SESLHD PROCEDURE COVER SHEET COMPLIANCE WITH THIS DOCUMENT IS MANDATORY Feedback about this document can be sent to [email protected]NAME OF DOCUMENT Work, Health and Safety Risk Management TYPE OF DOCUMENT Procedure DOCUMENT NUMBER SESLHDPR/212 DATE OF PUBLICATION November 2012 RISK RATING High LEVEL OF EVIDENCE Completed hazard registers, workplace inspections, and risk assessments. REVIEW DATE November 2013 FORMER REFERENCE(S) SESLHNPD/82 EXECUTIVE SPONSOR or EXECUTIVE CLINICAL SPONSOR Sharon Litchfield - Director Workforce Development AUTHOR Peggy Pollock, Manager Workforce Safety Injury Management [email protected]POSITION RESPONSIBLE FOR THE DOCUMENT Peggy Pollock, Manager Workforce Safety Injury Management [email protected]KEY TERMS WHS Risk Management SUMMARY Procedure for the management of Work, Health and Safety risks in SESLHD. Provides guidance on relevant system procedures and forms required to actively reduce the risk of worker injury in SESLHD and to assist in achieving legislative compliance.
Transcript
SESLHD PROCEDURE
COVER SHEET
COMPLIANCE WITH THIS DOCUMENT IS MANDATORY Feedback about this document can be sent to [email protected]
NAME OF DOCUMENT
Work, Health and Safety Risk Management
TYPE OF DOCUMENT
Procedure
DOCUMENT NUMBER
SESLHDPR/212
DATE OF PUBLICATION
November 2012
RISK RATING
High
LEVEL OF EVIDENCE
Completed hazard registers, workplace inspections, and risk assessments.
REVIEW DATE
November 2013
FORMER REFERENCE(S)
SESLHNPD/82
EXECUTIVE SPONSOR or
EXECUTIVE CLINICAL SPONSOR
Sharon Litchfield - Director Workforce Development
Procedure for the management of Work, Health and Safety risks in SESLHD. Provides guidance on relevant system procedures and forms required to actively reduce the risk of worker injury in SESLHD and to assist in achieving legislative compliance.
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1. POLICY STATEMENT The NSW Ministry of Health, Occupational Health and Safety Policy and Workers Compensation and Injury Management Policy PD2005_360 and Risk Management - Enterprise-Wide Policy and Framework - NSW PD2009_039 both mandate that all NSW Health organisations adopt a risk management approach to Work Health and Safety. This procedure has been developed as a guide to the implementation of the Work Health and Safety Risk Management framework in SESLHD. By following the steps, principles and practices laid out in this procedure the management and workers of SESLHD can be reasonable assured that they are complying with the requirements of Health Policy and the Work Health and Safety Act (the WHS Act) No 10, Work Health and Safety Regulation 2011 and the How to Manage Work Health And Safety Risks Code of Practice.
2. BACKGROUND Risk management is a proactive process that helps SESLHD respond to change and facilitate continuous improvement in our business. Risk management entails a systematic and planned approach to managing all reasonably foreseeable hazards and their associated risks. The basic tenet of risk management is to act on what could be to:
Make the most of an opportunity;
Prevent a foreseeable loss from occurring. Work Health and Safety Risk Management on the whole is designed to prevent loss by preventing harm to people though it also presents opportunities for increasing productivity and improving services. WHS Risk Management comprises 5 basic steps, this procedure is designed to help you understand those steps and use them to improve our work by making it safer and less fault prone which in turn benefits our patients. This procedure is the Generic Health and Safety Risk Management procedure the basic principles and steps applied within it also apply to the other work risk areas. To ensure we are compliant with legislative requirements it is recommended that the specific procedures and associated forms are used for:
Chemicals/Dangerous goods
Construction work
Electricity
Environment
Equipment
Falls
Manual Handling
Noise
Task
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Please note that in some cases several „assessments‟ may be required to ensure a task is safe. For example Environment, Manual Handling, Noise, Equipment and Chemicals/Dangerous Goods assessments should be conducted for high pressure chemical cleaning. In these cases it is recommended that a Job Safety Analysis (JSA) is conducted to identify the individual hazard areas and their corresponding controls. Specific concepts related to WHS Act risk management such as „reasonably practicable‟ are also explained within this procedure to guide the end user in appropriately applying WHS risk management decision making. This procedure is SESLHD‟s response to the requirements placed on it, its Officers and Workers to have and use a Work Health and Safety Risk Management System. Definitions for this procedure are contained in the SESLHD WHS Dictionary.
