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«Policy Directive Ministry of Health, NSW 73 Miller Street North Sydney NSW 2060 Locked Mail Bag 961 North Sydney NSW 2059 Telephone (02) 9391 9000 ...»

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Policy Directive

Ministry of Health, NSW

73 Miller Street North Sydney NSW 2060

Locked Mail Bag 961 North Sydney NSW 2059

Telephone (02) 9391 9000 Fax (02) 9391 9101

http://www.health.nsw.gov.au/policies/

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Work Health and Safety: Better Practice Procedures

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Document Number PD2013_050

Publication date 16-Dec-2013

Functional Sub group Personnel/Workforce - Occupational Health & Safety

Personnel/Workforce - Security

Summary The purpose of this Policy Directive, and more specifically, the attached Better Practice Procedures is to support Agencies to implement an effective work health and safety management system that is consistent with NSW Work Health and Safety (WHS) legislation; and provide information to clarify the duties and responsibilities of officers and managers/supervisors in contributing to a safe and healthy work environment.

Replaces Doc. No. Work Health and Safety: Better Practice Procedures [PD2013_005] Author Branch Workplace Relations Branch contact Workplace Relations 9391 9850 Applies to Local Health Districts, Board Governed Statutory Health Corporations, Chief Executive Governed Statutory Health Corporations, Specialty Network Governed Statutory Health Corporations, Affiliated Health Organisations, Public Health System Support Division, Community Health Centres, Dental Schools and Clinics, Government Medical Officers, NSW Ambulance Service, Ministry of Health, Public Health Units, Public Hospitals Audience Senior managers and supervisors Distributed to Public Health System, Community Health Centres, Dental Schools and Clini

–  –  –

WORK HEALTH AND SAFETY - BETTER PRACTICE PROCEDURES

PURPOSE

The purpose of this Policy Directive is to:

• Support Agencies to implement an effective work health and safety management system that is consistent with NSW Work Health and Safety (WHS) legislation.

• Provide information to clarify the duties and responsibilities of officers and managers/supervisors in contributing to a safe and healthy work environment.

This policy applies to all Public Health Organisations and all other bodies and organisations under the control and direction of the Minister for Health or the Director-General of Health, including the NSW Ministry of Health. This Policy also applies to Albury Wodonga Health in respect of staff who are employed in the NSW Health Service. Throughout the attached Better Practice Procedures these organisations are referred to as ‘Agencies’.

MANDATORY REQUIREMENTS

Each Agency, through its officers and manager/supervisors, must:

• Take all reasonably practicable actions to ensure the health and safety of workers when it:

Directs or influences work carried out by a worker* o Engages or causes to engage a worker to carry out work (including through o subcontracting) o Has management or control of a workplace.

*A worker is anyone who carries out work for the agency and includes, for example, employees, volunteers, students on clinical placement, contractors (including Visiting Practitioners) and subcontractors.

• Ensure, as far as is reasonably practicable, the health and safety of other persons when they are visiting the workplace (eg. patients, hospital visitors and sales representatives).

• Ensure they consult, cooperate and coordinate with all other organisations with which the Agency shares a work health and safety duty in relation to the same matter eg organisations that lease property on Agency premises.

IMPLEMENTATION

Health and safety in the workplace is a key business risk and must be considered in all planning decisions of the Agency. The Chief Executive, and other officers, should actively drive WHS through communication structures embedded in the Work Health and Safety Management System.

