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Appendix BMethods and Definitions
Each standard received was compared against the Review Questions (see next page) to identify its currency, status and intended use, and the 27 variables set out in Table No. 1. A brief description of each of these variables is given in this Appendix. Following a comparison with the OHSMS variables, a short appraisal of the standard was prepared, together with a summary if its content. The question of whether it meets the criteria to be considered "a system" is discussed. Any significant items which were not captured by the Review Question form or the Checklist, are also highlighted in this Appendix. The analysis was reviewed by members of the project team and a number of external reviewers, as indicated in Appendix D.
ILO/IOHA Project
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Standard/Guidance Document Origin:
Name of Standard/Guidance Document:
Reference Number: |
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1. When was the standard/guidance document published?
(date)
2. Has it been officially published? Or is it a draft?
(yes/no)
3. Is it known whether there are pending revisions?
(yes/no)
4. It is published by what type of organization?
(government, national standards org., professional association, other)
5. What kind of OHSMS is it?
(part of an original OHS law/act, a national regulation, voluntary consensus standard, professional association best-practice, other)
6. Is it used by regulatory agencies to accomplish agency mandates/goals?
(yes/no)
7. Is it considered an auditable standard?
(yes/no) As stated in the standard/guidance document.
8. Is it an auditable standard?
(yes/no) Answer after completing checklist. Are clauses stated as "shall" or "should." Is this a guidance document (e.g. ISO 9004 or 14004) that is not meant to be an auditable standard?
9. Is it a management system?
(the five general system elements are: input, process, output, feedback, and open-system elements). All five elements of the general systems model must be present. The feedback and open-system elements are considered most crucial to this definition. Use the checklist to make determination.
10. Are there technical appendices? What do they cover?
(yes/no) Provide description if yes.
11. Is it known whether a companion evaluation/audit guidance document has been prepared?
(yes/no)
12. Does the standard state limitations to its use?
(yes/no) Provide description if yes.
1.0 Management Commitment and Resources
Management commitment to occupational health and safety may be operationally defined as: 1) the allocation of sufficient resources for the proper functioning of an OHS program or management system; 2) the establishment of organizational structures whereby managers and employees are supported in their OHS duties; and, 3) a senior management representative, who is responsible for overseeing the proper functioning of the OHSMS, is designated.
1.1 Regulatory Compliance and System Conformance
Many governmental regulations and non-governmental standards impose requirements on occupational health and safety management and, therefore, can affect the way an OHSMS is designed, implemented, and operated. Organizations need to understand incorporate the governmental regulations and non-governmental standards which apply to them, and to incorporate their requirements into the policies, procedures and goals of the OHSMS.
1.2 Accountability, Responsibility, and Authority
These variables address the manner in which an organization defines the roles of personnel who are involved in OHSMS management, and the employees, supervisors, and managers who are affected by it. Crucial to role definition is the manner in which occupational health and safety and OHSMS accountability, responsibility, and authority are defined, supported, and enforced by senior management.
2.0 Employee Participation
Employee participation in OHS management may be operationally defined in any number of ways. The key requirement is that employees have input into OHS considerations, and that the input is meaningful, valued, and can affect policies and practices. Many OHS professionals have identified employee participation in occupational health and safety management as the variable essential to successful OHS management and illness/injury reduction, for example through joint employee/employer committees, steering/task/working groups, etc.
3.0 Occupational Health and Safety Policy
The OHS policy represents the foundation from which OHS goals and objectives, performance measures, and other system components are developed. The OHS policy should be short, concise, easily understood, approved by the highest level of management, and known by all employees in the organization. It can be expressed in terms of organizational mission or vision statements. It is a document that expresses the organization’s OHS values.