3. RESPONSIBILITIES
3.1 Employees will: comply with procedures for work health and safety risk management; and any measures put in place to protect their own, patients, visitor and others legally on our premises health and safety.
Workers are required to participate in the SESLHD Work Health and Safety risk management process to ensure they meet their obligations under the WHS Act and Regulation 2011.
3.2 Line Managers will: follow SESLHD procedures for risk management.
Demonstrate their duty of care to do no harm by implementing SESLHD WHS and IM policies and procedures evidenced by:
Ensuring all their workers are trained and informed of work hazards and the associated risk controls;
Monitor the work environment to ensure it is safe and without risk of harm;
Monitor workers health where required;
Consult with workers and their representatives on health and safety matters;
Ensuring appropriate Safe Work Procedures (SWP‟s) are developed, implemented, all relevant workers are trained in them;
Workers WHS performance is monitored and evaluated in line with the Performance development policy PD 131 and Performance development handbook HB 009;
Have documented departmental emergency procedures which are regularly check and evaluated for their effectiveness;
Ensuring all the departments risk management processes are documented and auditable;
Reporting WHS performance to their Network Managers/ Service Managers;
Escalating WHS risks to their managers for resolution where the control is beyond their delegation;
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Reporting notifiable incidents in line with SESLHD procedures and WHS Act and Regulation requirements.
3.3 District Managers/Service Managers will:
Demonstrate their leadership in duty of care to do no harm by monitoring WHS and IM performance and confirming the establishment and maintenance of SESLHD WHS Risk and Injury Management (IM) policies and procedures. Resolve WHS issues brought to their attention in a timely and informed manor. Report your departments/services WHS risk management achievements and deficits to the SESLHD Chief Executive and Board. Apply due diligence to show that you have taken every reasonable precaution to ensure the departments and services under your control is acting to prevent harm to its workers and others.
3.4 Medical staff will:
Demonstrate their due diligence and leadership in their duty of care to do no harm by ensuring they are up to date with the latest SESLHD WHS and IM policies and procedures, use of work health and safety risk control resources and information when working on behalf of SESLHD.
4. PROCEDURE
Before you begin: Consulting with your workers about all work, health and safety issues is a mandated requirement of the WHS Act. Consulting with workers at every stage of the work, health and safety risk management process helps to inform worker understanding of the hazards and risks and the reason for change. Consultation also facilitates continuous improvement. Consultation should be planned, systematic and cover all reasonably foreseeable hazards and associated risks along with the agreed risk controls and implementation strategy. Where a control is rejected by the organisation the consultation Code of Practice requires that the reason for that rejection to be noted and provided to the workers affected. To assist in a reliable health and safety risk management result it is important to consult with workers at every stage of the following process.
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WHS Risk Management Procedure Diagram
4.1. Step 1- identify hazards
This must be an active and ongoing process. Identifying hazards in the workplace and hazardous jobs is the key element in WHS risk management. The term “Hazard” should be interpreted as anything that may cause harm or endanger the health, safety or welfare of workers, volunteers, contractors, students, patients or visitors.
How to identify hazards
Consultation- Hazards can be identified by talking to workers to find out what they consider to be hazardous or problems at work
Direct observation - Hazards can be identified by directly observing the workplace, or the way work is done. For example: conducting workplace safety inspections, safety audits, etc.
Investigating incidents and analysing incident data - Hazards can be identified by notification of hazards and injuries, investigating incidents or analysing IIMS incident reports and workers compensation data.
