continuously improve its capacity to maintain working and learning spaces and strengthen its framework. They also support work areas to implement and continuously improve the application of the WHSMS within their working and learning activities.
This procedure is aligned with ACU’s Planning Framework, the University’s Mission, Vision and Values, and International Standard ISO 45001: Occupational health and safety management systems – Requirements with guidance for use, and other requirements.
The WHS section of Organisational Unit Plans should be developed in the first quarter of each year and should be monitored and reviewed for progress, at least every six months, by organisational units.
The WHS section of the plan supports organisational units to implement and embed the University’s WHSMS within their working and learning areas (which they manage or influence). It also informs WHS objectives and targets, and associated actions which are published in the University’s WHS Action Plan (Refer to Section 6).
These organisational units are also required to:
- Identify a minimum of the Top Five WHS risks that impact upon their organisational unit (See 4.1, below); and
- Implement other minimum requirements that are pre-populated into the template for annual Organisational Unit Plans (4.3).
A minimum of the Top Five WHS risks, which impact upon organisational units, can be identified by:
- Analysing summary riskware reports of hazards, near misses, incidents and injuries;
- Performing a Gap Analysis - assessing whether the organisational unit’s working and learning activities (which it manages or influences) is reflective of the scope of the risks that impact upon an organisational unit and/or their stakeholders;
- Reviewing published information and resources about hazards and risks, and establishedtreatments for managing these risks - associated with specific types of working andlearning environments;
- Addressing health and safety concerns/expectations of staff and significant stakeholders;
- Analysing health and air monitoring results;
- Annual reviews of risk registers; and
- Conducting WHS Inspections and external audits.
These WHS risks will be physical and/or psychological and may have the potential to harm the environment and property. These WHS risks and the associated treatments should be entered into organisational unit risk registers by the end of Quarter 1, each year.
Organisational units should submit a Service Central request if they require support to access summary riskware reports.
4.2.1 Content Developed by Human Resources
The content to be pre-populated within the WHS Section of Organisational Unit Plans will be developed by the Human Resources. These minimum requirements will be developed annually and reviewed, and endorsed by the Senior Executive, including the WHS Management Committee.
This content will be submitted to OPSM by mid-October, each year, and will inform the template for Organisational Unit Plans that is published in the fourth quarter.
4.2.2 OPSM Integrates these Requirements into the Template for the Plans
These and other minimum requirements will be pre-populated within the WHS Section of the template for Organisational Unit Plans by the Office of Projects and Strategic Management (OPSM), by late October, each year. OPSM staff will also modify the Risk Register template, on an ongoing basis, to reflect current and future requirements for the inclusion of a minimum number of WHS risks within these registers.
The following requirements (listed below), will be pre-populated within the WHS Section of Organisational Unit Plans from October 2019, and ongoing requirements, will be informed by bi-annual planning and review processes:
- Significant hazards and WHS risks are identified and treated, and reassessed when there are changes in the working or learning environment, or incident reports expose gaps in compliance or the effectiveness of treatments;
- A minimum of the Top Five WHS risks that are impacting on an organisational unit should be placed on organisational units’ risk registers in Quarter 1, each year;
- Opportunities for improvement should be identified – these improvements may be informed by non-conformances, WHS Inspections, Job Safety Analysis, completing WHS inspections and ergonomic checklists;
- Ensuring that hazards, near misses, incidents and injuries are logged in riskware within 24 hours and these reports are investigated, and treatments that manage these WHS risks are documented within relevant riskware Action Plans;
- WHS should be one of the agenda items for team meetings;
- Nominated Supervisors provide local WHS inductions and refreshers to staff, students, other supporting staff and others to understand how they contribute to the WHSMS;
- WHS competencies are part of the annual Performance Review and Planning process and are listed within Position Descriptions;
- WHS training records should also be uploaded to Service Central requests, so they can be uploaded on to staff records;
- Staff receive appropriate training to apply safe operating procedures and identify, and manage hazards and risks;
- Health and air monitoring will be conducted, when it is required; and
- Organisational units will consult with Health and Safety Representatives (HSR), staff, students, contractors and others about WHS issues.
The Senior Executive/Executive may assign responsibility to a designated staff member to collate documentary evidence that their organisational unit has actioned these requirements. This documentation should inform the annual declaration that should be made by organisational units, during Quarter One, which states that these requirements and the WHSMS has been applied to their working and learning activities. These records may also be requested during internal audits of the University’s WHSMS.
The Senior Executive and Executive, including the WHS Management Committee, will also conduct bi-annual planning processes and reviews of the WHSMS and will monitor the effectiveness of the framework (see 5.1.3) more frequently.
Human Resources will support the University’s Senior Executive and Executive, including the WHS Management Committee, to conduct these bi-annual planning and review processes which are aligned with the ACU Planning Framework.