–  –  –

CONTENTS

1 Introduction

1.1 About This Document

1.2 Enterprise Risk Management

1.3 Key Definitions

1.4 Legislative Framework

2 Key Features of the Legislation

3 Overview of a Work Health & Safety Management System

3.1 What is a Work Health Safety (WHS) Management System?

3.2 Components of an Work Health Safety Management System

4 Components of a WHS Management System

4.1 WHS Policy/Statement of Commitment

4.2 Management Responsibility: Structures and Governance Arrangements

4.3 Planning Process

4.3.1 WHS and strategic, operational and service delivery planning

4.3.2 Incorporating WHS in the planning process

4.3.3 WHS Planning

4.4 Consultation, representation and participation

4.4.1 Consultation duties of an Agency

4.4.2 What is reasonably practicable in relation to the duty to consult?

4.4.3 Purpose of consultation

4.4.4 When is consultation required?

4.4.5 How to consult – consultative arrangements

4.5 Risk Management

4.5.1 What is risk management?





4.5.2 The risk management process

4.5.3 Risk management and consultation

4.5.4 Specific requirements for high risk activities/high risks

4.5.5 Record Actions Taken

4.5.6 Multi-layered control strategies

4.6 Information, Training, Instruction and Supervision

4.6.1 Duty to provide information, training, instruction or supervision

4.6.2 Information

4.6.3 Training

4.6.4 Keeping training records

4.6.5 Instruction and Supervision

4.7 Injury Treatment and Management

4.8 Claims Management

4.9 Incident Recording, Investigation, Analysis and Review

4.9.1 Investigating, Analysing and Reviewing Incidents and Near Misses................. 22 4.9.2 Triggers for investigating incidents

4.9.3 NSW Ministry of Health reporting requirements

4.9.4 WorkCover NSW reporting requirements

–  –  –

4.10 Measuring and Evaluating WHS Performance

4.10.1 System Audits

4.10.2 Compliance checks/audits

4.10.3 Hazard specific audits

4.10.3.1 Incident investigation

4.10.4 Remedial action

4.11 Reviewing the WHS Management System

4.12 Chief Executive Reporting and Leadership

5 ADDITIONAL INFORMATION

5.1 Health Surveillance

5.2 Registers and plans

5.2.1 Register of Injuries

5.2.2 Risk Register

5.2.3 Hazardous Substances Register - ChemAlert

5.2.4 Asbestos and ACM Register and Labelling

5.2.5 Asbestos Management Plan

5.3 Health and Safety Representatives - Provisional Improvement Notices

5.4 When a WorkCover Inspector Visits

5.4.1 Powers to Enter a Workplace

5.4.2 Role of the WorkCover Inspector

5.4.3 Powers on Entry

5.4.4 Powers to obtain information, documents or evidence from a person............... 29 5.4.5 Enforcement measures

5.4.6 Display a Copy of a Notice issued by an Inspector in the workplace............... 29

5.5 When a Union Representative Visits – Entry Permit Holders

5.5.1 Protocols with unions

5.5.2 Powers to Enter a Workplace

5.5.3 Conditions for Entering a Workplace

5.5.4 Register of WHS entry permit holders - Industrial Relations Commission......... 31 RESOURCES

Standards

Key Codes of Practice

LIST OF APPENDICES

–  –  –

1 Introduction

1.1 About This Document The purpose of this document is to provide a framework within which the Work Health and Safety (WHS) Act 2011 and Work Health and Safety Regulation 2011 can be implemented in all Agencies.

It has been developed so that officers (as defined in section 1.3), managers and supervisors can

understand the scope of the role they have in contributing to:

• The development, implementation and monitoring of a Work Health and Safety (WHS) management system; and

• A safe and healthy workplace.

The document is divided into the following sections:

Section 1 Introduction Section 2 Key Features of the Work Health and Safety legislation Section 3 Overview of a WHS Management System Section 4 Components of a WHS Management System explained, along with the requirements of duty holders and Section 5 Additional information.

Information in each section has been arranged to include, at the beginning, the responsibilities of officers and managers.

Note: Injury management and return-to-work are important components of any WHS management system and are separately addressed through PD 2013_006 Injury Management and Return to Work Policy and Procedures as injury management and return to work are not covered by WHS legislation.

In this document the term:

• Must and will – indicate a mandatory action required that must be complied with

• Should – indicates a recommended action that should be followed unless there are sound reasons for taking a different course of action.