Reviewing product information- Hazards can be identified by reviewing the product information supplied with substances, material, plant, equipment and tools
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Reviewing workplace design- Hazards can be identified by reviewing the design and layout of workplaces in relation to workflow or where incidents or mishaps occur
Equipment damage or breakage- is a sign that processes are not in control and a hazard is realising a risk of harm.
Building damage- as with equipment damage breakage identifies a hazard.
Common hazards or hazardous jobs include:
keyboard work for long periods without a break activities that involve lifting or people, carrying materials or equipment trip hazards like trailing cords, frayed carpet or boxes in walkways using a hazardous substance for cleaning or in a laboratory process noise generated by machinery or during loud events solar heat and UV radiation when working outdoors working with infectious patients or micro-organisms that may cause infection working with sources of ionising radiation dealing with clients or other people who are potentially violent working with sharp instruments, e.g. needles and blades working with or close to machinery with moving parts driving long distances to or from fieldwork.
When to identify hazards
Initially if the hazard identification process has not been applied to the workplace, work activities or plant, equipment, tools, substances and other materials used or stored at work.
Prior to introducing something new – i.e.
before introducing new plant, equipment, tools, substances or material, to the workplace;
when designing a new workplace or prior to occupying a new workplace;
before introducing a new work activity, service etc
Prior to altering something –i.e.
before altering the way a work activity is performed, or the way a service is provided
before altering the design or layout of a workplace, or the way it is used, cleaned or maintained
before altering the design of plant, equipment, tools or the way they are used, cleaned, inspected, maintained, disposed of etc
before altering the way substances are used, handled, transported stored or disposed of.
When work is being carried out. For example when conducting or supervising work activities.
When something occurs which did or could have harmed someone - for example as part of the incident investigation process?
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When new or additional information becomes available - industry hazard alerts, manufacturer alerts and recall notices, general public hazard notifications.
4.2. Step 2 – Assess the Risk
A work group may have a considerable number of hazards or hazardous jobs to be managed. Therefore, highest priority should be assigned to those that have the greatest potential for loss or injury. There are two aspects to be considered when prioritising the risks:
likelihood that someone will be harmed, ie how many people are exposed, how often or how long a person is exposed etc, and
potential consequences of exposure to the hazard, ie whether serious injury may result.
Use the ERMS risk matrix to assign a “risk rating” to a hazard. Where exposure is more likely and the potential consequences more severe give these hazards the highest priority for prompt resolution. Any tasks that are found to present an imminent risk of serious injury or other adverse event should be halted until suitable controls are put in place to reduce the risk to an acceptable level. When considering the likelihood or consequences of exposure, bear in mind any existing risk control measures, e.g. An item of equipment with Safe Operating Procedures (SOP‟s) in place and being used. The existence and use of these risk control measures (the safe Operating Procedures) will reduce the potential for injury. Any new or additional controls need to recognise and include the current controls and be of a higher level in the Risk Control Hierarchy. Review the list of Codes of Practice (CoP) and the WHS Regulation to determine if the identified hazard has mandated controls set by them. If the hazard is dealt with in the CoP the controls listed in the CoP are the mandated minimum controls for that hazard. If you already have the required CoP controls in place and a risk is still present
continue with a risk assessment. If you do not have the entire CoP recommend controls in place go to step 4.4 and
develop an implementation plan for the mandatory controls. A risk assessment is an information gathering exercise used to find out what makes something hazardous. When assessing the risk, it is essential to consult with those directly involved in doing the hazardous work to obtain first hand information about hazard exposures and potential problems and solutions. Gather information and seek advice about hazards and risks from regulators, industry associations, unions, technical specialists and safety consultants. Manufacturers and suppliers can also provide information about hazards and safety precautions for specific substances (safety data sheets), plant or processes (instruction manuals).