This inaugural bi-annual planning that was scheduled to commence at the start of Quarter 3, 2019, will include the following assessments and determinations:
- The University’s context (see 5.1.1), including the external and internal issues that could impact upon the WHSMS, significant stakeholders and their expectations – including needs that will inform the framework; and the scope of the WHSMS;
- The identification and review of WHS risks and opportunities (5.1.2) for improving the WHSMS; and
- WHSMS performance, including an assessment of the suitability, adequateness and effectiveness of the framework (see 5.1.3 for more information) for managing WHS risks and governance.
These identification and review processes will inform the development of measurable WHS objectives and targets and the WHS Action Plan that is enabled by the ACU Planning Framework.
Note: The University’s Strategic Plan 2015 to 2020, includes a commitment to continually improving and implementing effective governance and management practices to deliver high quality outcomes.
5.1.1 Assessing the University’s Context
The University will consider the external and internal issues that are relevant to its mission, values and mission and that impact upon its ability to maintain and continuously improve its WHSMS, including the achievement of WHS objectives and targets.
Table 1: Examples of external and internal issues that may impact upon the WHSMS:
Cultural, social, political (including government funding), legal, financial, technological, economic and nature surroundings, market completion within the higher education sector.
Governance, organisational structure, roles and accountabilities.
New competitors within the higher education sector, contractors, subcontractors, suppliers, partners and providers, new technologies, legal changes and new occupations.
Changes to the Enterprise Bargaining Agreement (EBA) and associated working conditions.
Key drivers and changes in the higher education sector.
The University’s culture.
New knowledge about products that impacts upon health and safety, and treatments.
The form and scope of contractual arrangements, including outsourced activities.
Other interested parties , in addition to staff, which are relevant to the WHSMS will also be identified. Their expectations and needs should be assessed, and decisions will be made about which of these needs will help shape the compliance requirements of the WHSMS. Some needs and expectations are mandatory e.g. prescribed in laws, regulations and associated Codes of Practice.
The University will define the boundaries of its WHSMS, including the scope of compliance, and which aspects of its operations and activities (managed and influenced) the framework will apply to.
The scope of the boundaries of the WHSMS should be broad enough to include those activities and services that will impact upon WHS performance and the University’s compliance with legal and other requirements. It should not exclude activities or services that have or can impact upon ACU’s WHS performance or compliance with legal or other requirements.
5.1.2 Assessing WHS Risks and Opportunities
The review of the University’s significant risks will be informed by:
- An assessment of whether there are gaps in the identification of the University’s risks i.e. after comparing the scope of the University’s working and learningactivities (which it manages and influences) with previously identified risks;
- AHEIA benchmarking performance, including Lost Time Injuries;
- Reviews of published information and resources about hazards and risks that areassociated with the working and learning activities the University manages or influences;
- Specific concerns and needs/expectations of staff and other significantstakeholders;
- The results of any health and air monitoring activities;
- The results of internal audits and WHS inspections;
- Changes in working and learning activities;
- Review of risk registers; and
- A review of riskware reports.
The University will also assess opportunities to improve WHS performance and the framework. This review will consider opportunities to adapt work, work organisation and the work environment to staff, options for eliminating hazards and reducing risks, and other opportunities which will strengthen the WHSMS.
Examples of opportunities for improving WHS performance:
- Ensuring WHS inspections and internal audits of the WHSMS are conducted;
- Ensuring WHS issues are considered prior to relocating facilities and during the design of new processes and capital projects;
- Raising the profile of Senior Executive’s support for/leadership of the WHSMS;
- Job hazard analysis (job safety analysis) and task related assessments;
- Incident and non-conformity investigations that inform corrective actions; and
- Ergonomic and other injury prevention-related assessments.
Human Resources will also support the Senior Executive and Executive Staff, including the WHS Management Committee, to conduct a bi-annual review of the suitability, adequacy and effectiveness of the WHSMS, which will inform future improvement actions.
Table 2: Questions – Informing an Assessment of the framework’s suitability, adequacy and effectiveness:
Does the WHSMS fit the University and its operations? Is it culturally aligned and integrated with business systems and enabling frameworks?
Is the WHSMS implemented appropriately?
Is it achieving the intended outcomes? e.g. (1) Is it supporting ACU to identify and manage its most significant risks; and (2) Does the WHSMS strengthen governance?
The following factors will also be considered during this initial review in 2019 and in subsequent bi-annual reviews:
- The status of actions from previous reviews;
- An initial assessment/reviews of changes in the internal and external issues (See 5.1.1) that are relevant to the WHSMS such as the needs and expectations of interested parties, legal and other requirements, and risks and opportunities;
- Changes in identified WHS risks, including those WHS risk which impact upon ACU’s capabilities to achieve its intended outcomes for the framework, and opportunities;
- The extent to which the WHS&W Policy and WHS objectives and targets have been met;
- WHS Performance;
- Including trends in incidents and hazards, non-conformities, corrective actions and continual improvement;
- Monitoring and measuring results;
- Results of the evaluation of compliance with legal and other requirements (see Section 6);
- Audit results;
- Consultation and participation of staff, students, and others;
- Risks and opportunities;
- Adequacy of resources for maintaining an effective WHSMS;
- Relevant communications with interested parties; and
- Opportunities for continual improvement.
