Element - 2 NEBOSH IG1 - How health and safety management systems work and what they look like

How health and safety management systems work and what they look like

Learning Outcomes:

• Give an overview of the elements of a health and safety management system and the benefits of having a formal/certified system
• Discuss the main ingredients of health and safety management systems that make it effective – policy, responsibilities, arrangements

2.1 What they are and the Benefits they bring: The Basics of a Health and Safety Management System: the ‘Plan, Do, Check, Act’ Model

In the Element 1, we saw that managing occupational health and safety is important and there is no doubt left that if businesses have to survive then organizations have to manage their occupational health and safety risks. The next question that comes in our mind is how we can efficiently manage health and safety in our organization? The answer lies in a simple management model known as the Deming Cycle. This cycle is also known as the P-D-C-A cycle or the Plan- Do –Check- Act cycle. It is a cycle which remains rotating continuously. It starts with:

1. Plan: This involves setting up a target and planning of how it can be achieved.
2. Do: This involves implementing the plan in a systematic way.
3. Check: Periodically the targets set, needs to be checked whether they are been achieved or not and whether the results achieved are in line with the expectations.
4. Act: This step closes the cycle indicating whether any improvements need to be made for any unachieved targets and at the same time deciding on new targets, for those which are achieved.

The above cycle is used in creating management systems like ILO-OSH 2001, ISO 9001, ISO 14001 and ISO 45001:2018.

ILO’s Occupational Safety and Health Management System (ILO-OSH: 2001 Model) The key elements are:

1. Policy (PLAN)
2. Organizing (PLAN)
3. Planning and Implementation (DO)
4. Evaluation (CHECK)
5. Auditing (CHECK)
6. Action for Improvement (ACT)
7. Continual Improvement. (ACT)

Policy: It is a statement of intent made by the top management showing their commitment with respect to aims and objectives in maintaining and practicing good safety and overall reducing accidents or even achieving zero harm.

Organizing: This element speaks about the roles and responsibilities of various levels towards health and safety, delegation of authority, and channel of communication, within the organization, right from the MD to the assembly worker and also that of specialist staff.

Planning and Implementation: This element will focus on detailed arrangements to go about achieving the targets set in the policy section. While policy speaks about ‘what needs to be achieved’, this section speaks about ‘how it can be achieved’. This section will have procedures for carrying out risk assessments, accident investigations, etc. 

Evaluation – (Monitoring, Review, Measurement, and Investigation): This includes methods to monitor and measure the performance. Some monitoring methods could be proactive like for e.g., a safety tour, safety sampling and safety survey while others could be reactive like for e.g., measuring accident, absenteeism and ill-health data.

Audit: It is a planned, systematic and critical evaluation of the health and safety management system by a competent person. It will identify weaknesses and suggest changes in the health and safety management system implementation process or in the setting of inadequate or unrealistic targets. The audit will also ensure that the organisation is in compliance with necessary legislation according to the nation and previous audit records.

Action for improvement: It is at this stage the results of monitoring are compared to the set objectives and targets. If the set targets are achieved, then enhanced targets can be set for the future, but if targets are not met, then the organization needs to evaluate the reasons for nonachievement and take corrective and Preventive actions. It may be necessary to make changes either in the policy, organizing or the planning sections. 

Continual Improvement: The health and safety management system follow a continuous cycle; it needs to continuously progress and achieve better and greater targets. The whole idea is not to remain static but to keep on continually improving.

ISO 45001:2018: Occupational Health and Safety Management System (H&SMS)

ISO 45001:2018 is the newly developed health and safety management system certification standard to replace OHSAS 18001. It adopts Annex SL top-level framework for ensuring enhancement in overall health and safety performance of an organisation. Being a key driver for any organization, this standard has set of procedures and standards for helping the organization to achieve its OH&S objectives. Moreover, it encourages the inputs of internal and external stakeholders as part of developing the risk-based approach to health and safety management.

Similar to OHSAS 18001, this globally recognized certification standard incorporates the PDCA concept into the Annex SL top-level framework.

