Partnerships in Injury Reduction Audit...

Audit Report

Audit for

Covenant Health – St. Michaels Health Centre

October 20, 2014

2012 CCSA Audit Report

2

Table of Contents Executive Report 3

Employer Information 4

Contact Information 4

Scope of Audit 4

Auditor Information 5

Company Profile / Explanation of Audit Scope 6

Scoring Summary Results 7

Conclusion 8

Appendix – Organization ChartError! Bookmark not defined.

Appendix – Summary Site and Interview Sampling Information Sheet 12

Appendix – Site Information Sheet 14

Appendix – Pre-Audit Meeting Minutes 16

Appendix – Post-Audit Meeting Minutes 17

Detailed Audit Report 18

1. Management Leadership and Organizational Commitment 19

2. Hazard Identification and Assessment 29

3. Hazard Control 37

4. Ongoing Inspections 48

5. Qualifications, Orientation and Training 56

6. Emergency Response 63

7. Incident Investigation 68

8. Program Administration 77

Observation Report 85


3

Executive Report

Employer Information

Employer Name:

(As registered with WCB)

Covenant Health - St. Michael’s Health Centre

Employer Trade Name:

(If applicable)

Billing Address: 1400 9th Avenue South, Lethbridge, Alberta T1J 4V5

Contact Information

Name: Geoff Hoeppner Phone: 780-342-8736

Email: [email protected] Fax: 780-342-8744

Scope of Audit

COR No.: 20090810-2435 COR Expiry:

Audit Type:

☐ External / COR Certification

X Internal / COR Maintenance

Audit Purpose:

☐ External / Renewal

X Internal

☐ Qualifying Audit

Total Facilities: 2 Facilities Audited: 2

WCB Account No(s). 3156836 WCB Industry Code(s):

Start Date: End Date:

Report Date:


5

Auditor Information

Privacy, Confidentiality, Conflict of Interest and Disclaimer Statement:

The Audit will be conducted with the utmost integrity, confidentiality and no conflict of interest. The facts

stated in the audit will be recorded accurately and according to the information received at the time of the

audit. The intent of the audit is to give guidance, enhance current programs, and suggestions for

improvement, not to undermine any current processes in place, or assume liability for changes or use of

the document for any reason other than the original intent. I agree to submit my audit within an

acceptable time frame and address all deficiencies in a timely manner. I hereby certify that I participated

in at least one (1) of the three (3) key areas of conducting the audit (documentation review, interviews

and observations). Additionally, if this is my qualifying audit I certify that I have written the Audit Report in

my own words.

Lead Auditor: Name: Matthew Godarzi Phone: 780-342-8733 Company: Covenant Health Fax: 780-342-8744 Address: 11111 Jasper Avenue, Certification: 094-13 Edmonton, Alberta T5K 0L4

X Documentation x Interviews x Observations Date: October 20, 2014

Audit Team Members:

Name: Phone:

Company: Fax:

Address: Email:

Certification:

Address: Email:

Certification:

☐ Documentation ☐ Interviews ☐ Observations Date:


6

Company Profile / Explanation of Audit Scope

Covenant Health is Canada's largest Catholic provider of healthcare, serving 12 communities across Alberta. Their facilities provide a range of healthcare services, including acute care, continuing care, assisted living, hospice, rehabilitation and respite care, and seniors' housing. Serving people of all faiths, cultures and circumstances, Covenant health builds on a 150-year legacy of providing compassionate, quality care in Alberta. Included in the scope of the audit were two of the Covenant Health facilities in Lethbridge, including the St. Michaels Health Centre and St. Therese Villa

St. Michael’s Health Centre Built on the legacy of the Sisters of St. Martha of Antigonish, who founded St. Michael’s Hospital in 1929, St. Michael’s Health Centre was opened in 2001 and serves those in Southern Alberta who need continuing care, inpatient and outpatient rehabilitation programs and services, and palliative care. It is a state of the art residential-style facility was constructed on the historic 13th Street site of the old St. Michael’s Hospital. The residential model ensures personal choice, dignity and respect for the patients and residents who are accommodated in individual and personalized rooms in smaller home-like groupings. St. Michael’s Health Centre offers a multi-faceted range of rehabilitation, palliative and

continuing care services. St. Therese Villa, Lethbridge The new Villa opened April 15th, 2008 as part of the St. Martha’s Care Group, St. Michael’s Housing Association, whose roots go back to 1929 and St. Michael’s Hospital, founded by the Sisters of St. Martha of Antigonish. St. Therese Villa provides Designated Assisted Living (DAL) combining accommodation services with other supports and care with 196 staff, and has a 200 bed capacity. Nursing staff work 3 shifts that cover the 24 hour period. The facility meets the needs of a wide range of people, but not those who have highly complex and serious health care needs. St. Therese Villa offers their residents requiring assisted living a place where they are treated with kindness and compassion and an environment in which their dignity is preserved


7

Scoring Summary Results

Element Number

Total

Points

Possible

Points not

Applicable

(N/A)

Total

Points

Points

Scored

Final

Score

1. Management Leadership and

Organizational Commitment 115 0 115 108 94%

2. Hazard Identification and

Assessment 170 0 170 148 87%

3. Hazard Control 160 0 160 114 71%

4. Ongoing Inspections 95 0 95 87 92%

5. Qualifications, Orientation and

Training 100 0 100 92 92%

6. Emergency Response 110 0 110 73 66%

7. Accident and Incident

Investigation 125 0 125 97 78%

8. Program Administration 125 0 125 112 90%

Total Audit Points

1000

0

1000

831

83%


8

Conclusion

It was a pleasure to conduct this audit for Covenant Health. On-site activities were conducted on all two

sites included in the scope of the audit between September 9 and September 12. A total of 68 interviews

were conducted, sampling staff from a wide variety of departments, positions, shifts, experience, etc. The

auditor would like to thank all employees for their co-operation and participation in bringing this audit to a

successful completion. Managers, Supervisors and Workers from all work areas and shifts did their best

to supply all the required documentation and interview information.

Areas of Key Strength:

Employees had a good overall awareness of their specific health and safety responsibilities, as

well as hazard and incident reporting requirements.

All work areas had very consistent and up to date hazard assessment documentation in place.

All workplace inspections were completed as quarterly required within the Units/departments.

All employees received job specific training and completed orientation within the first week of

employment.

All investigations reports are reviewed by Manager and Supervisors.

There is a system is in place to communicate health and safety issues with employees, provide

feedback opportunities, and ensure follow up on health and safety issues.

The health and safety system is evaluated annually through the use of an audit process

Areas of Key Suggestions:

A hard copy of Current Alberta OH&S Legislations wasn’t readily available in the sites. It is

suggested to ensure a current copy of Alberta OH&S Legislations is kept at all units /departments

which is readily accessible to the all staff, and the staff are made aware of the legislation copy.

Some health and safety hazard had not been identified for job and task in the Units/departments

(included cytotoxic drugs, O2 cylinder, etc.). It is suggested that all units/department, to review

their hazard assessments to ensure that each sampled position specific Task Hazard assessment

systematically identified the health and safety hazards related to the position’s key tasks.

There are lack of some measures and procedures to control some of the risks in facilities. These

risk included violence (patient abuse) airborne pathogen, cytotoxic and hazardous drugs, etc. It is

suggested to

Review the existing control measures and determine whether they are adequate.

Consultant with OHS team to identify other controls which may be needed to reduce the risk.

(Examples: N95 mask, cryogenic gloves, safety procedures, buddy system, training, panic

alarms, security cameras…)


9

Observation indicated employees are using surgical mask during their work activity and also that

PPE were kept in locking room and weren’t readily available to employees in the care Units that.

Documentation verified that most of the employees have been not fit tested for N95 mask at both

sites. Ensure all employees are using proper PPE in their work are as outline in Alberta OHS

codes (Part 18 Section 228) and Covenant Health policy and procedures regarding. In addition,

all PPEs must be readily available within the Units/departments.

Worker participation and involvement in key OHS activities such as hazard assessments, formal

safety inspections, and incident investigations is inconsistent and lacking in areas. It is suggested

to foster enhanced worker participation in these activities, as well as increase the communication

of such participation and the outcomes of the activities to all affected staff. This will ensure that

workers’ perspectives are sufficiently addressed and included, and contribute to the overall buy-in

and promotion of a positive health and safety culture. It is further suggested consider keeping a

hard copy of updated hazard assessments (with sign-off sheet) and completed work place

inspection in the binders within the units.

Some of the employees who did not believe that they received appropriate OHS training (include

hazard assessment, work place inspection, incident investigation, and emergency response,

etc.). And also, they unaware if key employees who conducting incident investigation, hazard

assessment and work place inspection have received training had not received on these

techniques. It suggested encouraging all employees to complete Covenant Health OHS online

training courses (included OHS awareness for workers awareness, and workplace abuse &

harassment, etc). It is further suggested to create a spreadsheet and transfer all training

activities into the spreadsheet in order monitor all employees training activities (included online

OHS training courses, annual and refresher training, job specific training).

