• Section 1 - Governing Policy
• Section 2 - Scope
• Section 3 - Background
• Section 4 - University WHSMS Planning Processes that Inform  the WHS Action Plan
• Bi-Annual Assessments and Reviews
• Section 5 - ACU WHS Action Plan
• Defining WHS Objectives and Targets
• WHS Action Plan
• Section 6 - Ongoing Performance Monitoring of the Framework and WHS Action Plan
• Traffic Light Reporting
• Continuous Improvements in WHSMS
• Section 7 - Revisions made to this Procedure
• Section 8 - Further Assistance
• Section 9 - Associated Information

Section 1 - Governing Policy

(1) This 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 the University manages and influences.

Section 3 - Background

(3) This ACU Planning Framework and 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.

(4) 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.

(5) This Procedure is aligned with ACU’s Planning Framework, ACU Mission, Identity and Values, and International Standard ISO 45001: Occupational Health and Safety Management Systems – Requirements with guidance for use, and other requirements.

Section 4 - University WHSMS Planning Processes that Inform  the WHS Action Plan

(6) The Senior Executive and Executive, including the Work Health and Safety Management Committee, will also conduct bi-annual planning processes and reviews of the WHSMS and will monitor the effectiveness of the framework (see clause 3) more frequently.

Bi-Annual Assessments and Reviews

(7) People and Capability will support the University’s Senior Executive and Executive, including the Work Health and Safety Management Committee, to conduct these bi-annual planning and review processes which are aligned with the ACU Planning Framework.

(8) This bi-annual planning commenced in 2019 and should be conducted at the start of Quarter 3, every two years. It should include the following assessments and determinations:

1. the University’s context (see clause 10), 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;
2. the identification and review of WHS risks and opportunities (clause 14) for improving the WHSMS; and
3. WHSMS performance, including an assessment of the suitability, adequateness and effectiveness of the framework (see clause 17, Table 2 and clause 18 for more information) for managing WHS risks and governance.

(9) 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. 

Assessing the University’s Context

(10) The University will consider the external and internal issues that are relevant to its mission and  values 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:

(11) 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.

(12) The University will define the boundaries of its WHSMS, including the scope of compliance, and to which aspects of its operations and activities (managed and influenced) the framework will apply.

(13) The scope 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.

Assessing WHS Risks and Opportunities

(14) The review of the University’s significant risks will be informed by:

1. 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 learning activities (which it manages and influences) with previously identified risks;
2. Australian Higher Education Industrial Association (AHEIA) benchmarking performance, including Lost Time Injuries;
3. reviews of published information and resources about hazards and risks that are associated with the working and learning activities the University manages or influences;
4. specific concerns and needs/expectations of staff and other significant stakeholders;
5. the results of any health and air monitoring activities;
6. the results of internal audits and WHS inspections;
7. changes in working and learning activities;
8. review of risk registers; and
9. a review of Riskware reports.

(15) 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.

(16) Examples of opportunities for improving WHS performance:

1. ensuring WHS inspections, WHS risk assessments and internal audits of the WHSMS are conducted;
2. ensuring WHS issues are considered prior to relocating facilities and during the design of new processes and capital projects;
3. raising the profile of Senior Executive's support for/leadership of the WHSMS;
4. job hazard analysis (job safety analysis) and task related assessments;
5. incident and non-conformity investigations that inform corrective actions; and
6. ergonomic and other injury prevention-related assessments.