The University will develop bi-annual WHS objectives and targets and an associated WHS Action Plan that will be informed by the planning activities that are outlined in this procedure and the ongoing measurement evaluation (refer to the WHSMS Performance Measurement and Evaluation Procedure) and monitoring (Section 7). These performance measures and plans will facilitate continuous improvements in WHS performance and the WHSMS.
A minimum of three WHS objectives and three targets will be developed for the 2020 to 2021 WHS Action Plan and the number of performance measures, and these objectives and targets, will be reviewed and updated every two years.
The WHS objectives and targets:
- Will be aligned with the WHS&W Policy;
- Are measurable and informed by SMART Principles ;
- Will include Lead and Lag Indicators;
- Are informed by applicable requirements, assessments of risks and opportunities, and consultations with staff and their representatives;
- Influenced by the performance reviews and planning for the WHSMS;
- Monitored on a six-monthly basis by Human Resources and OPSM; and
- Will be communicated to all Senior Executives, staff of the University and their representatives, such as local WHS Committees, the ACU Staff Consultative Committee and HSR.
These performance measures may also be informed by the Commonwealth Government’s Work Health and Safety Strategy 2012 – 2022, which prioritises reducing musculoskeletal disorders, mental health conditions, noise induced hearing loss and other conditions.
These WHS objectives and targets will be developed by the Senior Executive and Executive Staff, including the WHS Management Committee. The Audit and Risk Committee will also be engaged about these performance measures and will be endorsed by the Vice Chancellor and President by mid-October every two years.
The WHS Action Plan will be developed every two years. Human Resources will support the Senior Executive and Executive Staff, including the WHS Management Committee, to ensure that it is:
- Be informed by the bi-annual review of WHS and WHSMS performance;
- Include actions to realise the WHS targets and objectives (Ref to 6.1), which are integrated into the University’s business processes and frameworks;
- Align with the ACU Planning Framework;
- Be appropriately resourced to help ensure the WHS objectives and targets are achieved;
- Assign responsibility for actions and deadlines;
- Include a communications and engagement section;
- Define what/how aspects of the University’s WHS performance will be measured, monitored and evaluated; and
- Outline how the Senior Executive will communicate with organisational units and staff about their role in contributing to the success of the plan and the WHSMS.
The University will implement and maintain processes for monitoring, measuring, analysing and evaluating the performance of the WHSMS. The following performance measures will be evaluated each year, and any deficiencies will be help inform any revisions or bi-annual updates to the University’s WHS Action Plan and corrective action logs.
Table 2: Performance Monitoring of the Framework and WHS Action Plan
Gaps and Deficiencies will be Addressed, by:
How compliant is the University with legal, including Codes of Practice, and other requirements?
Have relevant hazards and associated risks, which are associated with its operations and activities been identified and managed?
Human Resource, in collaboration with Properties and Facilities, and other organisational units.
Audit and Risk Committee will also assess these risks during their annual review of organizational-unit risk registers
Is the University on track to achieve its WHS targets and objectives?
Human Resources, in collaboration with OPSM.
How effective are the University’s operational controls, including procedures?
Human Resources, in collaboration with Properties and Facilities and other work areas. The WHS Management Committee and Audit and Risk Committee will also be engaged with this review.
Human Resources and/or Properties and Facilities will action any gaps that are identified.
Human Resources, in consultation with the WHS Management Committee and OPSM, will develop more detailed criteria and publish the criteria for assessing, monitoring and analysing the performance of the WHSMS. This performance monitoring process and the bi-annual planning processes will help shape the WHS Action Plan.
Internal audits also provide some insight into the University’s performance against these criteria, gaps in compliance and opportunities for improvement.
The University’s progress toward achieving the WHS objectives and targets, which inform the WHS Action Plan and Organisational Unit Plans, will be reviewed by Human Resources staff who will provide performance data for each organisational unit and reported to the relevant Senior Executive Member. Qualitative data may also be provided as part of the WHS Action Plan 2020-2021 Traffic Light Reporting processes.
The performance monitoring and review processes will support the University to continuously improve the suitability, adequacy and effectiveness of the WHSMS by ensuring that reviews of the WHSMS inform the WHS Action Plan and associated WHS sections of Organisational Unit Plans to facilitate some of these performance improvements.
The University will also:
- Develop Senior Executive communications that promote the benefits of contributing to the WHSMS;
- Promote the benefits to staff and staff representatives, such as WHS Committees and HSR, of implementing actions that facilitate continuous improvement of the WHSMS; and
- Maintain documentation, in alignment with the requirements of the Records; and Document Control Procedure, which provide evidence of the continual 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.
|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
- Work Health and Safety, and Wellbeing (WHS&W) Policy
- WHS Risk Management Procedure
- WHS Risk Assessment Form
- WHS Risk Assessment Form for Practical Activities/Research
- WHS Communication and Consultation Procedure
- ISO 45001 – Occupational Health and Management System
- AS/NZS 4801 – Occupational Health and Management System
- ACU Strategic Plan
Page last updated: 2020-02-19
Short url: https://policies.acu.edu.au/2340348