• Section 1 - Summary
• Section 2 - TEQSA/ASQA/ESOS Alignment
• Section 3 - Scope
• Section 4 - Definitions
• Section 5 - Policy Statement
• Section 6 - Procedures
• Part A - Summary of Roles and Responsibilities
• Part B - Monitoring Workplace Health and Safety
• Monitoring the health of workers 
• Monitoring safety in work areas 
• Monitoring the implementation and effectiveness of WHS risk controls 
• Monitoring WHS induction, training, competency and worker WHS performance
• Monitoring WHS actions 
• Monitoring legal and other requirements 
• Maintaining equipment for safety monitoring and measurement 
• Part C - Monitoring of WHS Management System
• Auditing the WHSMS 
• Review of WHS documents 
• WHS Management System Management Review 
• Performance Evaluation
• Section 7 - Supporting Documents and Information

Section 1 - Summary

(1) This Procedure sets out the requirements for monitoring and evaluating the performance of workplace health and safety processes, and the health and safety of workers at Victoria University in order to provide oversight of workplace conditions and identify improvements for the Workplace Health and Safety Management System (WHSMS).

Section 2 - TEQSA/ASQA/ESOS Alignment

(2) HESF: Standard 2.3 Wellbeing and Safety.

(3) Standards for Registered Training Organisations (RTOs) 2015 (Cth): Standard 8.

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

Section 3 - Scope

(5) This Procedure relates to all activities under the management and control of Victoria University and applies to affected workers; including staff, students, contractors and visitors. 

Section 4 - Definitions

(6) Hazard - Anything that has the potential to cause harm, injury, illness.

(7) Audit – means a systematic, independent and documented process for obtaining audit evidence and evaluating it objectively to determine the extent to which the audit criteria are fulfilled.

(8) Objectives - Objectives state what is intended to be accomplished.

(9) Organisational Units - This term is used as a collective term for the following: Faculty, Division, School, Department, Directorate, Centre and Business Units.

(10) Performance indicators - are measures to review whether objectives have been met. They include rates, ratios or indices which reflect how well the WHS management systems or its elements are operating.

(11) Targets - define a detailed quantified performance requirement that arises from the WHS Objectives that needs to be met in order to achieve those objectives.

(12) WHS Monitoring - A systematic process of observing how activities are being performed and assessing whether this is consistent with documented OHS risk management practices, standards and legislative requirements.

(13) WHS Performance - The performance related to the effectiveness of the prevention of injury and ill health to workers; including staff, students, contractors and visitors, and the provision of safe and healthy workplaces.

Section 5 - Policy Statement

(14) Health and Safety Policy

Section 6 - Procedures

Part A - Summary of Roles and Responsibilities

Part B - Monitoring Workplace Health and Safety

Monitoring the health of workers 

(15) The health of workers is actively monitored by Heads of Units, WHS Consultants/Advisors and the Occupational Health team via hazard and incident reports. These include reports about workplace incidents, exposure to occupational hazards, and any impacts of non-work-related injuries or ill health. Hazard and incident reporting is governed by the Health and Safety - OHS Incident Reporting and Investigation Procedure.

(16) WorkCover claims arising from workplace incidents are monitored by the relevant WHS Committee via de-identified data. 

(17) Where hazardous activities are reasonably likely to lead to ill health, the health of workers performing these activities is proactively monitored through department/school’ health surveillance program and participation is determined via consultation with the HSW Team. 

Monitoring safety in work areas 

(18) Workplace health and safety risks are monitored via regular review of the WHS Risk Register, local area risk registers, and centrally and locally managed risk assessments. These documents detail workplace risks, risk levels and required risk controls, to enable Heads of Units and Managers/Supervisors to understand and manage WHS risks in the work areas under their control. These processes are governed by the Risk Management Procedure.

(19) The provision of emergency management and safety systems is monitored by Operational Planning & Asset Management.

(20) Monitoring of first aid equipment is outlined in the Health and Safety - Workplace First Aid Procedure.

(21) Workplace conditions are monitored via regular workplace inspections, which provide a visual check that hazards and risks are being managed appropriately in the workplace, as per business unit local inspection plans. Inspections should include checks of fire equipment and first aid kits. 

(22) For work being undertaken by contractors, a monitoring program is developed by the Contractor Responsible Person, and is tailored to the type of work being conducted, as outlined in the Health and Safety - Contractor Management Procedure - General Contractors.

(23) Workplace safety is also monitored via hazard and incident reporting, to understand how workplace conditions may be impacting on workers, and where workplaces can be improved to eliminate or reduce risks to workers. This is managed according to the Health and Safety - OHS Incident Reporting and Investigation Procedure.

Monitoring the implementation and effectiveness of WHS risk controls 

(24) WHS risk controls are implemented to manage specific workplace health and safety risks. Requirements for WHS risk controls are documented in the HSW procedures and guidance material, risk registers, risk assessments, local safe work instructions, and WHS action plans (arising from hazard and incident reports, evacuation reports, workplace inspection reports, self-assessments, audits and WHS plans).