The generic Workplace Inspection Checklist mainly represents patient care areas, and although it

can be modified, little customization was observed in the sampled documentation in the units /

departments. It is suggested to develop area / operation specific inspection checklist templates

for each of the main departments / types of work areas (i.e. dietary, housekeeping, maintenance,

etc.), and to make those available to all locations.

Although there are some supplies and equipments available in the both sites, both sites do not

meet all legislature requirements for First Aid as outlined in Alberta OHS cods, part 11. This

requirement included provision of first aid services supplies and equipment ( lack of first aid kid’s

#3), first aid kit are not visible readily available, first aid provider (LPN and RN completed online

supplementary first aid course), designated first aid area, first aid signage etc. It is suggested to

implement Covenant Health first aid plan in both sites to comply with Legislations.

23% of interviews indicated that some employees have not been able to participate in emergency

drill. Also, employees stated that some of the emergency response drills had not been conducted

after OHS representative left the site. It is suggested to conduct regularly emergency drill with all

units and all shifts to ensure employees is kept up-to-date on emergency procedures for the site.

It is further suggested to continue with the practice of reviewing the code of the month with all

staff members.

Only 40% of sampled incident investigation reports properly identified direct, indirect and root

causes, and had appropriate recommended corrective actions documented. It is suggested that

thorough root cause analysis is applied to all investigations to determine the most effective

preventative measures, and that this be properly and fully documented in the investigation reports

or other attached information. It is further suggested to ensure that all recommended corrective

action be also properly and fully documented on the investigation report forms. This ensures that

investigations result in the most effective recommendations to prevent recurrence, and that these

recommendations can be tracked more effectively.


10

Although an action plan had been developed as a result of the previous audit, several item of

action plan had not been completed. Also, some employees interviewed were unaware of

previous audits results and action plan. It is suggested to ensure that an action plan is developed

and systematically implemented over the next year. It is further suggested to ensure all

employees are aware of audit process and action plan results. This can be done by discussing

the audit with the employees through the OH&S meetings and Staff meeting, and also posting

action plan on OHS board

Overall the both sites have a comprehensive health and safety management system in place. It is very apparent that a large amount of work has gone into the development and implementation of the health and safety program and preparation for this audit. Congratulations on a good score which is well deserved by the ongoing, consistent dedication and efforts of all staff. To maintain the Certificate of Recognition and to receive the WCB PIR incentives an external audit will again be required to renew the COR prior to the date stated on the Certificate of Recognition in 2015. Thank you once again and keep up the good work. Please contact myself if you have any questions, comments, or require further assistance. Sincerely, Matthew Godarzi


11

Appendix – Organization Chart


12

Appendix – Summary Site and Interview Sampling

Information Sheet

Employer: Covenant Health – St. Michael’s Health Center

BC Account #: 3156836 Industry Code: 82705 – Health Units

Total Number of Sites: Minimum Number of Sites: Total # of Sites included in

Audit:

Contractors and volunteers? X Yes ☐ No # Interviewed: 4

Total 71

Detailed Representative Sampling Information:

Interview Sampling Details

Department Shift Total #

Interviewed Department

Shift Total # Interviewed D E N D E N

Senior Managers 1 n/a n/a 1 Rehabilitation 2 1 0 3

Managers 4 n/a n/a 4 Education 2 1 0 3

RN 3 2 1 6 Social Services 0 0 0 0

LPN 4 3 3 10 Administration 7 0 0 7

HCA 3 2 6 11 Pharmacy 1 0 0 1

RA 3 4 4 11 Laundry 1 0 0 1

Maintenance 3 0 0 3 Housekeeping 2 1 0 3

Dietary Services 2 1 0 3 Others:

Recreation 2 1 0 3

Total Number of Employees Interviewed: 67

Role

Number of Employees Total # of Employees Per

Role

Total # of Employees

Interviewed / Role Full-Time

Part-Time

Casual

Senior Managers 1 0 0 1 1

Managers 6 0 0 6 4

Supervisors 5 0 0 5 3

Workers 167 186 179 532 59

Total # of Employees: 544

Minimum # of Interviews Required: 64

Total # of Employees Interviewed: 67


13

Work Site Sampling Details

List each site under the WCB Account #

Included in Audit

Scope?

Total Number of Employees

Number Interviewed

St. Michael’s Health Centre Yes 333 42

St. Therese Villa Yes 211 29

NOTE: if there is more than one site included in the audit, one Site Sampling Sheet must also be

completed for each site and included in the Audit Report.

Additional Explanation of sampling if required:


14

Appendix – Site Information Sheet Site Name: St. Michael’s Health Centre

Account #: 3756836 Industry Code: 82705 – Health Units

Site Specific Detailed Interview Sampling:





Senior Managers 1 n/a n/a 1 Recreation 1 0 0 1

Managers 3 n/a n/a 3 Rehabilitation 2 1 0 3

RN 1 2 1 4 Education 1 0 0 1

LPN 2 2 1 5 Social Services 0 0 0 0

HCA 1 0 3 4 Administration 6 0 0 6

RA 1 1 2 4 Pharmacy 1 0 0 1

Maintenance 2 0 0 2 Laundry 1 0 0 1

Dietary Services 3 1 0 4 Other:

Housekeeping 1 1 0 2 13



Role


Role Full-Time

Part-Time

Casual

Senior Managers 1 0 0 1

Managers 4 0 0 3

Supervisors 3 0 0 2

Workers 19 12 4 35



15

Appendix – Site Information Sheet Site Name: St Therese Villa

WBC Account #: 3756836 Industry Code: 82705 – Health Units

Site Specific Detailed Interview Sampling:





Senior Managers 0 0 0 0 Education 0 0 0 0

Managers 1 n/a n/a 1 Social Services 0 0 0 0

RN 2 0 0 2 Administration 1 0 0 1

LPN 2 1 2 5 Pharmacy 0 0 0 0

HCA 2 2 3 7 Others:

RA 2 3 2 7 Housekeeping Aramark Contract

Maintenance 1 0 0 1 Dietary services Aramark Contract

Recreation 1 0 0 1 Landry Aramark Contract

Rehabilitation 0 0 0 0 Aramark Contractors

3 1 0 4



Role


Role Full-Time

Part-Time

Casual

Senior Managers 0 0 0 0

Managers 1 0 0 1

Supervisors 1 0 0 1

Workers 11 9 3 23



16

Appendix – Pre-Audit Meeting Minutes

Date: September 10, 2014 Time: 8:30-9:30 Attendees: James Ostoya(Manager, Post Acute Rehab Program), Lian Baceda(Manager, LTC), Debbie Kohutek(Supervisor, Food Services), Lisa Zubach(Manager, Supportive Living, Dementia), Jim Riedhuber(Interim Site Manager), Deb Dodman(Aramark Lead), Tracy Kopp,( Executive Secretary) Agenda:

Introductions of audit team

Purpose of the audit

Sites included in audit and audit schedule

PIR and CCSA Partnerships audit instrument

Describe the audit process and the timing of the process 1. Review of documents 2. Interviews 3. Observation tour

Discuss confidentiality of audit process and auditor code of ethics

Post audit meeting is scheduled for Friday, December 6, 2013

Discuss FAQs and invite other questions or comments


17

Appendix – Post-Audit Meeting Minutes

Date: September 12, 2014 Time: 12:30-13:45

Attendees: James Ostoya(Manager, Post Acute Rehab Program), Lian

Baceda(Manager, LTC), Debbie Kohutek(Supervisor, Food Services), Lisa

Zubach(Manager, Supportive Living, Dementia), Jim Riedhuber(Interim Site Manager),

Deb Dodman(Aramark Lead), Tracy Kopp,( Executive Secretary)

Agenda:

A general overview of the audit

Debriefing of the audit findings:

Key Strengths for each element

Key Recommendations for each element

Scoring summary is not completed by this time so specific scores were not

discussed

Approximate timelines for audit report completion is October 19, 2013

Submission of final report to the CCSA for quality assurance review

Delivery of final report to facility once the quality assurance review has been

received from CCSA

in hard copy and digital format

Invite questions from all participants

Thank you to all participants for their involvement and cooperation in the audit

process


18

Detailed Audit Report


19

Continuing Care Safety Association for Safety Partnerships

Audit Report – November 2011

1. Management Leadership and Organizational Commitment

Questions Score Instructions Notes

1.1 Is there a written Health and Safety

Policy for the organization?

(5 points)

5

Verified by reviewing written policy.

Must be a policy document.