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The risk assessment should consider each of the following risk factors: physical activity required for the task, e.g. if it involves physical exertion,
etc nature of the hazard itself, e.g. hazardous substances, machinery,
sharps/blades, radiation, potentially violent clients or intruders etc individuals involved in the process, ie their level of training and expertise, their
physical capacity to perform the task, their health status ie., any existing condition that may increase the risk as can age, pregnancy, allergy etc
The risk assessment may find that one or more of these risk factors are present. This will be instructive in selecting suitable risk controls in the next step, Step 4.
4.3. Step 3 control the risks
The ways of controlling risks are ranked from the highest level of protection and reliability to the lowest as shown in the table below. This ranking is known as the hierarchy of risk control. The WHS Regulations require duty holders to work through this hierarchy when managing WHS risks.
Risk Control Hierarchy Area of control
effect Control safety performance
Control assurance
1. Elimination Safe workplace Highest Most
2. Substitution;
Safe work task
Level of health
and safety protection
Reliability of
safety outcome
3. Isolation;
4. Engineering;
5. Administrative; The person needs to work
safely. 6. Personal protective
equipment. Lowest Least
If there are any legislative prescribed measures that need to be applied, they must be incorporated in the risk management process. Likewise Codes of Practice or Australian Standards hazard controls must be applied in all cases where they relate.
Based on the information gathered in the risk assessment, the following risk control decisions need to be made:
what needs to be done to eliminate the hazard; or minimise the risk of harm;
what level of residual risk will remain after these measures have been implemented; and
what first aid, emergency and contingency plans need to be in place should an injury/illness result from incidents caused by the residual risk/s;
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could we be creating any additional risk/s by the implementation of the proposed control measure/s.
The results of the risk assessments and the risk control decisions must be communicated to all relevant workers affected by the hazard. In the WHS Act, reasonably practicable, in relation to the duty to ensure the health and safety of workers and others, means that which can, reasonably be done to ensure health and safety, taking into account and weighing up all the factors.
An example of reasonably practicable applied.
Item Hazard Exposure Injury risk potential
Control Cost Reasonably Practical
Risk reduced to
Falls on Hospital site
Steps Frequent High risk of Injury/s to back, hip, leg, arm and/or head
Hand rail $ 375 installed Yes Moderate
Falls on Hospital site
Steps Frequent High risk of Injury/s to back, hip, leg, arm and/or head
Elevator chair
$12,000 installed + $275 per year electricity and maintenance
No Very Low
Falls on Hospital site
Steps Frequent High risk of Injury/s to back, hip, leg, arm and/or head
Ramp and hand rail
$950 Yes Low
In the above example the Reasonably Practicable „Duty of Care‟ is met with the hand rail or the ramp and handrail (Both of these controls are detailed within the Building Code of Australia (BCA)). The cost of the Elevator while reducing the risk of falls to the lowest level is not a „recognised‟ control for falls from a Code of Practice or Standard and could be deemed „not reasonably practicable‟.
Please note - In this example additional conditions have not been considered. Each situation would require individual consideration based on the complete set of circumstances surrounding it. A ramp may not be practical because of the space available so a hand rail alone would be the next most „reasonably practical‟ control. The cost of controlling a risk may be taken into account in determining what is reasonably practicable, but cannot be used as a reason for doing nothing. The higher the risk of harm, the less weight should be given to the cost of controlling the hazard or risk. If the risk is extreme cost has no bearing on the need to implement an effective control. If two control measures provide the same levels of protection and are equally reliable, you can adopt the least expensive option.
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Cost cannot be used as a reason for adopting controls that rely exclusively on changing people‟s behaviour (Training) or actions (Safe Work Procedures) when there are more effective controls available that can change the risk through substitution, engineering or isolation.
Implementation of the risk control measures
Management, in consultation with effected workers, must ensure that the risk control measures are implemented in a timely manner.