4.0 Goals and Objectives
The development of OHS goals and objectives follows naturally from the OHS policy development activities. With the OHS policy established, there is a foundation upon which OHS goals and objectives can be built. The establishment of OHS goals and objectives represents the beginning of a progression from the conceptual realm of the OHS policy to an operational realm as expressed in the overall system structure/design and OHSMS manual/documentation or information system. They should be measurable and appropriate to the size, nature, and complexity of the organization’s activities.
5.0 Performance Measures
The ability to measure OHS performance over time is essential to eliminating occupational injuries and illness, and to verify continuous improvement. To achieve this, the organization should develop performance measures that are consistent with the OHS variables expressed in the OHS policy and goals and objectives, and measure both preventive ("upstream") and trailing performance indicators.
6.0 System Planning and Development
System planning and development activities address both initial OHSMS development and ongoing revision and modification of the system. These variables address the manner in which the overall structure and form of the OHSMS will be developed, implemented, and subsequently modified to achieve the required level of performance and continuous improvement.
6.1 Baseline Evaluation and Hazard/Risk Assessment
A baseline evaluation or review of the organization’s existing OHS management practices and OHS hazards is necessary before a robust OHSMS can be completely designed or implemented. The baseline evaluation needs to identify OHS hazards and their associated risks clearly. This information is essential to the development of numerous OHSMS components, including the training system, hazard control system, and the emergency preparedness and response system. Failure to properly identify hazardous and associated risks can lead to inadequate employee protection on one hand, or overzealous protective measures, which are not cost effective, on the other.
7.0 OHSMS Manual and Procedures
The OHSMS manual or its electronic equivalent is the document where OHS and OHSMS policies and procedures are to be found. The manual should be easily accessible to employees, taking into account levels of education and possible language barriers. It should be written in clear language and should use graphic illustrations where possible to communicate the intended information.
8.0 Training System
The term training system is used broadly to reflect the importance of knowledge dissemination and skill development in a well functioning OHSMS. OHS training has been an integral component of OHS management for many years. It is universally recognized as an essential element in maintaining a healthy and safe workplace.
8.1 Technical Expertise and Personnel Qualifications
Successful OHSMS operation requires qualified and competent personnel. This includes personnel in the organization who have direct OHSMS responsibilities as well as external consultants who may provide OHS services to the organization.
9.0 Hazard Control System
The hazard control system is broadly defined to include the various methods used to reduce or eliminate occupational hazards, and the methods through which the control system is modified as workplace conditions change. Control methods are typically defined in terms of administrative controls, personal protective equipment (PPE), or engineering controls.
9.1 Process Design
Process design addresses the OHS actions associated with the installation of new processes or operations. Examples are: the installation of new office work stations; modifications made to an existing manufacturing process; or, development of a new hazardous waste disposal operation.
9.2 Emergency Preparedness and Response System
Emergency preparedness and response refers to the manner in which the organization prepares for and responds to OHS emergencies and accidents. Emergency preparedness and response system actions are initiated and conducted immediately when events occur that can cause illnesses, injuries, or fatalities. Emergency response covers many possible hazard scenarios including, for example, evacuation of an office building, spill of a flammable liquid, release of a toxic gas, incapacitation of workers by unknown agents, and health from the elements (flood, earthquake, excessive heat/cold, etc.).
9.3 Hazardous Agent Management System
The term hazardous agent refers to chemical, biological and physical agents, including such things as radioactive materials, noise, heat, cold, lasers, and hazardous wastes. The hazardous agent management system is an important component of the more broadly defined hazard control system. The key issues addressed here are the identification of hazardous agents, understanding of their risks, elimination or control of the risks, and establishment of mechanisms to ensure the actions of all those involved in the process are effectively coordinated.
10.0 Preventive and Corrective Action System
Preventive and corrective action refers to actions taken in response to, or in anticipation of, system breakdowns or high hazard/risk events. Central to an effective system is that in which actions should be as anticipatory as possible. That is, actions should be taken in advance to prevent an incident or other unplanned event that might adversely affect worker health, or that would require emergency or other response actions. Safe working procedures and practices are key elements of this system.