Clause 1: Scope

The scope highlights the requirements for establishing and implementing occupational health and safety management system (OH&S) in an organisation and also provides guidance to achieve the intended outcomes of its management system which includes 

1. Enhancing health and safety at work
2. Complying with legal and other requirements
3. Dealing with non-conformities and system deficiencies
4. Accomplishing continual improvements in OH&S performance
5. Satisfying the needs and expectations of workers and other stakeholders

Clause 2: Normative references

There are No regulatory references associated with the new ISO 45001:2018. It is simply included for maintaining consistent numbering across all ISO management system standards

Clause 3: Terms and definitions

This clause explains the terms and definitions applicable to the specific standard. For example,

Term “Occupational health and safety opportunity“ defined as circumstance or set of circumstances that can lead to improvement of OH&S performance

Term participation defined as involvement in decision- making. It includes health and safety committees and workers’ representatives.

For detailed guidance about terms and definitions related to ISO 45001:2018, refer

• ISO Online browsing platform: available at https:// www.iso.org/obp
• IEC Electropedia: available at http://www. electropedia.org/

Clause 4: Context of the organisation (H&SMS framework):

Focuses on  the  evaluation  of  the  “context”  of  an organisation which includes:

1. Understanding the organization and its context (e.g. number of workers, size, geography, culture, technology used, ethical and environmental responsibility, legal requirements and other requirements)
2. Understanding the needs and expectations of workers and other interested parties
3. Determining the scope of the OH&S managements system by considering internal and external issues, work-related activities etc.
4. Establishing and implementing OH&S management system as per the standards and requirements prescribed in the ISO 45001:2018

Clause 5: Leadership and worker participation

Details about how the organization provides guidance on:

1. Demonstrating leadership, commitment and active support from top, senior, middle and junior management categories
2. Developing an OH&S policy
3. Specifying roles, responsibilities and authorities to achieve the intended objectives of OH&S management system
4. Outlining the processes in relation to consultation and participation of workers

Clause 6: Planning (Plan)

This clause specifies the plan to:

1. Identify and assess the risks and opportunities involving organisation and workers
2. Address the risks and opportunities that have been identified
3. Prepare and respond to the identified risks, opportunities and other emergency conditions
4. Manage legal and other requirements

Clause 7: Support (Do)

For proper functioning of OH&S management system, this clause discusses the requirements of support on

1. Resources (e.g. human, natural, infrastructure)
2. Competence
3. Awareness (i.e. OH&S policy and OH&S objectives)
4. Communication (i.e. Internal and external)
5. Documented information

Clause 8: Operation (Do)

Briefs on the operational planning and control requirements relating to the OH&S management system covering:

1. Elimination of hazards and reduction of OH&S risks
2. Management of change (i.e. introduction of new products, changes in legal requirements, any technological advancements etc.)
3. Procurement of products and services, contractor’s activities and operations and outsourcing arrangements
4. Emergency preparedness and response

Clause 9: Performance evaluation (Check)

It encompasses the following to evaluate the performance of OH&S management system:

1. Monitoring, measurement, analysis and performance evaluation
2. Internal audit
3. Management review

Evaluation of compliance

1. To ensure the compliance with the legal and other requirements, the organisation should
2. Establish and maintain the process and systems to fulfil the compliance obligations
3. Have adequate knowledge to understand its compliance status
4. Identify and take actions regarding non-compliance, if needed
5. Retain documented information as evidence of the compliance evaluation results

Clause 10: Improvement (Act)

To ensure perfections and continual improvement of the OH&S management system, this clause takes into account of the following aspects:

1. Incident (e.g. near misses, ill-health, injuries)
2. Non-conformity (e.g. incompatible PPE, breaching legal requirements, violating manufacturer’s instructions)
3. Corrective action (e.g. finding out the root cause of the incident, reviewing the non-conformities)
4. Ways to achieve the continual improvement (e.g. safe work practices, new technology, seeking assistance from experts and third party consultants, competence enhancement)

Benefits of having a Formal/ Certified Health and Safety Management System:

1. A formal occupational health and safety management system approach is increasingly favoured by regulators throughout the world, and may be legally required in some regions
2. Modern goal-setting legalisation implies the need for an occupational health and safety management system as a form of self-regulation
3. Multi-national organisations favour a consistent, standardised approach throughout the organisation - just like the business management system (‘globalisation”)
4. Having a certified health and safety management system gives a competitive edge to organizations as it is an effective way to prove to their customers and other stakeholders that their health and safety is well managed and the products/ services offered by them are produced in a safe and healthy environment.
5. Many national and international tenders require the bidder to have a certified health and safety management system. Hence it makes business and economic sense for the organization to adapt to a formal system.