To award the 5 points, the policy must

include:

- declaration of management commitment to

health and safety

- overall goals and objectives

- general responsibilities of managers,

supervisors, workers and contractors

regarding health and safety

- requirement to comply with applicable

government regulations

- requirement to comply with organization’s

own health and safety standards

Strength: Covenant Health has a Health and

Safety Policy (# II-130) contained in the Corporate

Policy and Procedures Manual. The policy states

that Covenant Health is committed to providing a

safe place to work, basic responsibilities and

accountabilities for all employees, physicians,

volunteers, students and contractors, including the

responsibility to perform their work according to

legislative requirements and company standards,

as well as the overall goals of achieving zero harm

through the promotion and encouragement of

occupational health and safety and the mitigation

and elimination of workplace hazards and risks.

Full points were awarded based on the

completeness of the reviewed policy.

1.2 Is the policy signed by the current

senior operating officer?

(2 points)

2

Verified by reviewing documentation.

The signature must be that of the current

senior operating officer.

Strength: The health and safety policy is signed by

current president and CEO of the Covenant Health

Patrick Dumelie.

2 out of 2 points were awarded based on reviewed

of documentation.


20


1.3 Is the policy readily available to

employees?

(0-3 points)

3

Verified by observation or employee

interviews, as applicable.

Determine the method used by the employer

to make the policy readily available.

The current policy may be posted on bulletin

boards, in lunchrooms and/or reception

areas, and may be in employee handbooks,

safety manuals, and/or on computer.

Points are awarded based on the percentage

of positive observations, or on the

percentage of positive responses from

interviews.

Strength: 96% of interviews and 92% of

observations indicated that the Health and Safety

Policy is readily available to employees at both

sites.

The policy was observed to be posted on OHS

Board and in key areas throughout the facilities.

Interviews stated that the policy was also

discussed during orientation; new employees

received a copy of it.

3 out of 3 points were awarded based on the

percentage of positive indicators from the

interviews and observations.

1.4 Are employees aware of the policy’s

content?

(0-5 points)

5

Verified by employee interviews

Employees should be able to explain, in

general terms, the policy content.


of positive responses from interviews

Strength: 94% of employees interviewed were

aware of the general content of the Health and

Safety Policy. Interviewees provided examples of

the policy’s key messages, such as Covenant’s

overall commitment to health and safety, their

requirement to provide a safe working environment,

and that established standards and policies must

be followed, as well as the shared responsibility for

health and safety between all persons in the work

place.

5 out of 5 points were awarded based on the percentage of positive interview responses


21


1.5 Have specific health and safety

responsibilities been written for:

a. Managers? (5 points)

b. Supervisors? (5 points)

c. Workers? (5 points)

d. Contractors? (5 points)

5

5

5

5

Verified by reviewing documentation,

other than the policy (e.g. contracts, job

descriptions, and program manuals).

Depending on size or nature of the

organization, one or more of these

categories may not be applicable (n/a).

Strength: Documentations reviewed indicated that

health and safety responsibility have been writ ten for all of the organizational levels from the Senior Leadership Team to the managers, Supervisors, Workers, contractors, volunteers, and students. The written responsibilities are comprehensive, appropriate and clearly stated for each category. Full points were awarded for each category based on the comprehensive written responsibilities for each level in the organization.

Full points were awarded for each category based

on the comprehensive written responsibilities for

each level in the organization.

1.6 Are the following aware of their specific

health and safety responsibilities

covered by legislation and

departmental policy:

a. Managers? (0-5 points)

b. Supervisors? (0-5 points)

c. Workers? (0-5 points)

d. Contractors? (0-5 points)

5

5

5

5

Verified by employee and contractor

interviews.

Points may be awarded even though specific

written specific responsibilities (in question

1.5) are not in place.


of positive responses from interviews.

Depending on size or nature of organization,

one or more of these categories may be not

applicable. (N/A)

Strength: 100% of Managers and Supervisors,

Contractors and 96% of employees and

Contractors interviewed were aware of their health

and safety responsibilities, and could provide

examples of that. Common examples of specific

health and safety responsibilities included following

safe work procedures, watching out for each other

safety, participating in hazard assessment process,

the requirement to report incident and hazards,

getting involved in OHS committees, etc.

Full points were awarded for each category of

managers, supervisors, contractors, workers and

based on the percentage of positive interview

response.


22


1.7 Are employees evaluated on their

individual health and safety

performance?




5

5

5

Verified by employee interviews.

Employees at all levels should be able to

explain how their OH&S performance is

evaluated. Some examples are performance

appraisal, discipline process for non-

performance, letters from the employer,

positive reinforcement by supervisors, job

safety observations, management and

supervisor reviews, etc.



Strength: 100% of Managers and Supervisors,

and 96% of Workers interviewed stated that they

were evaluated on their individual health and safety

performance. Employees received feedback and

health and safety performance evaluations verbally

during informal interactions with their supervisor or

manager, as well as during formal annual

performance appraisals. In addition, it was noted

that non-disciplinary interventions and a

progressive discipline process are in place to

correct performance as required.


on the percentages of positive interviews.

1.8 Does the senior operating officer

communicate to employees, at least

annually, the organization’s

commitment to health and safety?

(5 points)

5

Verified by employee interviews to

determine how this is done.

Points awarded for at least 70% positive

response from employees interviewed.

Strength: 95 % of employees interviewed

indicated that the President / CEO of Covenant

Health, as well as the Site Senior Operating

Officers do communicate the organization’s

commitment to health and safety several times per

year. The President / CEO communicate the

commitment to and importance of health and safety

during his appearance in the bELITE training

Video. Senior Operating Officers communicate

regarding health and safety through memos, in

meetings, committees, and informal interactions.

Full points were awarded based on the percentage

of positive interview responses exceeding the

required 70%.


23


1.9 Do the most senior managers on-site

tour the work site to reinforce health

and safety practices and behaviors:

Every 6 months? (10 points)

OR

Yearly? ( 5 points)

10


Senior manager tours can be concurrent with

other business purposes.

Not all sites need to be included in the tours.

Points are awarded for at least 70% positive

response from employees interviewed.

Strength: 98% of employees interviewed stated

that on-site senior management tours the work site

regularly to reinforce health and safety practices

and behaviors. Interviews stated that the frequency

of tours ranges from monthly, to weekly, to bi-

annually, depending on the site.

10 points were awarded based on more than the

required 70% of interviews indicating tours every 6

months or more often


24


1.10 Is relevant current health and safety

legislation readily available at work

sites?

(5 points)

0

Verified through observation at work

sites.

Copy(s) of current occupational health and

safety legislation (federal, provincial, and

municipal) appropriate to the operation of the

work site(s) should be present on site.


response from observations.

Strength: 65% of observations indicated that the

current Alberta Occupational Health and Safety

Act, Regulation, and Code (2013 revisions) was

readily available to employee by means of the

computers. Several employees that were asked

about their access to the legislation during the

tours weren’t also able to demonstrate how they

can find the legislation on line. There wasn’t any

hard copy of Alberta OH&S Legislations on both

sites.

Recommendations: It is suggested to ensure all

Employees have access to the hard copy of current

Alberta OHS Legislations, and that the location of

the legislation is posted within Unit s/Department if

it is not apparent.

No points were awarded based on percentage of

positive interview response being below the

required 70%.


25


1.11 Is there a process in place that

addresses contractor health and safety

while on site?

(5 points)

5

Verified by interviewing contractors on

site and reviewing documentation.


response from persons interviewed and

documentation to conform the process.

If no contractors are on site, then the score is

based on documentation. For example, look

for a documented contractor orientation

program that ensures all contractors are

oriented to the hazards at their site.

Strength: 81% of interviews and 80% of reviewed

documentation reviewed indicated that a process in

place to address contractor safety while they are

on site. The health and safety policy states that

contractors will comply with the all applicable

legislations. Also formal contractor’s information

package provided to all contractors covering

comprehensive information including

responsibilities, work permits, start-up meetings,

and emergency response procedures, fire safety,

locations of emergency response equipment and

first aid, and infection controls. Interview confirmed

that items are discussed and followed.

Recommendation: It is further suggested to

review the process to address contractor health

and safety for some of the other types of

contractors being used on sites, such as persons

dealing with biomedical equipment, physicians, etc.

These types of contractors are not covered under

the standard contractor information package, and

generally not monitored by facility maintenance.

Establishing standardized processes and

responsibilities for the management of these

contractors will ensure greater consistency across

the various departments/units and sites.

5 out of 5 points were awarded based on the percentage of positive indicators exceeding 70%


26


1.12 Is there a process in place that

addresses visitor health and safety

while on site?

(5 points)

5

Verified by review of documentation or

employee interviews.

An external auditor is considered a visitor on

site.

Points are awarded based on at least 80%

positive indicators from documentation or

interviews.

Strength: 93% of the interviews and 100% of

reviewed documentation indicate that a process is

in place to address visitor health and safety while

on site. This procedure include posted information

and signage in facilities and, keeping restricted

access areas locked, staff monitoring visitors and

responding to any issues , hand washing and

infection, prevention procedures, on site protective

services and, check in and outs of units visitors,

interaction with staff . Also, Interviews indicated

that visitor health and safety is protected by

ensuring that the building and overall environment

are kept clear and free of hazards, Practicing good

housekeeping.


of positive indicators from the reviewed

documentation and interviews exceeding the

required 80%.