(25) Where work activities or work areas require specific WHS risk controls, the implementation and effectiveness of these controls is monitored by Managers/Supervisors and workers. Controls are monitored through consultation with workers or by direct observation during an inspection or a spot check. These observations, together with any WHS actions (if required), are recorded in the Workplace Inspection Checklist. Monitoring the effectiveness of WHS risk controls is overseen by the local WHS committee as part of the local WHS performance reporting. 

Monitoring WHS induction, training, competency and worker WHS performance

(26) To ensure workers have sufficient information and training to perform their work safely, Managers/Supervisors monitor completion of required WHS inductions and training (and refresher training) by workers in their business unit, including for staff, students, visitors and contractors from other units or organisations. The development and implementation of local WHS inductions and training, and competency in local procedures, is also monitored. 

(27) WHS induction and training records, including local records are checked regularly. Periodic checks of worker competency and safe work practices can be performed via on-the-job observation, with reference to the local WHS training procedure and relevant safe work instructions. 

(28) Performance of appointed health and safety roles is monitored by Heads of Units, including ensuring that local WHS committee meetings are held regularly, sufficient numbers of safety and emergency personnel are appointed, and WHS performance and progress with the WHS plan is monitored. These requirements are outlined in the Health and Safety - Accountability and Responsibilities Procedure.

Monitoring WHS actions 

(29) WHS actions arise when a WHS issue is identified and cannot be resolved immediately. They may arise from WHS plans, WHS audits, hazard and incident reports, workplace inspections, building evacuations, risk assessments, local WHS committee meetings, changes to legislation or other external requirements, and feedback during consultation about workplace changes. 

(30) Unit managers/supervisors assign WHS actions to an individual to be completed by a due date using ELUMINA QuickSafe. HSW Business Partners monitor the completion of WHS actions via ELUMINA QuickSafe, and report this information to local WHS committees for review.  

(31) See Flowchart: Reporting Hazard related to maintenance/facilities and Health and Safety - Issue Resolution Procedure.

Monitoring legal and other requirements 

(32) Legal and other external requirements are monitored by Victoria University Risk and Compliance team, Legal Compliance Officers and Health and Safety Leaders for implementation. The Director, Workplace Relations and Safety determines if any other external requirements should be incorporated into the Workplace Health and Safety Management System (WHSMS). 

(33) WHS Legislation updates are communicated at local WHS Committee Meetings by HSW Advisors/Business Partners.

Maintaining equipment for safety monitoring and measurement 

(34) Equipment used to monitor or measure levels of WHS hazards (e.g. levels of radiation, gases or noise) must be calibrated and maintained according to the manufacturer’s/supplier’s instructions and any applicable legislation, to accurately monitor workplace safety. 

(35) Records of maintenance and calibration are kept locally and reviewed regularly by the Managers/Supervisors responsible for the area or workers.

Part C - Monitoring of WHS Management System

Auditing the WHSMS 

(36) See HSW-1.6-GL-5-1.0 WHSMS Internal Audit Guideline.

(37) See HSW-1.6-GL-6-1.0 WHS Inspections Guideline.

Review of WHS documents 

(38) Regular review of WHS plans, WHS risk register, WHS policies, procedures, guidelines and associated tools is monitored by the Health Safety & Wellbeing (HSW) team. 

(39) Local WHS Committees monitor the regular review of risk registers and WHS plans for their unit. 

(40) Review of local WHS documents, WHS procedures, local risk assessments, safe work instructions and safety posters is undertaken by Managers/Supervisors and workers to ensure these documents are kept up to date. 

WHS Management System Management Review 

(41) Health, Safety and Wellbeing leaders must conduct a periodic management review of the organisation’s Workplace Health and Safety Management System (WHSMS).

(42) The management review must determine the: 

1. Adequacy of resources affecting WHS and wellbeing performance; 
2. Trends in risks and opportunities; 
3. Trends in incident investigations, non-conformities, corrective actions and continual improvement; 
4. Extent of meeting the Health and Safety Policy and strategic objectives; 
5. Changing circumstances related to WHS including: 
   1. Legal and other external requirements; 
   2. Interested parties; 
   3. Risks and opportunities; and, 
   4. Recommendations for improvement. 

(43) Outputs of the management review, including decisions and actions, are to be implemented to facilitate continual improvement of WHS performance and inform the strategic direction of the WHSMS.

Performance Evaluation

(44) Indicators of WHS performance are monitored to look for opportunities to continuously improve how WHS is being managed. A combination of lagging and leading indicators of WHS performance are regularly evaluated by local WHS Committees. Organisation-wide opportunities for improvement are documented in the WHSMS Management Review for action. 

Section 7 - Supporting Documents and Information

(45) Health and Safety - Accountability and Responsibilities Procedure

(46) Health and Safety - Hazard Management Procedure

(47) Health and Safety - Issue Resolution Procedure

(48) Health and Safety - OHS Consultation and Participation Procedure

(49) Health and Safety - OHS Incident Reporting and Investigation Procedure

(50) Health and Safety - Workplace First Aid Procedure

(51) HSW-1.6-GL-5-1.0 WHSMS Internal Audit Guideline

(52) HSW-1.6-GL-6-1.0 WHS Inspections Guideline