2.2 What Good Health and Safety Management Systems look like:

The Occupational Health and Safety Policy (as per Clause 5.2, ISO 45001:2018):

Role / Typical Content / Proportionate to the Needs of the Organisation:

Top management must establish, implement and maintain an OH&S policy that:

1. includes a commitment to provide safe and healthy working conditions for the prevention of work-related injury and ill health and is appropriate to the purpose, size, and context of the organization and to the specific nature of its OH&S risks and OH&S opportunities.
2. provides a framework for setting the OH&S objectives
3. includes a commitment to fulfil legal requirements and other requirements
4. includes a commitment to eliminate hazards and reduce OH&S risks.
5. includes a commitment to continual improvement of the OH&S management system.
6. includes a commitment to consultation and participation of workers, and, where they exist, workers’ representatives. 

The OH&S policy shall:

1. be available as documented information
2. be communicated within the organization
3. be available to interested parties, as appropriate
4. must be relevant and appropriate.

Typical Content

The health and safety policy is a written document which usually consists of the following three sections:

1.   General Statement of Intent:

The purpose of the statement of Intent section in health and safety policy is to:

1. State and illustrate the overall Aims and Objectives and a clear picture of management’s commitment towards health and safety.
2. Set objectives and quantifiable performance targets.

Difference between Aim, Objectives and Targets

Aim:

• Purpose or intention of the management commitment (intangible)
• Remains unchanged during policy revision

Objectives are longer term goals that are directly linked to the commitments in the companies’ health and safety policy such as:

• Meeting the legal requirements
• Provision of adequate health and safety training to all
• Risk assessment of all the relevant workplace activities.

Targets are linked to the objectives and are more easily measurable and aid in continual improvement. Some examples are:

• Meeting all the legal requirements related to mining department within the next 6 months.
• Ensuring 80% health and safety training completion within the next 12 months.
• Completion of 100% risk assessments for all the manufacturing activities in the next 12 months.

Ideally each policy commitment is supported by at least one objective and each objective at least by one target. Targets are Specific Performance requirements.

Specific reduction in:

• Number of accidents
• Cases of work-related ill health
• Sickness absence
• Number of civil claims
• Enforcement notices

Increase in:

• Reporting near miss / incidents / minor accidents
• Number of H & S trained employees
• H & S audit scores

Setting of SMART and Quantifiable Targets:

Now, we know that target setting is an essential part of the statement of intent and once targets are set only then they can be pursued and only then can we keep on measuring whether we have achieved the targets or not. Essentially the setting of targets and achieving it leads to continual improvement.

Let us now understand what we mean by SMART targets and how they can be set.

The targets set should be SMART, the acronym SMART stands for the following:

S – Specific - a clearly defined precise target

M – Measurable - it is possible to quantify the target

A – Achievable - can be achieved. (Agreed Upon)

R – Realistic - possible to achieve with the available time and resources

T- Timely - a deadline is set to achieve the target.

Let us look at an example of a target which is not SMART:

“Reduce the number of accidents”—here though the target talks about accidents it is not possible to measure it.

Let’s now convert the above target into a SMART target:

“Reduce the number of accidents to 50% of the previous years within the next 12 months”.