27


1.13 Does the employer provide the health

and safety resources needed (workers,

equipment methods, materials, and

money) to implement and improve

health and safety?




4

5

4



of positive interview responses

Strength: 80% of managers interviews,

100%supervisors interviews, and 72% of worker

interviewed stated that the sufficient resources are

provided to implement and improve health and

safety .Examples of resources include JWHS

committees, education and ongoing training,

personal protective equipments, extra funding to

address issues /emergency, code of the month

reviews, etc.

Recommendation: 20% of Managers, and 28% of

Workers interviewed felt that the resources

available to implement and maintain health and

safety at the work site were Insufficient. The

biggest concern voiced was a lack of time to keep

up with the required health and safety activities and

ensure worker participation. Other areas of concern

focused on a need for more hands-on training for

some critical skills, issues with aging equipment

and short staffing levels. It is suggested that

regular communications and dialogue with staff

from all work areas and shifts is promoted and

enhanced, so that issues can be discussed and

addressed in an ongoing basis. This will ensure

that resources are allocated to maintain the health

and safety of the work environment, and to support

the front line staff in their service delivery.

4 out of 5 points were awarded for the Manager

and Worker interviews based on the interview

responses and 5 out of 5 points awarded for

Supervisors.


28


Total Points Possible: 115

Audit Score

Total points possible: 108 - Points not applicable (N/A) 0 = Total points 108 Total Points scored = 108

(divided by)

X 100 = FINAL SCORE 94%

Total points = 115


29

2. Hazard Identification and Assessment


2.1 a. Does the employer have a list of all

jobs carried out at the work site?

(0-15 points)

b. Has the employer compiled a list of

all tasks associated with each job?

(0-15 points)

30


A list of employee occupations/jobs should

be in place, and the various tasks within

those occupations/jobs should be identified.


of jobs and tasks inventoried.

Strength: A very concise inventory of the

jobs/positions has been developed and updated through over two years (2011 and 2012). Each job has the breakdown of tasks associated with the performance of the specific job. The inventory includes a hazard assessment for each position. Hazards assessment binder maintained in administration office. Also an electronic copies are readily available online which maintained in the Database (K drive). Full points were awarded based on of percentage of job and tasks being inventoried


30


2.2 Are health and safety hazards identified

for the jobs and tasks?

(0-30 points)

29

Verified by reviewing documentation to

determine if there is a system in place to

identify hazards associated with the jobs and

tasks (Refer to 2.1).

Both health and safety hazards should be

identified to ensure that ergonomic risks,

exposure to chemicals, noise, heat stress,

etc. are addressed. Consider road safety if

driving is a component of the job inventory.


of jobs and tasks for which hazards have

been identified compared to the total number

of jobs and tasks identified. In other words,

the maximum score allowed for this

question will be determined by the total

score awarded in question 2.1.

For example, if only 50% of the points were

awarded in question 2.1, question 2.2 will be

scored out of 15 (50% of the original 30

points available for the question).

Key Strength: The review of the hazard

assessment documents indicated that all of the required position specific Typical Task Hazard Assessments were available at the units / departments sampled during the audit. Hazards assessments are address almost the entire hazards associate with the positions. Identified health and safety hazards includes chemical, physical, biological, and psychosocial Hazards. Recommendation: Documentation sampling in

care units indicated that hazard associated with cytotoxic drugs had not been identified within the care units. It is suggested that all care units, periodically review their hazard assessments to ensure that task hazard assessments are available for each position / job conducted in their area. This will ensure that health and safety hazards are identified for each job task. 29 out of 30 points were awarded based on the percentage of positive indicators from the reviewed documentation


31


2.3 Have the health and safety hazards

been evaluated according to risk?

(0-30 points)

29


There must be a system/process for

evaluating risk.

System should include an assessment of

the:

- Potential consequences of exposure to

the hazard (severity)

- Likelihood of an incident occurring

(probability)

- Degree of exposure to the hazard

(frequency)

This evaluation could be qualitative (High,

Medium, Low, A, B, C,) or quantitative (3, 2,

1).


of hazards that have been evaluated

compared to the health and safety hazards

identified in 2.2. In other words, the

maximum score allowed for this question

will be determined by the percentage score

awarded in question 2.2. (See question 2.2

for example.)

Strength: All health and safety hazards identified

in job Hazards Analysis forma are ranked according to the risk. The ratings are determined by combining of probability, frequency of exposure, and severity. Also, ranking hazards uses a 1 to 4 scale to rate each component. The maximum score is therefore 12.

Recommendation: It is suggested that the hazard

evaluation process is continued to be applied consistently when the existing hazard assessments are further refined.

29 out of 30 points were awarded based on the score achieved in question 2.2.


32


2.4 Are identified health and safety hazards

prioritized according to risk?

(0-30 points)

29

Verified by reviewing documentation to

determine if a system to assess the

evaluated hazards and rank them from the

highest to lowest. In other words, the

maximum score allowed for this question

will be determined by the percentage score

awarded in question 2.3.

Strength: All health and safety hazards in job

Hazards Analysis form are prioritized into low medium or high risk categories, based on the outcome of their risk evaluation and overall rating total. These total values represent three different risk / priority classifications. 3-6 points equates to low risk /priority, 7-9 to medium risk / priority, and 10-12 to high risk / priority. Recommendation: It is suggested that the hazard

evaluation process is continued to be applied consistently when the existing hazard assessments are further refined. 29 out of 30 points were awarded based on the score achieved in question 2.3.


33


2.5 Are workers involved in health and

safety hazard identification and

assessment?

(10 points)

0

Verified by review of hazard assessment

documentation and interviewing workers

to confirm whether the involvement in the

formal hazard assessment process is

meaningful.

At least 70% of those interviewed must be

aware of worker involvement to award

points. Not all workers need to be involved.

Worker involvement could be through health

and safety committees, teams, safety

representatives, projects, pre-job planning,

etc.

Strength: hazard assessment document review

indicated that the worker involvement in the hazard assessment process is clearly marked by naming the workers that are involved in the process. Element 2 of the Covenant Health Occupational Health and Safety Program states that employees performing the work being assessed must be involved in the hazard assessment through either direct participation or by reviewing the report completed by others. Recommendation: Only 67% of interviews

were aware of worker involvement in the health and safety hazard identification and assessment processes. It is suggested that the results of hazard assessment development, updates, or reviews be communicated to all affected workers, to ensure each employee is aware of the hazard assessment pertaining to their job and of the worker involvement and input opportunities in the hazard assessment process. No points were awarded based on less than the required 70% of interviews being aware of worker involvement in the identification and assessment of hazards.


34


2.6 Are key employees trained in the

process of hazard identification and

assessment?

(0-10 points)

6

Verified by review of documentation and

interviewing key employees.

Key employees lead the hazard assessment

process (team leaders, etc.).

Score: 0 - 5 points for documentation

0 - 5 points for interviews


of positive indicators.

Strength: 80 % of reviewed documentation and

39% of interviews indicating that key employees

have received training in the process of hazard

identification and assessment. Hazard identification

and assessment training is included in both the

Covenant Health Leaders and workers Guide to

Occupational Health and Safety courses, which are

available online. Training records indicated that

none of key employees have completed one of

these courses; however, Interviews indicated that a

number of them had attended CCSA and others

hazard assessment training.

Recommendation: It is suggested that all

Managers, Supervisors, and the Workers assigned

to participate in the hazard assessment process

complete this course as required by element 2

(hazard management) of the OHS program. This

will ensure that key persons are knowledgeable,

and better able to participate in and facilitate the

hazard assessment activities. It is further

suggested to provide in-house training sessions for

those employees who can’t use computers

4 out of 5 points were awarded based on the interview responses, and 2 out of 5 based on the available documentation.


35


2.7 Are the health and safety hazard

assessments reviewed when changes

to the operation are implemented?

(0-30 points)

25

Verified by records review and employee

interviews.

Documentation may include meeting

minutes, supervisor’s logbook, assessment

documents, etc.

Changes to the operation could include

introduction of new equipment, processes,

products, materials, etc.

Score: 0 – 10 points for documentation

0 – 20 points for interviews

Interview points are awarded based on the

percentage of positive indicators.

Strength: 90% of reviewed documentation and

81% of interviews indicated that health and safety

hazard assessments are reviewed when changes

to the operation are implemented. 95% of sampled

hazard assessments were current, last reviewed /

updated in 2014. In addition, seven specific

samples were noted of hazard assessments having

been completed or revised as a result of

implemented changes. 81% of employees

interviewed indicated that the Typical Task Hazard

Assessments are reviewed annually or that

changes are discussed when new equipment or

new procedures are implemented.

Recommendation: 19% of Interviews indicated

that some employees are unaware of the updated

hazard assessment when changes to the operation

are implemented. It is suggested to communicate

hazard assessment changes to the all employees.

