• Section 1 - Summary
• Section 2 - Scope
• Section 3 - Policy/Regulation
• Section 4 - Procedures
• Part A - Summary of Roles and Responsibilities
• Part B - Governance, Accountability and Roles
• Principles
• Roles and Responsibilities
• Part C - Monitoring Workplace Health and Safety (WHS)
• Monitoring Worker’s Health 
• Monitoring Workplace safety
• Monitoring WHS risk controls and actions
• Monitoring WHS induction, Training, Competency and Worker WHS Performance
• Legal & Other Requirements
• Safety Monitoring Equipment
• Part D - Monitoring WHS Management System (Assurance)
• Auditing the WHSMS  
• Three Levels of WHS Assurance 
• Review of WHS Documents 
• Management Review 
• Part E - Performance Evaluation and Reporting
• Part F - Escalation and Issue Resolution
• Part G - Records and Systems
• Section 5 - HESF/ASQA/ESOS Alignment
• Section 6 - Definitions

Section 1 - Summary

(1) This Procedure defines how Victoria University (VU) governs, assigns accountability for, and assures the performance of its Workplace Health and Safety Management System (WHSMS). It sets out roles and responsibilities, monitoring and audit mechanisms, and performance evaluation processes to drive continuous improvement.

Section 2 - Scope

(2) This Procedure applies to all activities under the management and control of Victoria University and applies to all University staff, students, contractors and visitors. 

Section 3 - Policy/Regulation

(3) Health and Safety Policy

Section 4 - Procedures

Part A - Summary of Roles and Responsibilities

(4) See Part B ‘Roles and Responsibilities’ below. 

Part B - Governance, Accountability and Roles

Principles

(5) Accountability requires accepting responsibilities and owning outcomes. Leaders at all levels must demonstrate due diligence, resource the WHSMS appropriately, and verify that controls and processes are operating as intended.

(6) VU measures and holds people to account through:

1. Measurement against university Workplace Health and Safety (WHS) performance targets and objectives;
2. Safety management system auditing (internal/external);
3. Performance management and development processes, with HSW responsibilities incorporated into position descriptions and assessed via annual performance appraisals.

Roles and Responsibilities

Part C - Monitoring Workplace Health and Safety (WHS)

Monitoring Worker’s Health 

(7) VU monitors worker health to ensure risks are effectively managed through: 

1. incident/hazard reports, occupational health reviews, and WorkCover claims data, in accordance with the Health and Safety - OHS Incident Reporting and Investigation Procedure.

Monitoring Workplace safety

(8) VU monitors workplace safety across all areas through: 

1. Tracking WHS risks through regular review of central and local risk registers, and by conducting risk assessments in accordance with the Risk Management Procedure; 
2. Monitoring emergency systems through Operational Planning & Asset Management; 
3. Checking first aid equipment as per the Health and Safety - Workplace First Aid Procedure; 
4. Reviewing workplace conditions through regular inspections, including fire equipment and first aid kits, in line with local inspection plans;
5. Overseeing safety performance via hazard and incident reporting, in accordance with the Health and Safety - OHS Incident Reporting and Investigation Procedure; and, 
6. Monitoring contractor safety through tailored programs developed by the Contractor Responsible Person, as per the Health and Safety - Contractor Safety Management Procedure.
7. See Flowchart: Reporting Hazard related to maintenance/facilities and Health and Safety - Issue Resolution Procedure.

Monitoring WHS risk controls and actions

(9) VU ensures that risk controls and corrective actions are in place and effective by: 

1. documenting WHS controls in procedures, risk registers, assessments, and action plans;
2. Managers and workers monitoring controls through consultation, inspections, and spot checks;
3. Local WHS committees reviewing the effectiveness of controls; 
4. Initiating WHS actions when issues cannot be resolved immediately. They may come from audits, inspections, incident reports, risk assessments, committee meetings, WHS plans, legislative changes, or consultation feedback; 
5. Assigning and tracking actions in Elumina Quicksafe; and, 
6. HSW Business Partners providing oversight and reporting to WHS committees.

Monitoring WHS induction, Training, Competency and Worker WHS Performance

(10) VU ensures that all persons performing work are trained and competent by: 

1. Requiring completion of mandatory WHS inductions, training and refreshers; monitoring local competency in procedures;
2. Maintaining accurate, current training and induction records; verifying competency and safe work practices through record reviews and on-the-job observation;
3. Requiring Heads of Units to oversee WHS role performance, ensure WHS committees meet regularly, appoint sufficient safety and emergency personnel, and track progress against WHS responsibilities. 