Organization shall consider following factors when setting objectives:

1. Responsibility of setting the targets: This responsibility lies with the top management and they are set with guidance received from safety professionals and in consultation with workforce.
2. Setting of targets at each divisional and departmental level: The targets and objectives set by the top management becomes the basis of targets set at the departmental level. Individual managers are given their individual targets and they, then cascade it down the line to individual workers. In this way each individual in the organization becomes aware of not only the companies’ objectives but also the role he or she is going to play in achieving it.
3. Ensuring legal compliance: While setting objectives and targets, the organization needs to check whether there is any legal compliance pending and if yes, it is a good idea to convert its implementation into a time bound target.
4. The hazards and risks present: The hazards inherent in the workplace and the risks created must be taken into account when setting the objectives. This to ensure that only the relevant hazards are pursued for improvement rather than trivial or irrelevant. For e.g.: a construction company has to be more concerned about working at height and excavation rather than the risks involved to keyboard operators.
5. Use of technology: As the technology improves and we know that this improved technology not only aids in improving productivity and quality but also provides with new ways of reducing the risks present, hence adopting of new technology to aid in managing the risks could also be taken up as an objective. For e.g. it is now possible to keep a track of lone workers on the field through mobile phones and GPS, while a few years back organizations had to rely on landline phones and pagers.
6. Financial, operational and business requirements: For a safety objective to be implemented it requires not only financial support but also resources in terms of managerial time and proper planning. This tells us that the safety objectives need to be seamlessly integrated with the other non-safety objectives so that they can be implemented without any conflicts with other goals.
7. Views of interested parties: Target setting, though the responsibility of the top management, it needs to be set only after due consideration of the views of all the interested parties. This will not only provide a holistic approach but also motivate the people whose views have been taken. To achieve this, workers, managers and supervisors could be consulted. Customers’ views could be taken, auditor’s comments and suggestion in the audit reports can also be referred to while setting the objectives.

Organization Section:

The purpose of organization section in health and safety policy is to define structure, role, and responsibilities, delegation of authority, channel of communication etc. within the organization.

Sample organization chart showing the chain of command
and the flow of information from top to bottom

Arrangement Section:

The purpose of arrangement section in health and safety policy is to list out the details of systems and procedures employed to achieve the aim set out in the statement section.

Proportionate to the Needs of the Organisation:

It should be clear to us that a policy written for one company may not be suitable for another organization because of various changes like location, product, processes, equipment etc. Some industries are inherently high risk like oil and gas installation, their requirements and policies would be completely different from that of a cement manufacturing plant. Every organization is free to create their own policies and procedures, but the only requirement here is health and safety should be managed correctly, there should be legal compliance and the system should lead to continual improvement

Responsibilities – all workers at all levels of an organisation have responsibility for health and safety

While the statement of intent tells us, what needs to be achieved, the organization section tells us who will achieve it.

This section deals with people and their operational duties in relation to health and safety. It outlines the chain of command for health and safety management and identifies the roles and responsibilities of staff to enable clear delegation of duties.

The Organization section will usually consist of an organization chart showing the chain of command and the flow of information from top to bottom and the flow of feedback which is normally from bottom to top. This section will include the following groups together with their associated responsibilities.

The MD or CEO is ultimately responsible and accountable for the entire organization

Managers and supervisors at all levels are responsible for correctly interpreting the policy and cascading down the line the top managements’ objectives and targets. Creating effective plans and procedures to achieve these targets and continuously monitoring them both by active and reactive ways. They are responsible for the day-to-day working of the organization and reporting of both successes as well as shortcomings. All employees are responsible for acting safely by following the procedures laid down.

Competent persons like fire marshals, first aiders and occupational nurses are also provided with operational duties.

Health and safety practitioners are responsible for providing the correct advice to the management and employees in achieving the overall safety.

Impact of Allocation of Responsibilities in Health and Safety Policy

• Make sure all the workers in the organization are aware of their roles and responsibilities in achieving the aims set out in the health and safety policy statement
• Motivate the workforce by highlighting senior management’s commitment and efforts in enhancing health and safety culture of the organization
• Helps to identify individual competencies and training needs

Practical Arrangements for Making it Work:

After having understood what is to be done and who will do it, let us now understand how it is to be done. The Arrangements section as the name suggests talks about the arrangements that will help in achieving the set objectives and targets in a systematic way.

What needs to be part of the arrangements section, depends upon the company, its product and its operations. For.eg, a manufacturing company handling heavy equipments needs to have procedures in place for heavy lifting using cranes, while a call center needs to have procedures in place to take care of workplace stress endured by their employees.