11.0 Procurement and Contracting
Products and contractors can impact workplace health and safety. This OHSMS variable addresses the need to be aware of such impacts and the need for mechanisms to control them. This can include minimum requirements for the behavior of contractors while on the organization’s premises. In some cases, it may be appropriate for contractors to follow all of the organization’s safety rules. It can also include a mechanism to evaluate the manner in which all incoming products or items may affect workplace health and safety.
12.0 Communication System
The communication system can be defined and implemented in several ways. In its most basic form, a viable communication system should identify how, and to whom, information for the proper functioning of the OHSMS will be transmitted. A well-functioning communication system with defined feedback channels is essential for a successful OHSMS. This system component provides the means by which all other system variables relate and interact.
12.1 Document and Record Management System
The document and record management system addresses the way the organization manages and organizes OHSMS documents and records; this can include both hard-copy and electronically stored information. A well-functioning document and record management system is an essential prerequisite for effective communication of policies, standards and procedures, and for an organisation’s ability to be able to demonstrate that it is achieving what it said it would. It is of particular importance in organizations that are pursuing OHSMS registration or certification. The document and record management system provides one of the key indicators of whether the OHSMS is currently in conformance, and whether the probability is good that conformance will be maintained over time.
13.0 Evaluation System
The evaluation system is broadly defined and includes baseline evaluations, auditing, self-inspection and self-correction, incident investigation, medical surveillance, and management review activities. These activities are fundamental to the system’s ability to function and sustain itself over time, and ensure continuous improvement.
13.1 Auditing and Self-Inspection
OHS auditing and self-inspection are specific activities of the evaluation system where information is gathered and assessed on individual OHS programs and systems. These activities include an assessment of changes in OHS hazards and the ability of the OHSMS to respond properly to the changes. Auditing and self-inspection activities provide essential information to other OHSMS components, including the training, hazard control, and preventive and corrective action systems.
13.2 Incident Investigation and Root Cause Analysis
Incident investigation and root cause analysis refers to the activities conducted to determine the origin and cause(s) of accidents, near miss accidents, injuries, fatalities, or breakdowns in the OHSMS. An important aspect of Incident Investigations is the performance of a root cause analysis is to see at what point(s) the OHSMS failed, and how it can be modified to present a reoccurrence.
13.3 Health/Medical Program and Surveillance
Health and/or medical programs and surveillance refers to the activities associated with providing occupational health services within the organization, and the development and operation of a health surveillance and promotion program. An occupational health surveillance program, when workplace hazards dictate, is a key component of an OHS systems approach, and provides feedback on the effectiveness of the hazardous control system.
14.0 Continual Improvement
Continual improvement may be operationally defined and implemented in any number of ways. The basic notion is that the organization should seek ways to achieve ongoing improvement of occupational health and safety performance. The ultimate goal of continual improvement activities is to eliminate worker injury and illness, and to move towards the ultimate goal in a measured and consistent manner.
15.0 Integration
Integration refers to the actions the organization takes to integrate its occupational health and safety functions and procedures with other management system and business processes in the organization and in the community. A successful OHSMS requires that the elements of the OHSMS be connected, or related, to other key functions in the organization. This means that OHS issues and aspects of the OHSMS will be part of the organizational culture, and that the goals and objectives become the organsational goals, and goals for managers in the organisation.
16.0 Management Review
The overall performance of the OHSMS is evaluated through management reviews. It is through this activity that the OHSMS, the organization, and the environment external to the organization are linked. This involves evaluating the OHSMS’s ability to meet the overall needs of the organization, its stakeholders, its employees, and regulating agencies.