To ensure that everyone has been included in this

communication, consider keeping a hard copy

sign-off sheet behind each hazard assessment in

the binders within the units.


positive indicators from reviewed documentation,

and 16 out of 20 based on the interview responses.

Total Points Possible: 170 148


36

Audit Score


(divided by)


Total points = 170


37

3. Hazard Control



38


3.1 Have hazard controls been identified

and implemented?

a. Engineering? (0-25 points)

b. Administrative? (0-25 points)

c. Personal Protective Equipment

(PPE)? (0-15 points)

20

20

12


observation as appropriate. Verification

process involves looking at the

recommended hazard control measure in the

hazard assessment document and verifying,

through either observation or documentation,

that controls have been put into place.


of controls implemented compared to the

number of hazards identified in question 2.4.

The maximum score allowed for this

question will be determined by the

percentage score allowed in question 2.4.

Strength: 80% of the reviewed documentation and

observations indicated that appropriate hazard

controls have been identified and implemented in

the various work areas. Engineering hazard controls

included mobile lifts and overhead lift systems,

trolleys, pallet jacks, carts, locked doors for

restricted access, noise enclosure, ergonomically

adjustable computer work stations, lock

housekeeping cart, ant-fatigue/ anti-slip mats,

machine guards, fume hoods and ventilation, etc.

Administrative controls included safe work policies

and procedures, infection control and prevention

emergency response quick reference charts, MSI

prevention, chemical safety information, office

ergonomic breaks poster, use of good lifting

techniques, proper hand hygiene practices,

warning signs, etc. PPE controls included a variety

of gloves, gowns, steel toe boots, hair nets, ear plug

and ear muff, oven mitts, face shields, goggles, etc.

Recommendation: 20% of the reviewed

documentation and observations indicated that

some required hazard controls were not identified

or not consistently implemented. It is suggested

that special attention is paid to controls required for

potential health hazards, including airborne

pathogen, violence and patient abuse, chemical

hazards (cytotoxic and hazardous drugs), etc. To

ensure that appropriate controls are in place such

as engineering control (dress alarm, radio, cell

phone, camera, curved mirrors), PPE (N95 mask),

and administrative control (safe work procedures, ).

20 out of 25 points were awarded for the

engineering and administrative controls, and12 out

of 15 for the PPE controls


39


3.2 Are workers involved in establishing the

control of health and safety hazards?

(10 points)

10


At least 70% of workers interviewed must be

aware of worker involvement in the

development, review or implementation of

controls. Worker involvement could be

through health and safety committees,

teams, safety representative, etc.

Not all workers need to be involved, but the

auditor must confirm that workers were

involved in the formal hazard control

process.

Strength: 70% of interviews indicated that workers

are involved in establishing controls for identified

health and safety hazards. Interviews stated that

workers are involved by being part of the hazard

assessment teams, reviewing their position specific

Hazard Assessments and commenting on them,

discussing controls during staff meetings or as part

of the JWHS committees, reporting requirements

through E-Facility or to the supervisor / manager,

being part of teams to develop safe work practices

and procedures, etc.

Key Recommendation: 30% of interviews were

unaware of worker involvement in the

establishment of hazard controls. It is suggested to

ensure you include all employee levels and

positions in the hazard assessment and control

processes in all work areas. In addition, it is

suggested to communicate the results of such

process and the worker involvement and input

opportunities to all affected staff to ensure their

awareness of the hazard controls and worker

involvement in their development.

10 points were awarded based on the percentage


required 70%.


40


3.3 Are employees using controls

developed for identified health and

safety hazards?

(15 points)

0

Verified by employee interviews and

observation.

Compare/observe employee performance

against hazard controls developed in

question 3.1.

Points are awarded based on any

combination of interviews and observations

to achieve 90% positive response.

Strength: 90% of observations and 85% of

interviews indicated that employees are using the

developed hazard controls. Interviews stated that

employees are consistent in their use of the

required hazard controls, and observations noted

that employees were using most of required PPE,

use appropriate body mechanics, have equipment

guards in place, etc. in all work areas that were

toured.

Recommendation: Employee interviews indicated

that although employees are using most of the

control in their work place, many of the employees

are not using proper PPE (such as N95 mask,

gloves) within the work areas in the sites. It is

suggested to ensure all employees knowledgeable

about control hazards affecting them. Ensure all

employees are using proper PPE (included N95

mask) in their work are as outline in Alberta OHS

codes (Part 18 Section 228) and Covenant Health

policy and procedures regarding.

No points awarded based on positive interview

response and observations being below the

required 90%


41


3.4 Is there a process for maintaining

equipment and preventing the use of

defective equipment?

(10 points)

10



Review maintenance and work order

records. Interview workers to confirm

defective equipment is removed for repair.

Points are awarded based on any

combination of interviews and documentation

to achieve 70% positive response.

Key Strength: 100 % Documentation review and

95 % of employee’s interview indicated that a

process is in place for maintaining equipment and

preventing the use of defective equipment. These

are maintenance procedures on the site as follow:

Preventive maintenance which check quarterly all equipments on the site.

Computer based system E-Facility maintenance which records are coordinate on-demand maintenance activities. Employees use E-Facility to maintain and report defective equipments within units/departments.


of positive interview responses and reviewed

documentation exceeding the required 70%.


42


3.5 Does management enforce the use of

engineering controls?

(0-10 points)

5

5

Verified by worker interviews and

observation.

Interview workers (0-5 points)


percentage of positive responses.

Observation (0-5 points)

On the observation tour, observe whether

management is enforcing the use of

engineering controls. Observations points

are awarded based on the percentage of

positive observations.

Strength: 96% of observations and 93% of

interviews and indicated that management

enforces the use of engineering controls.

Interviews stated that management monitors the

consistent use of engineering controls by staff

during their daily rounds and informal observations.

Noncompliance is initially addressed through non

disciplinary interventions, such as reminders,

instructions and coaching. Observations indicated

that employees are generally using the required

controls.

Recommendation: It is suggested to reinforce the

importance of consistent enforcement of all

required engineering controls to staff from all work

areas and shifts. Actively monitoring and enforcing

standards will help in overall injury reduction

efforts.

5 out of 5 points were awarded for the observations

and 5 out of 5 points for the interviews, based on

the percentage of positive indicators from each.


43


3.6 Does management enforce the use of

safe work procedures, rules and work

practices?

(0-10 points)

5

5

Verified by worker interviews and

observation.




Observations (0-5 points)


management is enforcing the use of safe

work procedures, rules and work practices

when there is a violation. Observation points

are awarded based on the percentage of

positive observations.

Strength: 96% of observations and 93 % of

interviews indicated that management enforces the

use of safe work practices and procedures.

Interviews stated that management monitors the

consistent use of administrative controls by staff

during their daily rounds and informal observations.

Non-compliance is initially addressed through non-

disciplinary interventions, such as reminders,

instructions, and coaching. During observation

tours employees were observed using the required

controls.

Recommendation: It is suggested to reinforce the

importance of consistent enforcement of all

required administrative controls to staff from all

work areas and shifts. Actively monitoring and

enforcing standards will help in overall injury

education efforts.

5 out of 5 points were awarded for the observations

and 5 out of 5 points for the interviews, based on

the percentage of positive indicators from each


44


3.7 Is the required PPE available?

(10 points)

0

Verified by observation and worker

interviews.

Auditor must observe that the PPE identified

in the hazard control document (refer to

question 3.1) is readily available for

employee use.


positive indicators using any combination of

observation and interviews.

Strength: 60% of observations and % 66 of

interviews indicated that most of required PPE is

readily available to employees at both sites and

work areas.

Recommendation: Employee interviews indicated

that although employees are using most of the

require PPE in their work area, many of the

employees have been not N95 mask fit tested

mask at both sites. Also, employees are using

surgical mask during their work activities.

Observations indicated that PPE were kept in

locking room and was not readily available to

employees in the care Units.

The decision whether or not to require workers to

use either surgical masks or respirators must be

based upon a hazard analysis of the workers'

specific work environments and the different

protective properties of each type of personal

protective equipment. Alberta OHS codes stated

that If respiratory protective equipment is used,

employers are required to provide the appropriate

equipment, maintain and store it properly, and

ensure that it is properly fitted to the individual

worker.

It is suggested to ensure all employees are N95

mask fit tested and used N95 mask (if necessary).

In addition, All personal PPEs are readily available

within the Units/departments.

No points awarded based on positive interview

response and observations being below the

required 90%


45


3.8 Where Personal Protective Equipment

(PPE) is used as a method of control,

are employees trained in the use, care

and maintenance of the protective

equipment?

(0-15 points)

3

7

Verified by observation and employee

interviews.

Interview (0-5 points)


percentage of positive responses indicating

that training was provided.


Observation points are awarded based on

the percentage of positive observations

confirming that PPE is used, cared for and

maintained properly and as instructed.