Some general health and safety arrangements are as follows:

• Employee health and safety code of practice.
• Accident investigation and reporting.
• Identifying and providing health and safety information, instruction and training.
• Consultation with workers in issues concerning health and safety.
• Emergency preparedness including fire procedures.
• Welfare and first- aid provision.
• Monitoring of plant and equipment, their maintenance and risk assessments.
• Developing safe systems of work and permit to work systems to control hazards.
• Developing effective lines of communication
• Implementing corrective and preventive actions for management of hazards
• Provision of PPE, storage space for the same and training to use them.
• Ensure effectiveness of arrangements by periodic assessments with different techniques and strategies

Some of the specific health and safety arrangements are as follows:

• Lone working.
• Noise / vibration control.
• Control of exposure to toxic materials.
• Control of contractor and visitors.
• Control of transport risks.
• Waste disposal

Keeping it current: when you might need to review the health and safety management system

A policy once made cannot be considered as a document which can exist for a lifetime. To keep the policy ‘live’ and ‘current’, a cycle of reviewing and revising (if required) the policy needs to be done. There are many reasons as to why a policy needs to be reviewed:

• Change in the legislation.
• Enforcement agency after an audit or an accident investigation finds fault in the policy.
• There is a change in the management structure.
• There is an introduction of new machinery, processes or technology.
• There have been changes following consultations with the employees.
• When requested by a third party such as an insurance agency or a client.
• Where an audit, investigation or risk assessment suggests that the policy is no longer valid.
• After sufficient time has elapsed after the previous review (e.g. most organizations have an annual review).

Summary

• Health and safety management system is a process of well-coordination, systematic and structured approach to effectively manage health and safety risks at workplace
• The following things should be considered to develop and maintain effective health and safety management system in an organization.
• Clear defined policy
• Well-defined plans
• Strong management commitment
• Provision of sufficient resources
• Systematic training programme
• Effective monitoring and reporting of performance
• Process for reviewing and enhancement
• PDCA Cycle (Plan-Do-Check-Act) or PDSA Cycle (Plan-Do-Study-Act) is a continuous four-stage management model that is used to gain expertise knowledge for the continual improvement of a product or service. It is also known as Deming Cycle
• Stages of PDCA cycle
  

S.No	Stage	Function
1	Plan	<   Identify and define the problem <   Determine the root cause of the problem
2	Do	<   Find solutions to the identified problem <   Test the solutions on a small scale <   Measure the results of different solutions
3	Check	<   Measure effectiveness by comparing the results <   If not satisfied with any of the results, repeat “Do” and “Check” phases until a comprehensive solution is obtained
4	Act	<   Implement the solution which has high success rate <   Repeat the phases for further continual improvement of products or services

• ILO Guidelines on Occupational Safety and Health Management Systems (ILO-OSH 2001) based on the stages of “Plan- Do-Check-Model”. Its key elements are pointed out in the below table

1	Policy (Plan)	<   Employer develops clear and concise written occupational safety and health (OSH) policy based on the inputs from workers and their representatives <   OSH policy ensures -         Protection of safety and health of all employees -         Prevention of work-related injuries -         Compliance with national laws and regulations -         Participation of workers for continual improvement of OSH management system
2	Organizing (Plan)	< Employer and senior management allocates responsibility, accountability and authority right from top level to bottom level of workforce for development and enhancement of OSH management system

3	Planning and Implementation (Do)	<   In this section, the employers develop plans with systematic approach for effective implementation of OSH management system <   Plans are developed and prioritized based on the deficiencies found in the -         Initial review -         Risk assessment
4	Evaluation (Check)	<   This section deals with measure and monitor of safety and health performance to reveal when and where improvement is needed <   Two types of monitoring methods −    Active monitoring – Checking safety and health standards before unwanted event occurs. E.g. Safety inspections, safety sampling, safety tours and surveys −    Reactive monitoring – Reacting after things have gone wrong. E.g. Accidents and incidents investigation, injuries and illness, absenteeism, property damage or near misses
5	Audit (Check)	< In this section, audit is carried out by the competent person to determine whether health and management system is effective in satisfying the organizational health and safety policy and objectives
6	Action for Improvement (Act)	<   In this section, arrangements are made to implement preventive and corrective actions suggested by OSH management system audits and management reviews −    Corrective Action: §   Eliminate the cause for a detected non-conformity (deviates from prescribed standards) and its recurrence §   It is based on past events −    Preventive Action: §   Eliminate the cause for non-conformity to occur. §   It is based on future Example of corrective and preventive action Bike stops in the middle of a road on a long journey and the problem is due to carbonization of spark plug. In this case Corrective action: Carry extra spark plug on a long journey Preventive action: Identify potential problems that may occur and establish remedies for the same
7	Continual improvement	<   In this section, the above mentioned steps are repeated for further enhancement of health and safety management system