Basis for the Universal OHSMS model used in this analysis
The 27 OHSMS variables used in the analysis conducted were developed during the construction of a Universal OHSMS Assessment Instrument (UAI) at the University of Michigan (Redinger, 1998). From the initial discussions in The Michigan Occupational Health and Safety (OHS) Policy Group which led to the development of the UAI, an identified goal was to construct an instrument which would be able to measure the effectiveness of a wide range of OHSMSs. Even though it was acknowledged by some in the group, and their colleagues, that this goal might be difficult to achieve, it was clear that it would be a significant contribution to the OHS field if one single instrument could be constructed. In order to meet this goal of developing a universal assessment instrument, it was first necessary to identify and define the universe of OHSMSs and create a universal OHSMS upon which the UAI would be based.
To define this universe, 13 publicly-available systems were reviewed, seven of which were OHSMSs. The remaining six systems were quality assurance management systems (QAMS) or environmental management systems (EMS). Three OHSMS and one EMS models were selected for use in the UAI development process. These four models were selected because they provided the most comprehensive management system approaches and contained the essential elements of all of the models reviewed. The four models are referred to herein as input models. These input models are:
The VPP was selected because it represents the most comprehensive OHS management system approach within OSHA and encompasses elements of other systems approaches in OSHA, such as the 1989 Guidelines, Consultation’s SHARP/form 33, the Performance Evaluation Profile (PEP), and the draft OHS program standard. The British OHSMS contains two approaches. One is based on ISO 14001 and the other is based on the British Health Safety Executive’s (HSE) OHS Guidelines HS(G) 65. Both of these approaches were considered during the development of the Instrument. The AIHA’s OHSMS is an ISO 9001-based OHSMS. Strictly speaking, ISO 14001:1996 is not an OHSMS. It was selected based on its increasing visibility since its promulgation in 1996. Initial indications are that many organizations have been organizing their OHSM functions, along with environmental management functions, according to the ISO 14001 model.
Input Model Partitioning
Following their selection, the four input models were partitioned into their respective individual variables; these variables can also be called, auditable clauses.
The four input models were transferred from hard copy to electronic form. Once in electronic form, the models were reviewed and partitioned into individual auditable clauses. Care was taken to ensure that the unique clause reference numbers were maintained during this process. In order to guide the model partitioning process, the following decision rules were developed and followed.
Input Model Partitioning Rules
Regrouping and Labeling
Following the partitioning of the input models into single auditable clauses, the clauses were regrouped according to common issues. As with the model partitioning process, decision rules were developed and followed to guide the clause regrouping process. These decision rules follow.
Regrouping and Arrangement Rules
From initial regrouping efforts to the final grouping, five iterations were conducted. Each iteration included the application of the decision rules to the clauses. The iterations were continued until the decision rules were wholly satisfied. Additional iterations were necessary as to ensure that 1) elements truly contained only one auditable issue, and 2) that groupings were as precise as possible.
Following the final grouping, two quality-control exercises were performed. The first involved the review of the groupings by a panel of 12 OHS or management-systems experts. Comments from the reviewers were incorporated. Second, once in its final form, hard-copies of the input models were checked against each input element in electronic form to ensure that no input elements were omitted or deleted during the five iterations and panel review activities. Necessary corrections were made.
Labels for these groupings (referred to as UAI sections) were generated based on the major concept or distinction represented in the groupings and knowledge of the labels that represented the input elements from the original models. The labeling effort was also influenced by systems theory, policy analysis, and program evaluation nomenclature.
Overall Instrument Structure
Based on various systems, policy analysis, and program evaluation models, the UAI structure was created. The UAI sections were grouped into five categories as follows:
These categories are partially based on the policy analysis model developed by Brewer and deLeon and a simplified systems model.
The UAI sections, as arranged in the five categories listed above, were then arranged according to a construct which identified 1) occupational health and safety in the organization, 2) the organization, and, 3) the external environment (Figure No. 1). This construct is significant in that it reflects the open system nature of OHSMSs and its need to interact with the organization as a whole, as well as with the external environment. In this construct, the external environment is defined as stakeholders and regulating agencies/units who have an interest in the organization’s performance.
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