Strength: 70% of observations and % 66 of

interviews indicated that employees are trained in

the use, care, and maintenance of the PPE they

are required to use. Interviews indicated that

training for the required PPE is provided during

orientation, job specific training, annual essential

education, etc. Observation verified that the PPE

was in good conditions, as well as the correct use

and storage of PPE in the various work areas.

Recommendations: 25% 0f observation and 34%

of the interviewed indicated that employees are not

wear mask correctly and consistently. Employees

are using surgical mask instead of the N95 mask. It

is important that all manager, supervisor and

employees understand the significant differences

between these two types of personal protective

equipments. The decision whether or not to require

workers to use either surgical masks or respirators

must be based upon a hazard analysis of the

employees' specific work environments and the

different protective properties of each type of

personal protective equipment. Surgical masks are

used as a physical barrier to protect the user from

hazards, such as splashes of large droplets of

blood or body fluids.N95 masks are designed to

reduce a worker's exposure to airborne

contaminants .it is suggested to ensure all

employees are using proper PPE as outline in their

hazard assessment.

4out of 5 points were awarded based on the

percentage positive indicator from interview, and 5

out of 5 from observation, and 5 out of 5 from

documentation.


46


3.9 Is the use of PPE enforced?

(0-15 points)

4

4

4

Verified by review of documentation,

observation and worker interviews.

The key here is enforcement.

Documentation review (0-5 points)

Determine if there is a management system

in place (e.g. written document, discipline

process) and if it is followed.



percentage of positive responses. Use

interviews to verify that the management

system is followed.



management is enforcing the use of PPE.

Observation points are awarded based on

the percentage of positive observations.

Strength: 73% of interview and 76% of

observation and 85% of reviewed documentation

indicated management enforces the use of all

required PPE.

A covenant Health Discipline and Termination

policy (policy no11-20 in the Corporate Policy and

Procedures Manual) outlines the progressive

discipline process and refers to the potential for

disciplinary action in cases of non-compliance to

expected policies and procedures. When non-

disciplinary interventions have not resulted in

acceptable work performance progressive

discipline is applied. This includes verbal warnings,

written warnings, and suspension without pay and

termination Interviews indicated that use of require

PPE controls is monitored in all areas. 80 % of

observation verified consistent proper PPE use by

staff, and storage of PPE in the units and

departments. Also 73% of Interviews verified that

management monitors the consistent use of

required PPE by staff during their daily rounds and

informal observations confirm the process to

address non-compliance. 76% of Observations

indicated that employees are generally using the

required control.

Recommendations: Ensure all employees are

aware of Covenant Health policy and procedures

regarding PPE enforcement. In addition, it is

suggested to ensure all employees are using

proper PPE as outline in their hazard assessment

4out of 5 points were awarded based on the

percentage positive indicator from interview, and 4

out of 5 from observation, and 4 out of 5 from

documentation


47



Audit Score


(divided by)


Total points = 160


48

4. Ongoing Inspections


4.1 Is there a formal written process that

includes frequency of formal

inspections by:



c. Worker participation? (5 points)

5

5

5

Verified by review of documentation.

Process could be in the form of a policy,

plan, procedures, etc.

Frequency is established by the employer

based on the health and safety hazards.

Inspections should be done on a regular

basis to cover all work areas at least

annually.

Strength: Documentation reviewed indicating that

there is formal written inspection policy and

process in place. Element 3 (work place safety

inspection process) outlines the standard

requirements for workplace inspections. Formal

inspections are to be completed by inspection

teams consisting of a manager and/or supervisor

responsible for the department/area, a

representative of the local health and safety

committee if applicable, or another employee

appointed to the inspection team. Formal

inspections are to be conducted on a minimum

quarterly basis in each work area.


on the reviewed documentation.


49


4.2 Are formal health and safety

inspections carried out in accordance

with the process by:



5

5

Verified by review of documentation (e.g.

inspection records), and by management

and supervisor interviews. Must also

verify the frequency of inspection is being

followed (reference question 4.1).

Formal documentation must exist to award

points.

Verify through interviews that inspections are

carried out by the individuals, and at the

frequency indicated in the documentation. At

least 70% of those interviewed must confirm

that the process is followed.

Depending on size or nature of the

organization, there may not be managers or

supervisors. In either case, one of these

categories may not be applicable (n/a).

Strength: 100% of reviewed documentation, 100%

Of manager and supervisor interviews indicating

that formal health and safety inspections are

conducted and completed as required by Covenant

health Standard requirements for workplace

inspections (Element 3).

.

5 out of 5 points were awarded for each category

based on the percentage of positive indicators from

reviewed documentation and interviews exceeding

the required 70%.


50


4.3 Are workers involved in the

inspections?

(15 points)

15

Verified by worker and supervisor

interviews.

There must be evidence of worker

involvement in inspections to award points

(e.g. doing inspections).

At least 70% of those interviewed at each

site must be aware of worker involvement.

Not all workers need to be involved.

Strength: review Interviews indicting that 72% of

persons interviewed were aware of worker

involvement in the formal workplace inspections.

Recommendation: 28% of interviews indicated

that Some employees had been involved in the

formal inspection in some units/departments;

however this was not done consistently at all sites

and units /departments. It is suggested that all sites

promote regular worker involvement in the formal

inspection processes, and that this is

communicated to all staff. Involving workers from

all shifts on a rotating basis is very beneficial to

ensure greater participation and awareness of the

activity, as well as ensuring better monitoring of the

different work processes and hazard controls that

may be specific to certain shifts.


51


4.4 Are the individuals designated to

conduct formal inspections given

appropriate training?

(0-10 points)

5

4

Verified by documentation and employee

interviews.


Review training records to verify training is

appropriate. Points are awarded based on

the percentage of individuals who have

received the appropriate training.


Interview designated individuals to confirm

they have received the appropriate training.



Strength: % 95 of documentation reviewed and

75% of interviews documentation indicated that

individuals designated to conduct formal inspection

have received training on how to conduct formal

workplace inspections.

Recommendation: Although majority of

documentation indicating employees received

training on formal inspection, 75% of employee’s

interviewed show they were unaware of who has

received the training for formal inspections.

Workplace inspection training is included in the

Covenant Health OHS Awareness Workers online

course. It is suggested that all employees complete

this course. This will ensure that all employees are

knowledgeable, and they are able to conduct and

document thorough safety inspections


interview responses, and 5 out of 5 based on the

available documentation.


52


4.5 Is a site/operation specific checklist

used for the inspection?

(0-10 points)

5


inspection reports).

A site specific inspection checklist must be in

place at all operational sites/areas (could be

work sites, departments, operations, etc.)


of operational sites/areas using the checklist.

Strength: Documentation review indicated that a

generic Workplace Inspection Checklist is in place

which includes observations on the work

environment, task, hazardous / bio-hazardous

materials, equipment, and emergency response.

Other area specific inspection checklists were

noted to be used for kitchen areas, labs, pharmacy,

etc.

Recommendation: The generic Workplace

Inspection Checklist mainly represents patient care

areas, and although it can be modified, little

customization was observed in the sampled

documentation in the units / departments. It is

suggested to develop area / operation specific

inspection checklist templates for each of the main

departments / types of work areas (i.e. dietary,

housekeeping, maintenance, etc.), and to make

those available to all locations.

5 out of 10 points were awarded to represent the

percentage of areas that were adequately

represented in the observed inspection checklists

4.6 Are inspections reports reviewed and

signed off by management?

(5 points)

5

Verified by review of inspection reports.

The report must be signed off by the

manager, at least one level above the

supervisor responsible for the area.

Points are awarded if at least 90% of

inspection reports reviewed and signed off

by management.

Strength: 100% of sampled inspection reports

were signed-off by management. It is suggested

that managers review and signed-off the completed

inspection, and ensure that follow up has occurred

on the identified items.


of positive indicators from reviewed documentation

being below the required 90%.


53


4.7 Are deficiencies identified in the

inspection report corrected in a timely

manner?

(0-15 points)

5

4

5

Verified by review of documentation,

employee interviews, and observation.


of deficiencies corrected.


Documentation should include a timeframe

for correction (that is as soon as practical)

and who is responsible. Verification that work

was completed (e.g. work orders, purchase

orders, memos, etc.) should also be

available.


Interview management, supervisors and

workers to verify corrective action is done for

those actions that cannot be observed, and

determine whether corrective action is

completed in a timely manner.

Observations (0-5 points)


deficiencies identified in the documentation

have been corrected.

Strength: 98% of reviewed documentation ,76% of

interviews, and 96% of observations, indicated

that:

Deficiencies were observed to be identified

and documented in the inspection reports

Noted deficiencies had been followed up,

corrected and completed in a timely manner

The inspection forms had been reviewed and

signed off by management

Recommendation: Only 24 % of interviewed

indicated that they were unsure of the inspection

results or any follow up. It is suggested that each

work area communicate the inspection results and

corrective actions taken to all affected staff to

ensure their awareness of the activity and positive

outcomes.