To support the standards provided in this document, particular guidance around specific risk areas, such as Work Health and Safety – Other Workers Engagement (GL2013_011) and Fatigue – Preventing and Managing Work Related Fatigue (GL2007_023) can be found in NSW Health Guidelines http://www0.health.nsw.gov.au/policies/groups/pers_ohs.html and Information Sheets, such as Asbestos Management and Hazardous Chemical Management can be found at http://internal.health.nsw.gov.au/jobs/safety/index-safety.html.

–  –  –

1.2 Enterprise Risk Management Throughout this document the process described for the management of WHS risks is, where appropriate, consistent with the requirements of the NSW Health Risk Management Framework (PD2009_039 Enterprise Wide Risk Management Policy and Framework).

However it must be noted that the risk management standard, AS/NZS ISO 31000:2009, on which the Enterprise Wide Risk Management Policy and Framework is based has limited application to WHS as some of the strategies allowed by generic risk management processes are not acceptable under WHS legislation. For example, risk cannot be transferred to another party and a level of risk cannot be accepted. Under the WHS legislation, risk must be eliminated or, if that is not reasonably practicable, minimised so far as is reasonably practicable.

1.3 Key Definitions Agency: Throughout this document the term agency is used to mean: all public health organisations and all other bodies and organisations under the control and direction of the

Minister for Health or the Director-General of Health. Agencies include:

• The NSW Ministry of Health

• A Local Health District

• A statutory health corporation

• An affiliated health organisation in respect of its recognised establishments and recognised services.

Officers: An ‘officer’ means a person who:

• Makes or participates in decision making that affects the whole or a substantial part of the agency

• Has the capacity to affect significantly the agency’s financial standing.

Officers are generally only those people at the most senior levels of an agency who are in a position to prevent contraventions of the Work Health and Safety Act 2011. This will include Chief Executives, and is also likely to include other senior executives with substantial agency wide responsibilities such as Directors of Finance and Directors of Clinical Operations. Middle level managers and supervisors are generally not officers as their role is to implement the decisions of others or report to more senior levels within their Agency.

Members of Health District Boards are also likely to be considered as officers; however a Board Members Guideline has been developed to assist them with fulfilling their specific obligations.

Other persons: include patients, consumers, clients, customers, sales representatives and visitors entering or utilising the public health organisation’s workplaces.

Person conducting a business or undertaking (PCBU): Under the Work Health and Safety Act 2011 the term ‘employer’ is replaced by ‘persons conducting a business or undertaking’ (PCBU).

A PCBU conducts a business or undertaking alone or with other PCBUs, and is responsible for the primary duty of care for workplace health and safety, as far as is reasonably practicable.

The PCBU does not need to be a natural person and in NSW Health a PCBU is an agency ie:

• The NSW Ministry of Health

• A Local Health District

• A statutory health corporation

• An affiliated health organisation in respect of its recognised establishments and recognised services.

Worker: Anyone who carries out work for NSW Health is given the legal status of ‘worker’,

Workers include:

–  –  –

• Employees;

• Contractors, including Visiting Practitioners;

• Sub-contractors;

• Sub-contractors and employees of contractors;

• Employee of a labour hire company e.g. agency staff;

• Volunteers;

• Apprentices or trainees; and

• Students on clinical, work experience or other placements.

1.4 Legislative Framework The WorkCover Authority of NSW is the regulator of WHS in NSW.

It administers work health and safety, injury management, return to work and workers compensation laws and manages the workers compensation system in NSW.

See Appendix 1 for the Legislative Framework.

2 Key Features of the Legislation The Chief Executive must ensure that officers within the Agency are aware of their WHS obligations.

The NSW Work Health and Safety Act 2011 and Work Health and Safety Regulation 2011 have

introduced some significant changes to work health and safety in NSW. These include:



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