Legal & Other Requirements

(11) VU ensures compliance with legal and other requirements by: 

1. Risk, Compliance and WHS leaders monitoring legislative and regulatory changes and assessing implications; 
2. Communicating updates and required actions through WHS Committee meetings.  

Safety Monitoring Equipment

(12) VU ensures safety monitoring equipment remains effective by: 

1. Calibrating and maintaining safety monitoring devices (e.g., noise, gas, radiation) in accordance with relevant standards and manufacturer requirements;
2. Keeping accurate maintenance/calibration records with regular managerial checks.

Part D - Monitoring WHS Management System (Assurance)

Auditing the WHSMS  

(13) VU monitors WHSMS compliance by conducting internal audits in accordance with HSW-1.6-GL-5-1.0 WHSMS Internal Compliance Audit Guideline (Tier 2). 

Three Levels of WHS Assurance 

(14) VU maintains assurance over WHS performance through three levels of monitoring and review: 

1. Tier 1 - Local Area Inspections (First Level of Assurance)
   1. Local managers, supervisors and staff conduct inspections across business units, colleges and work areas; 
   2. Approved University checklists are used (e.g., General Office Area OHS Inspection) specialist providers are engaged for regulatory checks (e.g., fire systems, chemical storage, HVAC); 
   3. Hazards are identified proactively; compliance is confirmed; and risk management at the operational level is verified.  
   4. Refer to HSW-1.6-GL-6-1.0 WHS Inspections Guideline (Tier 1). 
2. Tier 2 – Compliance Audits (Second Level of Assurance)
   1. Internal audits conducted by the HSW Team using the approved audit tool;
   2. Objective reviews confirm procedures and statutory requirements are met, and Tier 1 inspections are completed; 
   3. Assurance is provided that the WHSMS is operating as intended and improvements are identified;
   4. Refer to HSW-1.6-GL-5-1.0 WHSMS Internal Audit Guideline (Tier 2). 
3. Tier 3 – External Audits (Third Level of Assurance)
   1. External audits coordinated by external Audit and Risk Management functions, independent of WHS operations; 
   2. Senior leadership and governance bodies receive assurance of compliance and the effective application of Tiers 1 and 2; 
   3. Validation that the WHSMS is robust, fit for purpose and strategically aligned; 
   4. Where elected, certification audits against ISO 45001 and surveillance audits are conducted by an external body.

Review of WHS Documents 

(15) The HSW Team reviews WHS policies, procedures, plans and registers for accuracy, relevance and currency; local committees and managers maintain up-to-date risk registers, procedures and safe work instructions for their areas.

Management Review 

(16) HSW leaders conduct regular management reviews of the WHSMS to assess:  

1. Adequacy of resources and overall WHS performance; 
2. Emerging risk and opportunity trends; 
3. Incident data and corrective action outcomes; 
4. Compliance with legal and external requirements; 
5. Alignment with WHS policy and strategic objectives.

(17) Findings and required actions arising from these reviews must be implemented to drive continuous improvement of the WHSMS.

Part E - Performance Evaluation and Reporting

(18) VU assesses WHS performance using both leading and lagging indicators (see HSW-1.6-F-14-1.0 HSW KPIs). Local WHS Committees review results and record improvement opportunities in the WHSMS Management Review.

(19) University-level targets and objectives are reviewed periodically to support continuous improvement and accountability.

Part F - Escalation and Issue Resolution

(20) WHS issues that cannot be resolved locally are escalated in accordance with the Health and Safety - Issue Resolution Procedure and the relevant governance pathway.

Part G - Records and Systems

(21) WHS actions are assigned and tracked in Elumina Quicksafe; audit and inspection records, training/competency records and calibration/maintenance records are retained per University records requirements.

Section 5 - HESF/ASQA/ESOS Alignment

(22) HESF: Standard 2.3 Wellbeing and Safety; 7.3 Information Management.

(23) Compliance Standards for NVR Registered Training Organisations and FPP Requirements 2025: Standard 20 Compliance with Laws.

(24) This Procedure also aligns with ISO 45001:2018 Clause 9.

Section 6 - Definitions

(25) Performance indicators: Measures (rates, ratios, or trends) used to assess whether objectives are being achieved.

(26) WHS Monitoring: A systematic process of checking whether work is carried out safely and in compliance with standards and laws.

(27) WHS Performance: Effectiveness in preventing injury and illness and providing a safe workplace.