5out of 5 points were awarded for the reviewed

documentation, and observations and 4out of 5

points were awarded for the reviewed interviews

based on the percentage of positive indicators.


54


4.8 Is there a system in place whereby

employees can report unsafe or

unhealthy conditions and practices?

(5 points)

5

Verified by a review of documentation and


The evidence of a reporting system is

verified by first reviewing documentation

(policy, procedure) to confirm there is a

process, and then through interviews to

confirm awareness.



documentation and interview results.


95% of employees interviewed indicated that a

system is in place whereby employees can report

unsafe or unhealthy conditions and practices.

These process and system are includes:

A Health and Safety Issue Resolution Process

is outlined in Element 1 of the Covenant

Health OHS Program.

Systems to report unsafe or unhealthy

conditions and practices include near miss and

incident reporting, and

E-Facility reports for facility maintenance.

Verbal reports to supervisors or managers

Use of communication and discussions of

issues during staff / team meetings or local

JWHS committee meetings.


of positive indicators from interviews and reviewed

documentation exceeding the required 80%.


55


4.9 Does the system for reporting unsafe or

unhealthy conditions and practices

ensure action is taken by management

in a timely manner?

(0-10 points)

9

Verified by interviewing employees.

Interview points for action taken are awarded

based on the percentage of positive

responses indicating that timely action was

taken, and could include informing

employees of the corrective action taken.

Strength: 90% of employees interviewed indicated

that timely action is taken by management when

unsafe of unhealthy conditions and practices are

reported.

Recommendation: It is suggested to ensure that

follow up actions taken in response to any reported

health and safety issues / concern are

communicated to all potentially affected staff. This

will ensure that all employees are made aware of

positive actions taken.


percentage of positive interview responses


Audit Score


(divided by)


Total points = 95


56

5. Qualifications, Orientation and Training


5.1 Is there a process in place to ensure

employees have the qualifications and

training to perform their jobs in a

healthy and safe manner?

(15 points)

15


training records, application forms, hiring

records and employee records) and


Documentation must exist to verify a process

is in place (can include things like degrees,

diplomas, certificates, trade certificates,

apprenticeship program diplomas, etc.).

Interviews should confirm that qualifications

and training are reviewed as part of the hiring

process, and are felt by workers to be

appropriate for the job.




Strength: 100% of interviews and 100% 0f

reviewed documentation indicated that a process is

in place to ensure employees have the

qualifications and training to perform their jobs in a

healthy and safe manner. These policy and

procedures is followed in recruitment process to

ensure that employees have the qualifications and

training to perform their jobs in a healthy and safe

manner.

The process includes developing job description,

advertizing Job, screening Job applications

(according qualification and experience outlined in

job posting), interviewing the candid ( by using a

formal interview guide and suitability rating

process), checking documents (certificate

,diplomas proof of current professional

registration), criminal record check and reference

check, and a pre placement assessment conducted

through the OHS department to verify vaccinations

and suitability for position.

Full points were awarded based on percentage of

positive indicator from reviewed documentation

exceeding the required 70%.


57


5.2 Are critical health and safety issues

addressed before the employee starts

his/her normal job responsibilities?

(0-15 points)

14

Verified by reviewing orientation

documentation and by employee

interviews.

Critical issues must include:

Organization Rules/Enforcement

Right to Refuse Unsafe Work

Emergency Response

Incident Notification

Critical Hazards

Score: 0-5 points for documentation

0-10 points for interviews



Strength: 91% of interviews and 95 %

documentation reviewed indicated that critical

health and safety issues are addressed with new

employees prior to starting their normal job

responsibilities. Critical health and safety issues

are discussed in the site orientation, department /

unit orientations, or position specific orientations

and buddy shifts.


all unit / department, site corporate orientations be

standardized to contain the required critical health

and safety issues, and be consistently

documented. With completion dates entered into

spreadsheets or a database which will enable more

effective monitoring and management of this type

of training. This will ensure that documentation can

be monitored and verify that all new employees

5 out of 5 based on the positive indicators from the

reviewed documentation, and 9 out of 10 points

were awarded based on the interview responses


58


5.3 Is the new employee orientation

completed within the first week of

employment?

(0-15 points)

14

Verified by reviewing records and

interviewing employees.

Look for orientation documentation.






that they had completed a unit / department,

general site orientation within their first day of

employment. Documentation review indicated that

95% of new employees have completed the

corporate or general site orientation.

Recommendation: 15% of interviewed indicated

that employees had not completed site orientation

within the week. Negative comments indicated

since the new program (2013) was introduced; the

employees are being oriented on their first day of

employment. It is suggested to continue with the

current process of orientation prior to the start of

the first day.

5 out of 5 based on the positive indicators from the

reviewed documentation, and 9 out of 10 points

were awarded based on the interview responses.

5.4 Does the new employee orientation

cover employer heath and safety

policies and procedures?

(10 points)

10

Verified by reviewing documentation and


Documentation includes orientation records

and orientation contents. Interviews should

support that the material is covered. Points

are awarded for at least 70% of positive

indicators using any combination of



90% of interviews indicated that the new employee

orientation covers key Covenant Health OHS

policies and procedures.

The site orientation, as well as various department

/ unit, and position specific orientation packages

included the Covenant Health Safety and Health

Policy, OHS responsibilities, infection prevention

policies and practices, ethics, information privacy

and IT security, PPIC, HR policies, etc.


of positive indicators from reviewed documentation

and interviews exceeding the required 70%.


59


5.5 Do employees receive the job specific

training required to perform their

jobs/assignments in a healthy and safe

manner?

(0-15 points)

5

9

Verified by reviewing training program /

training records and employee interviews.

Job specific training could include working

with a competent person until competency

can be demonstrated (e.g. buddy system).

Points are awarded based on percentage

positive indicators. Both health and safety

issues must be dealt with to obtain full points.


Examples of job specific training include

training on safe work procedures, PPE,

ergonomics, use of equipment, WHMIS, first

aid, defensive driving, TDG, etc. One way of

doing this is to look for a match between job

descriptions and training received.

Interviews (0-10 points)

Interviews should confirm whether the

training received is appropriate for workers to

perform their jobs/assignments in a healthy

and safe manner.

Strength:89% of interviews and approximately

97% of reviewed documentation indicated that job

specific training is provided during the site

orientation, unit / department orientation, job

specific orientations, buddy shifts, and in services

Recommendation: it is suggested to ensure all

workers receive job-specific training to workers

who may be exposed to a hazard. It is further

suggested to enter learning records into

a spreadsheet program in order to enable

Educators and Managers to more efficiently and

effectively monitor the completion of all training

requirements.


interview responses, and 5 out of 5 points for the

positive indicators from reviewed documentation.


60


5.6 Is on-going training provided as

required?

(0-15 points)

4

8



An organization may choose to set timelines

for ongoing training on some of these

subjects, or as legislated.




Documentation must show on-going training,

refreshers and recertification in job-specific

training (e.g. skills upgrading, WHMIS, first

aid, defensive driving, TDG, maintenance

procedures, respiratory protection, etc.)

Interviews (0-10 points)

Interviews should verify that on-going training

is provided.

Strength: 83% of interviews and 87%

documentation reviewed indicated that ongoing

training is provided to employees as required. This

includes the mandatory annual essential education,

which covers infection prevention and control, fire

safety, legislation, bELITE training, etc. and is

required for all staff.

Recommendation: 17% of Interviews and 13%

documentation reviewed indicated that essential

training had not been provided for some of

employees.

It is suggested to actively monitor the completion of

mandatory annual and refresher training, and to

provide feedback to managers regarding who has

not completed. In order to accomplish this in an

effective and time efficient manner, It is further

suggested to enter learning records into a training

record spreadsheet. This will provide timely records

and overviews of the percentage of training

completion, as well as lists of employee names

which still require the training.


interview responses, and 4 out of 5 for the positive

indicators from reviewed documentation.


61


5.7 When employees are transferred or

assigned new tasks, do they receive job

specific training?

(0-15 points)

13

Verified by reviewing training records and

interviewing employees.

Job specific training could include working

with a competent person until competency

can be demonstrated.

Score: 5 points for documentation




Strength: 83% of the interviews and 98% of

documentation reviewed indicated that employees

receive job specific training when they are

transferred or assigned new tasks. Usually, each

transferred employee receives the Unit/department

specific orientation. Training for new equipment or

procedures is provided through inservices or

courses for the affected staff

Recommendation: It is suggested to continue the

current procedures of training employees who are

transferred or receive new tasks. It is further

suggested to monitor completion of required job

specific training to ensure greater consistency in

the training completion and documentation when

employees who are assigned new tasks or

assignments.


interview responses, and 5 out of 5 for the positive

indicators from reviewed documentation.


Audit Score

Total points possible: 100 - Points not applicable (N/A) 92 = Total points Total Points scored = 92

(divided by)


Total points = 100


62


63

6. Emergency Response


6.1 a. Is there a written emergency

response plan for each work site

appropriate to the hazards at the

site?