The ideal risk control plan would have the following elements:
Trial
Document Work procedures
Competency based training, instruction and information
Measurement
Supervision
In some instances a trial is not possible – such as building a new building or installing a large item of specialised equipment though for most other activities a trial should be run and monitored to ensure the desired results will be achieved and give opportunity to correct any problems not identified in the risk assessment. Where the preferred measures cannot be implemented within a suitable timeframe (considering the level of risk presented by the hazard), interim measures must be put in place to control the risk until the preferred risk controls can be implemented. Management, in consultation with employees, must ensure that a Risk Control Action Plan is developed to document and coordinate the implementation of the risk control measures. Progress on implementing the Risk Control Action Plan should be monitored to ensure that it is being actioned within the time frames specified. If the hazard cannot be eliminated / controlled effectively at a local level it must be escalated in a timely manner to the appropriate senior manager for actioning. The person who has the delegation for the risk control is the „owner‟ of that risk and has the full Duty of Care to ensure the risk is controlled.
4.4. Step 4 – Review Control Measures and evaluate your WHS Risk Management
The control measures that you put in place should be reviewed regularly to make sure they are working as planned.
In your risk assessment you should have clearly defined the desired result of your controls as it is important to confirm that they are achieving the necessary health and safety outcome.
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Document your evaluations and communicate them to the workers in your area. This will also assist the workers in understanding if anything needs to change or if the agreed controls are achieving the desired result. There are certain situations where you must review your control measures under the WHS Regulations and, if necessary, revise them. A review is required: • when the control measure is not effective in controlling the risk • before a change at the workplace that is likely to give rise to a new or different health and safety risk that the control measure may not effectively control
• if a new hazard or risk is identified • if the results of consultation indicate that a review is necessary, or • if a health and safety representative requests a review. As a best practice approach to managing work health and safety related risk in SESLHD it is recommended that Safe Work Practices (SWPs) are reviewed every 3 years where none of the above review triggers have been identified within that time.
5. DOCUMENTATION
Bariatric Patient Risk Assessment & Care Plan
Chemical Inventory/MSDS Register
Chemical Substance / Chemical Use Training Register
Chemical Substance Risk Assessment
Community Visit Safety Checklist
Computer workstation self assessment sheets
Department Training Register
Detailed Plant and Equipment Risk Assessment Form
Electricity register and
Environment inspections
Generic risk assessment
Manual Handling risk assessment
Noise assessment
Risk register
Safe Work Procedure
Safety Rules
WHS Regular Workplace Inspection checklist
6. AUDIT
This procedure will be audited through the OHS & IM Profile every two years
7. REFERENCES
Work Health and Safety Act 2011. Work Health and Safety Regulation 2011 How to manage work health and safety risks Code of Practice.
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NSW Health PD2005-409 Workplace Health and Safety Policy and Better Practice Guideline
AS/NZS ISO 31000:2009, Risk management - Principles and guidelines
8. REVISION AND APPROVAL HISTORY
Date Revision No. Author and Approval
January 2005 0 Former SESAHS Hazard Identification, Assessment and Control Procedures: SESAHS OHSMS-09 Hazard reporting OHSMS-10.
February – August 2006
Draft 1-2 Merging of Former SESAHS OHS & IAHS OHS policy documents by Manager Systems Integration-Area Policy in consultation with Manager Workforce Services
March 2007 1 Manager, Systems Integration in consultation with Southern Hospital Network OHS Practitioners. Approved by Executive Sponsor, Matthew Daly, DCO acting for DWD. Final approval by Area Executive Committee 13 March 2007 as an interim area policy until March 2008.
June 2009 2 Karen Sutton (Area WSIMS OHS Officer) Change from PD to Procedure in accordance with the SESIH policy framework. Amended by T Williams. Approved by Chief Executive in Area Executive Team meeting 9.6.2009
April 2010 3 Inclusion of new form - F240 - Detailed Plant and Equipment Risk Assessment Form – prepared by Dieter Schultejohann
April 2011 4 Peter Kuszelyk, OHS Officer, Health Safety and Wellbeing. Amended to reflect change to Local Health Network and Cluster
October 2012 5 Dieter Schultejohann, WHS Officer, Health Safety and Wellbeing. Amended to reflect change in legislation.
November 2012
5 Approved by Sharon Litchfield Director Workforce Services
