• Section 1 - Governing Policy
• Section 2 - Scope
• Section 3 - Purpose of Audit Program
• Section 4 - Audit Program
• Section 5 - Self-Assessments to be Completed by Organisational Units
• Completing the WHSMS Self-Assessment Checklist
• Maintaining the Currency of the WHSMS Self-Assessment
• Engaging in WHSMS Improvement Opportunities
• Section 6 - Audit Competency
• Section 7 - The Audit Cycle
• Defining the Scope of Audits
• Audit Opening Meeting
• Conducting Internal Audits
• Audit Debrief
• WHSMS Audit Report
• Corrective Actions/Non-Conformances
• Section 8 - Revisions made to this Procedure
• Section 9 - Further Assistance
• Section 10 - Associated Information

Section 1 - Governing Policy

(1) The WHSMS Auditing Procedure is governed by the Work, Health, Safety and Wellbeing Policy.

Section 2 - Scope

(2) This Procedure applies to all of the working and learning activities that are managed and influenced by the University’s Work Health and Safety Management System (WHSMS or framework).

Section 3 - Purpose of Audit Program

(3) WHSMS audits will be conducted to assess compliance and identify gaps in the implementation of the University’s framework. For example, the audit program will support the University to ensure that its WHSMS enables the identification and management of its significant WHS risks, including governance requirements.

(4) These audits will also provide assurance to the University community and interested parties that the WHSMS has been applied to the activities that the University manages and some of the activities which it influences. The inclusion of WHSMS considerations as a secondary focus of other internal audits will also support the University to improve its governance and ensure that the WHS considerations inform working and learning activities, and decision making.

Section 4 - Audit Program

(5) A WHSMS audit program will be prepared and maintained by the National Manager, Health and Safety, in collaboration with the National Manager, Risk. The Work Health and Safety Management Committee and Audit and Risk Committee will review and authorise the annual audit program, inclusive of internal audits and may incorporate external audits. A significant percentage of internal audits - undertaken by the University’s internal auditor, which are not primarily conducted to review the WHSMS, may have a secondary focus on aspects of the framework e.g. the application of WHS risk management practices.

(6) The annual WHSMS audit schedule will be published within the WHS section of the intranet from April 2020. Additional audits may also identify and implement unscheduled audits.

(7) The WHSMS program will be informed by:

1. the maturity of the framework and the expectations of Senior Executive Members e.g. prioritising the certification of the system or defining ambitious WHS objectives and targets;
2. the level of WHS risks, including threats to the WHSMS, which are associated with working and learning activities;
3. WHS policies, WHSMS procedures and other operational controls;
4. assessments of the integration of the WHSMS with business processes and the framework;
5. results of previous audits;
6. the scope of the working and learning activities that ACU manages and influences;
7. expectations of staff members and/or their representatives, and the University’s interested parties; and
8. maturity of the WHSMS i.e. performance expectations will increase as the framework evolves in sophistication and the University increases its capacity to assess and manage WHS risk.

(8) Unscheduled audits, which may be limited in scope, may also be identified by the Audit and Risk Committee and implemented. These audits may be informed by:

1. previous WHSMS audit results;
2. recommendations from other organisational internal audits;
3. regulators inspections/entry reports;
4. operational changes;
5. management reviews;
6. spikes in specific types of incidents and/or hazards;
7. concerns of staff members or their representatives, or interested parties; and
8. identified non-conformities.

(9) Audits complement the annual assessments that People and Capability will conduct to assess compliance with WHS legislation and associated Codes of Practice, Standards and other requirements.

Section 5 - Self-Assessments to be Completed by Organisational Units

Completing the WHSMS Self-Assessment Checklist

(10) Organisational units should complete the WHSMS Self-Assessment Checklist on an annual basis. The questionnaire, which is published on the WHS intranet site, mirrors many of the requirements that are pre-populated within the template for Organisational Unit Plans. The completion of the questionnaire will support organisational units to implement the framework and prepare for audits, including compiling documentary evidence of compliance with WHSMS requirements.

(11) The completion of the WHSMS Self-Assessment Checklist will also inform the completion of the annual declaration that Members of the Executive and Senior Executive should complete by the end of the first quarter, each year. The declaration confirms that the WHSMS has been applied to the working and learning activities that a portfolio or organisational unit manages and influences.

Maintaining the Currency of the WHSMS Self-Assessment

(12) The National Manager, Health and Safety or a delegate will conduct an annual review of the Self-Assessment WHSMS Checklist for Audits in Quarter four, each year, to ensure that it is relevant and current.

Engaging in WHSMS Improvement Opportunities

(13) Organisational Units should also engage with WHSMS Improvement Opportunities, such as identifying new hazards, conducting WHS Inspections, Job Safety Analyses and identifying compliance gaps with the WHSMS.

Section 6 - Audit Competency

(14) Audit Programs and processes are developed by staff members and internal auditors that have successfully completed internal or Lead Auditor Training Program with a specialisation in Health Safety and/or Environment, or Quality Assurance. All internal auditors should be appropriately trained and experienced.

