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

Health and Safety Improvement Program (Continuous SelfAssessment) CSA Guidelines

October, 2014

Contents
1
2
3
3.1
3.2
3.3
3.4
3.5
3.6
3.7
3.8
3.9
3.10
3.11
4
5

Executive Summary .................................................................................................... 2

More information ......................................................................................................... 2
Context ....................................................................................................................... 2
Continuous Self-Assessment (CSA) process .............................................................. 2
Continuous Self Assessment (CSA) audit tool ........................................................ 3
University of Tasmania-wide and Organisational Unit Criteria..................................... 3
Scoring the Self-Assessment ...................................................................................... 4
Risk Register .............................................................................................................. 4
WHS Management Plan ............................................................................................. 4
Timing......................................................................................................................... 5
Program management and support ............................................................................ 5
Verification .................................................................................................................. 6
Review and Evaluation ............................................................................................... 6
Responsibility ............................................................................................................. 6
Glossary ..................................................................................................................... 7
Versioning .................................................................................................................. 7

Responsible Officer
Approved by
Approved and commenced
Review by
Responsible Organisational Unit

Executive Officer Human Resources

Executive Officer Human Resources
October, 2014
October, 2017
Work Health and Safety Unit

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

(October, 2014)
Page 1

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

Executive Summary
The objective of the University of Tasmania Health and Safety Improvement Program
is to continually test and challenge the Universitys 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.

More information
For further information, contact the Work Health Safety Unit
Email : health.safety@utas.edu.au

Context
The health and safety improvement program supports the Universitys Open to Talent
goals and objectives.

3.1

Continuous Self-Assessment (CSA) process

The following steps form the basis of the CSA process:

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

(October, 2014)
Page 2

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

3.2

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
Units 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.

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:

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

(October, 2014)
Page 3

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

measure the Universitys 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:

3.4

measure the Organisational Units 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.

Scoring the Self-Assessment

The following scoring process applies when completing the self-assessment:

3.5

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.

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 Units 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;

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

(October, 2014)
Page 4

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

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 Universitys
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 Universitys 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:

3.8

Organisational Unit assessment - mid October to the end of February

Organisational Unit review March and April
Faculty/Divisional review May

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;

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

(October, 2014)
Page 5

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

3.9

reporting annually to RMAA (for RAC) and the WHS Committee on

Organisational Unit and University-wide performance.

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 Universitys 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.

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

(October, 2014)
Page 6

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

Head of
Organisational Unit

WHS Unit

Reviewer
Risk Management
and Audit
Assurance
4

Glossary
Term/Acronym
Organisational
Unit
CSA
Deloitte
ControlTrack
system
RMAA
RMC

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 Units 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).

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

Versioning
Current
Version

Version 1

Health and Safety Improvement Program Guidelines (current

document) ; approved October 2014

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

(October, 2014)
Page 7

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

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

Score

Stage
definition

Unrated
The element
is not in
place

Framework
The
element is
in place

Implementation
The element is
in operation

Compliance
The element
is effective

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

Consolidation
The element
is
permanent/be
tter practice
5

There is
evidence that
the framework
and supporting
processes are
embedded and
are being
reviewed to
encourage
continuous
improvement

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

(October, 2014)
Page 8

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

Appendix 2 WHS

Elements and Sub-elements

1.

Management Responsibility

6.3

Permit to work

1.1

Work Health and Safety (WHS)

Policy

6.4

Workplace inspections

6.5

1.2

Legislative requirements

Standard operating procedures

(SOPs) and work instructions

1.3

Licences and certificates

6.6

Corrective actions

1.4

Objectives and targets

6.7

Emergency management

1.5

WHS management plans

6.8

Contractor management

1.6

Responsibility and accountability

6.9

First aid

1.7

Resourcing

6.10

2.

WHS training and induction

Hazardous chemicals and

dangerous goods

2.1

Induction for staff

6.11

Purchasing

2.2

Student, contractor and volunteer

induction and visitor instruction

7.

UTAS key risk factors

7.1

Psychosocial

2.3

Training

7.2

Driving

2.4

Leadership training

7.3

Travel and field activity

3.

WHS consultation and

communication

7.4

Ergonomic & manual handling

7.5

Noise management

3.1

WHS committees and HSRs

7.6

Marine safety (diving and boating)

3.2

Team meetings

7.7

Bio-safety and infection control

3.3

Performance reporting

7.8

Working from home

3.4

Escalation of issues

8.

Inspect, test and monitor

4.

WHS records

8.1

Plant and equipment

4.1

Document control

8.2

Health surveillance

4.2

Records management

9.

5.

WHS incident management

Audit and Management Review

of the WHS management system

5.1

Incident reporting

9.1

Audits

5.2

Incident investigation

9.2

Management review

6.

WHS risk management

10.

Health and Wellbeing

6.1

Risk management

10.1

Health and wellbeing

6.2

Hazard and near miss reporting

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

(October, 2014)
Page 9

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

Appendix 3: Continuous Self-Assessment Process

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

Page 10

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

Appendix 4: Plan on a Page

Jan

Feb

Mar

Apr

May

Academic
and
Business
Year

Continuous
Self
Assessment

Jun
Study &
E ams

Semester 1 (25 Feb 30 May)

Semester 3 (1 Jan - 23 Feb)

Jul

Oct

Nov

Dec

Study &
Exams
Semester 5 (18 Oct 31 Dec)

Business Plans and Budget Prep

Assessment

Assessmen
t Review

OU
Management
Review

WHS Action planning

Faculty
Management
Review

Assessment

WHS Resourcing/
Budget

External Verification
Open to Talent

UTAS Risk &

Audit
Objectives

Org Unit
Health Safety
Objectives

Sep

Semester 4 (31 May 13

Aligning and Integrating the Continuous Self Assessment with

the People, Business and Academic Years and the Business
UTAS WHS
Strategy and
Objectives

Aug

Semester 2 (14 Jul 17 Oct)

Goals and
objectives

Open to Talent
Through the
judicious
alignment of our
people,
infrastructure,
resources and
processes

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 OUs
routine business reviews.

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.

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

Page 11