Assessing the Suitability, Adequacy and Effectiveness of the WHSMS

(17) People and Capability will also support the Senior Executive and Executive Staff, including the Work Health and Safety 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:

(18) The following factors were considered during this initial review in 2019 and will be assessed in subsequent bi-annual reviews:

1. the status of actions from previous reviews;
2. an initial assessment/reviews of changes in the internal and external issues (see clause 10) that are relevant to the WHSMS such as the needs and expectations of interested parties, legal and other requirements, and risks and opportunities;
3. 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;
4. the extent to which the Work, Health, Safety and Wellbeing Policy and WHS objectives and targets have been met;
5. WHS Performance;
6. trends in incidents and hazards, non-conformities, corrective actions and continual improvement;
7. monitoring and measuring results;
8. results of the evaluation of compliance with legal and other requirements (see Section 6);
9. audit results;
10. consultation and participation of staff, students, and others;
11. risks and opportunities;
12. adequacy of resources for maintaining an effective WHSMS;
13. relevant communications with interested parties; and
14. opportunities for continual improvement.

Section 5 - ACU WHS Action Plan

Defining WHS Objectives and Targets

(19) 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.

(20) A minimum of three WHS objectives and three targets informed the inaugural WHS Action Plan 2020-2021 and the number of performance measures, and these objectives and targets, will be reviewed and updated every two years.

(21) The WHS objectives and targets:

1. will be aligned with the Work, Health, Safety and Wellbeing Policy;
2. are measurable and informed by SMART Principles;
3. will include Lead and Lag Indicators;
4. are informed by applicable requirements, assessments of risks and opportunities, and consultations with staff and their representatives;
5. influenced by the performance reviews and planning for the WHSMS;
6. monitored on a six-monthly basis by People and Capability; and
7. 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.

(22) These performance measures may also be informed by the Australian Work Health and Safety Strategy 2012-2022, which prioritises reducing musculoskeletal disorders, mental health conditions, noise induced hearing loss and other conditions.

(23) These WHS objectives and targets will be developed by the Senior Executive and Executive Staff, including the Work Health and Safety 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.

WHS Action Plan

(24) The WHS Action Plan will be developed every two years. People and Capability will support the Senior Executive and Executive Staff, including the Work Health and Safety Management Committee, to ensure that it is:

1. informed by the bi-annual review of WHS and WHSMS performance;
2. includes a requirement that each organisational unit places at least their top five treated risks on their risk register (CARM);
3. include actions to realise the WHS targets and objectives (refer to Section 6), which are integrated into the University’s business processes and frameworks;
4. specifies tasks (minimum requirements) that each organisational unit should action to apply ACU’s WHSMS and improve their management of risk;
5. align with the ACU Planning Framework;
6. be appropriately resourced to help ensure the WHS objectives and targets are achieved;
7. assign responsibility for actions and deadlines;
8. include a communications and engagement section;
9. define what/how aspects of the University’s WHS performance will be measured, monitored and evaluated; and
10. 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.

Section 6 - Ongoing Performance Monitoring of the Framework and WHS Action Plan

(25) 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 help inform any revisions or bi-annual updates to the WHS Action Plan and corrective action logs.

Table 3:  Performance Monitoring of the Framework and WHS Action Plan

(26) People and Capability, in consultation with the Work Health and Safety Management Committee, 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 bi-annual WHS Action Plan.

(27) Internal audits also provide some insight into the University’s performance against these criteria, gaps in compliance and opportunities for improvement.

(28) The WHSMS Performance Measurement and Evaluation Procedure also specifies Key Performance Indicators that are measured on a quarterly and annual basis. 

Traffic Light Reporting

(29) The University’s progress towards achieving the WHS objectives and targets, which informs the WHS Action Plan, will be reviewed by People and Capability 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 and annual AHEIA benchmarking.

Continuous Improvements in WHSMS

(30) 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.

(31) The University will also:

1. develop Senior Executive communications that promote the benefits of contributing to the WHSMS;
2. 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
3. maintain documentation, in alignment with the requirements of the WHSMS Records and Document Management Procedure, which provide evidence of the continual improvements.

Section 7 - Revisions made to this Procedure

(32) The revision table includes revisions up until this document was migrated into the current policy platform. Any later changes will show in the Status and Details tab.

Section 8 - Further Assistance

(34) 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 9 - Associated Information

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