Section 7 - The Audit Cycle

Defining the Scope of Audits

(15) The scope of WHSMS related audits will be informed by the expectations of the Vice-Chancellor and President, and Chief Operating Officer and Deputy Vice-Chancellor about the development of the WHSMS, including any requirements to certify the framework and realise WHS targets and objectives. The focus on these annual audits will be shaped by their expectations and the needs of the Review Sponsor.

(16) The Assurance Unit, Legal, Assurance and Governance Directorate, will contact the Review Sponsor approximately one month prior to an audit being scheduled to initiate a discussion and review of the draft scope and audit plan.

(17) The scope of WHSMS will be finalised at least two weeks prior to the commencement of the audit.

Audit Opening Meeting

(18) The audit team will chair an opening meeting with:

1. Review Sponsor and / or relevant Executive staff / Senior Manager;
2. a People and Capability representative, whenever the primary focus of the audit is the WHSMS;
3. a member of the Audit and Risk Committee; and
4. other appropriate staff.

(19) Agenda:

1. Scope of WHSMS audit or a general audit that assesses elements of WHSMS compliance;
2. How the audit will be conducted;
3. Access arrangements for laboratories;
4. Resources required (e.g. access cards, PPE etc;);
5. What the team will do if it encounters an unsafe situation; and
6. Report processes.

Conducting Internal Audits

(20) The audit is likely to commence with a ‘system walkthrough’ that will enable the University’s internal auditor to understand the processes, systems and controls under review. The auditors will then seek relevant background documentation and develop a program to test that these aspects of the WHSMS are working as expected.

(21) The audit team can progress through the audit in a number of ways, such as:

1. Observing – observing operational controls in place
2. Review of documentation – ensuring WHSMS policies, procedures, and local protocols are appropriate and current;
3. Assessing whether significant WHS risks have been identified and whether risks are appropriately assessed;
4. Assessing conformance and gaps in the application of the WHSMS or integration of WHS considerations into working and learning activities; and
5. Following audit trails to confirm evidence.

Audit Debrief

(22) At the conclusion of the audit, the audit team will debrief impacted relevant Executive staff and or their Nominees. The Review Sponsor will be invited to attend the debriefing if the sponsor is a Member of the Senior Executive.

(23) During the debriefing, meeting participants will be informed that the audit has concluded, audit findings and reporting processes.

(24) The audit team will follow up any outstanding items with relevant organisational units. Additionally, keys, Personal Protective Equipment(PPE) and other items will be returned by the auditors.

WHSMS Audit Report

(25) The audit team is responsible for finalising the audit report.

(26) The scope of the report:

1. An overview of the area and elements/procedures and processes audited;
2. Audit team composition, audit scope, staff and others interviewed;
3. Executive summary
4. Observations and key findings, including identified non-conformances;
5. Opportunities for improvement, which may inform future non-conformances;
6. Risk Ratings that are associated with recommendations; and
7. Graphical representation of findings.

(27) The draft WHSMS Audit Report will be reviewed by the audit team and will be distributed to relevant Members of the Executive or Senior Executive within 15 working days. Relevant Executive staff will be required to provide responses to the issues and recommendations within two weeks of receipt of the draft report.

(28) When recommendations are accepted:

1. An Action Officer and implementation date should be provided to enable follow up of the recommendations at a later date.

(29) When recommendations are rejected:

1. Relevant Executives need to provide detailed reasons for rejecting a recommendation and confirm that they are willing to be accountable for any risks that may be associated with non-implementation.

(30) Actions relating to audit findings, will be assigned a risk rating, and will be followed up and tabled at the next schedule Audit and Risk Committee meeting. The National Manager, Health and Safety, and National Manager, Risk will also report results to the Work Health and Safety Management Committee.

(31) A copy of the audit report will also be sent to the Chief People Officer to ensure that the recommendations of any WHSMS related report are aligned with the requirements of the framework and the University’s WHS risk management methodologies.

(32) The final report will be distributed to audit area participants and the following stakeholders:

1. Work Health and Safety Management Committee;
2. Audit and Risk Committee;
3. National Manager, Health and Safety;
4. National Manager, Risk; and
5. Relevant Health and Safety Representatives.

(33) A summary of WHSMS audit findings and progress updates will also be summarised in the relevant quarterly WHS report, by People and Capability, and distributed to the Senate, Work Health and Safety Management Committee, Audit and Risk Committee, ACU Staff Consultative Committee (ACUSCC) and local WHS Committees.

Corrective Actions/Non-Conformances

(34) Whenever audit recommendations have been assigned to the University, relevant portfolio or organisational unit should action these Corrective Actions/Non-Conformances within agreed upon deadlines.

Section 8 - Revisions made to this Procedure

(35) 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 People and Capability.

Section 9 - Further Assistance

(36) 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.

Section 10 - Associated Information

(37) For related legislation, policies, procedures and guidelines and any supporting resources please refer to the Associated Information tab.