• ISO 45001:2018 is the newly developed health and safety management system certification standard to replace OHSAS 18001. It adopts Annex SL top-level framework for ensuring enhancement in overall health and safety performance of an organisation It is also based on PDCA cycle and its key elements are:

1	Context of the organisation (H&SMS framework)	Establish and implement OH&S management system by evaluating organization and its context
2	Leadership and worker participation	Specify roles, responsibilities and authorities to achieve the intended objectives of the OH&S management system
3	Planning (Plan)	Suggest action plans to identify and assess the risks and opportunities involving organisation and workers
4	Support (Do)	Discuss the requirements of support like resources, competence, communication for effective functioning of OH&S management system
5	Operation (Do)	Brief on the operational planning and control requirements relating to the OH&S management system
6	Performance evaluation (Check)	Evaluate the performance of OH&S management system by means of monitoring, internal audit etc.
7	Improvement (Act)	Recommend the ways to eliminate non-conformities and achieve the continual improvement of the OH&S management system

• Benefits of having a formal/certified health and safety management system
• Having a certified health and safety management system gives a competitive edge to organizations as it is an effective way to prove to their customers and other stakeholders that their health and safety is well managed and the products/ services offered by them are produced in a safe and healthy environment.
• Many national and international tenders require the bidder to have a certified health and safety management system. Hence it makes business and economic sense for the organization to adapt to a formal system
• Occupational health and safety policy with reference to clause 5.2, ISO 45001:2018 Top management must establish, implement and maintain an OH&S policy that:
• includes a commitment to provide safe and healthy working conditions for the prevention of work-related injury and ill health and is appropriate to the purpose, size, and context of the organization and to the specific nature of its OH&S risks and OH&S opportunities.
• provides a framework for setting the OH&S objectives
• includes a commitment to fulfil legal requirements and other requirements
• includes a commitment to eliminate hazards and reduce OH&S risks.
• includes a commitment to continual improvement of the OH&S management system.
• includes a commitment to consultation and participation of workers, and, where they exist, workers’ representatives.
• The health and safety policy is a written document which usually consists of following three sections
• General Statement of Intent - State and illustrate the overall aims and objectives and a clear picture of management’s commitment towards health and safety
• Organization Section - Define structure, role, relationships, and responsibilities of key personnel within the organisation
• Arrangement Section - List out the details of systems and procedures employed to achieve the aim set out in the statement section
• Organization section deals with people and their operational duties in relation to health and safety
• Impact of allocation of responsibilities in health and safety policy
• Make workers aware of their roles and responsibilities in achieving the aims set out in the health and safety policy statement
• Motivate the workforce by highlighting senior management’s commitment and efforts in enhancing health and safety culture of the organization
• Help to identify individual competencies and training need

• Arrangement section describes about the arrangements that will help in achieving the set objectives and targets in a systematic way
• Some of the general health and safety arrangements are as follows
• Employee health and safety code of practice
• Accident investigation and reporting
• Identifying and providing health and safety information, instruction and training
• Consultation with workers in issues concerning health and safety
• Emergency preparedness including fire procedures
• Welfare and first- aid provision
• Monitoring of plant and equipment, their maintenance and risk assessments
• Developing safe systems of work and permit to work systems to control hazards.
• Some of the specific health and safety arrangements are as follows:
• Lone working
• Noise / vibration control
• Control of exposure to toxic materials
• Control of contractor and visitors
• Control of transport risks.
• Health and safety policy may be reviewed for the following reasons
• Change in the legislation
• Enforcement agency after an audit or an accident investigation finds fault in the policy.
• Change in the management structure
• Introduction of new machinery, processes or technology
• Employee consultation