(0-15 points)

b. Does the plan include:

- Communication procedures?

(0-5 points)

- Emergency phone numbers?

(0-5 points)

- List of responsible emergency

response personnel?

(0-5 points)

- Evacuation procedures?

(0-5 points)

5

5

5

5

Verified by review of emergency response

plans for each work site. On mobile sites,

plans may be kept in vehicles.

Emergency response is taking immediate

action to deal with injuries, fires, motor

vehicle accidents, bomb scares, chemical

spills, explosions, etc.

a. Review the plan and award points by

percentage of plan completion.

b. Each piece of supporting information

needs to be evaluated for completeness.

Award points based on the positive

indicators.

Key Strength: Written emergency response plans

were in place for all sites, including response

protocols for appropriate hazards. These included

emergency response procedures for code red –fire,

code green – evacuation, code white –violence /

aggression, code blue – cardiac arrest or medical

emergency, code purple – hostage situations, code

yellow – missing person, code black – bomb threat

/ suspicious package, code grey –air exclusion,

code brown – hazardous spill, code orange – mass

casualty incident, emergency lockdown, and

severe weather. The emergency response plans

were available online, as well as in hard copies in

all areas visited.

Site specific communication procedures,

emergency phone numbers, responsible personnel,

emergency equipment and its locations, and

evacuation procedures are included in the site

specific emergency response manuals. Quick

reference charts were available in many work

areas for easy reference of the various protocols

and procedures.


on the positive indicators from reviewed

documentation.


64


6.2 Do employees at the site understand

their responsibilities under the plan?

(20 points)

20

Verified by interviewing employees at the

site.

Requires at least a general understanding of

emergency response.

Points are awarded based on at least 90% of

positive responses from interviews.


aware of and knowledgeable about their roles and

responsibilities in the event of an emergency.

Recommendation: is suggested to ensure that all

staff receives the training they require for their

responsibilities under the emergency response

plan and protocols. Special attention should be

paid to weekend, night shift, and casual staff to

ensure that they are knowledgeable and competent

to respond to the various potential emergencies.



required 90%.

6.3 Are employees given emergency

response training appropriate to their

individual responsibility?

(0-10 points)

8


Deals with specific training required to

implement the emergency response plan on

site.




that they have received emergency response

training appropriate to their responsibilities. This

included instructions and reviews of the emergency

response procedures in site orientation, annual

essential education, and code of the month

reviews, as well as first aid and CPR training.

Recommendation: 22% of employees interviewed

felt they had not received appropriate emergency response training. It is suggested to ensure that all staff receives the training they require for their responsibilities under the emergency response plan and protocols. Special attention should be paid to weekend, night shift, and casual staff to ensure that they are knowledgeable and competent to respond to the various potential emergencies. 8 out of 10 points were awarded based on the interview responses.


65


6.4 Are emergency response drills

conducted annually or more often, as

required?

(10 points)

10

Verified by review of documentation. If

no documentation exists, interview

employees.

Deals with planned drills, not an actual

response. For example, an emergency

response drill could include a full blown

implementation of the emergency response

plan, review of the emergency response plan

at meetings, part of an operation, table-top

review, practice drills, etc.

Points are awarded if documentation

indicates that at least 70% of sites are

conducting drills, or (if no documentation

exists) by at least 70% of positive responses

from interviews.

Strength: 78% documentation reviewed and 77%

of interviews indicated that emergency drill conducted on monthly basis. The drills focus on the different colours as determined by Covenant Health. Fire drills occur monthly and are supplemented with the other Codes. Recommendation: 23% of interviews indicated

that some employees have not been able to

participate in emergency drill. Also, employees

stated that some of the emergency response drills

had not been conducted after OHS representative

left the site. It is suggested to consider conducting

table top drills with all units and all shifts to ensure

that everyone is kept up-to-date on emergency

procedures for the site. It is further suggested to

continue with the practice of reviewing the code of

the month with all staff members.


of positive indicator from reviewed documentation

exceeding the required 70%

6.5 Are emergency response records kept?

(5 points)

5

Verified by review of emergency response

records (e.g. First Aid Record Book).

This question cannot be marked as “n/a”. In

the absence of an actual emergency

response, employers should at least have

records of emergency response drills.

Strength: Documentation review indicated that

emergency response records are kept at all sites.

These records included first aid records, incident

reports, records of actual emergency responses, as

well as fire drills and other emergency response

exercises.

Full points were awarded based on the reviewed

documentation.


66


6.6 Are all records of emergency

responses, including drills, reviewed to

correct deficiencies?

(10 points)

10

Verified by review of documentation

This question cannot be marked as “n/a”. In

the absence of an actual emergency

response, employers should at least have

records of emergency response drills.

Strength: Documentation Reviewed indicated that

emergency response and drill records are

reviewed, and noted deficiencies are addressed.


documentation

6.7 IS the appropriate number of

employees trained in first aid, as

required by legislation?

(10 points)

0


Check legislation and review first aid

certificates. To award points, the auditor

must verify that legislated first aid

requirements have been met across all

shifts.

Recommendation: OHS code (part 11- section

182(2)) state that an employer must ensure that the

first aiders at a work site have successfully

completed a first aid training course approved by a

Director of Medical Services and hold a valid

certificate in first aid. RNS and LPNs must

complete either Supplementary First Aid or Valid

First Aid Certification Courses to be recognizing as

designated Standard and Emergency Level First

Aider.100% of documentation reviewed indicated

that none of the RNS and LPNs employees took

Covenant Health supplementary first on line course

aid or Standard Valid First Aid Certification training

course (as outlined in Part 11 First Aid of the

Alberta OHS Code). Therefore, none of them

recognize as first aider on the sites. It is suggest

encouraging all Linsang RNs employees to take

online supplementary first aid course.

No points were awarded based on the reviewed

documentation.


67


6.8 Do first aid supplies and facilities meet

legislated requirements?

(10 points)

0

Verified by observation.

Check supplies and facilities against first aid

regulation. To award points, the auditor must

verify that legislated first aid requirements

have been met at all visited sites and

facilities.

Strength: Observation tour indicated that both

sites had first aid kids #2, eyewash station, spill

kits, Automated External Defibrillators, etc.

Recommendation: Although There are some

supplies and equipments available in the both

sites, facilities are not meeting all legislature

requirements. This includes lack of the designated

first aid area, first aid kids #3, first aid signage, first

aid provider, etc.

No points were awarded based on the observation

reviews.


Audit Score


(divided by)

X 100 = FINAL SCORE 66 %

Total points = 110


68

7. Incident Investigation


7.1 Is there a written procedure that

requires the reporting of occupational

incidents and illness?

(10 points)

10


Documentation should require the reporting

of all types (i.e. incidents, illness) to award

full points.

Strength: Documentation review indicated that the

reporting of work-related Incidents, Injury, and

Illness policy and procedure is in Place outlining

reporting requirements and the investigation

process.

Element 6: Incident Management of the Covenant

OHS Program outlines the procedure to be used to

report occupational incidents and illnesses. The

document states that employees must report

incidents and near misses to their supervisor /

manager. This includes all serious incidents as

defined in the Alberta OHS legislation, as well as

all lost time, medical aid, property damage, first aid,

and near miss incidents. The procedure continues

to state the forms to be used, responsibilities, and

internal and external reporting / communication

requirements for each type of incident.

Full points were awarded based on the positive

indicators from the reviewed documentation


69


7.2 Are employees aware of their

responsibilities to report work-related

incidents and illness?

(0-10 points)

10





aware of their responsibilities to report work related

incidents, illnesses, and near misses, and

knowledgeable about the reporting processes to be

used.

Recommendation: Although employees

demonstrated a good awareness of their

responsibilities to report work-related incidents and

illness, some of them are un aware of incident

investigation process. It is suggested, to educate

all workers in the process of what happens after

they report an injury. Workers don’t need high level

information. They just need to know, that their

responsibility to report related incident and near

miss, and able to explain the report process


of positive interview responses.


70


7.3 Is there a written procedure for

investigating occupational incidents and

illnesses?

(15 points)

15


Documentation must require the investigation

of all types (i.e. incidents, illnesses) to award

full points.

Strength: Documentation review indicated that a

written procedure is in place for the investigation of

occupational incidents and illnesses.

Element 6: Incident Management of the Covenant

OHS Program outlines the incident investigation

procedure. This includes determining the facts of

what happened, identification of immediate,

underlying and root causes, recommendation of

control measures, implementation of controls

measures and effective documentation and records

keeping. The document continues to outline a

detailed seven step process for investigation of

incidents. This includes the initial response,

investigating the incident using 6 key questions,

identifying immediate, underlying and root causes,

developing and implementing corrective actions,

reporting the findings, communicating findings to

affected staff, and evaluating the effectiveness of

the implemented preventative measures.


documentation.

7.4 Is there an investigation report form?

(5 points)

5


The form must systematically record incident

or occupational illness occurrence

information, including the circumstances,

causes, corrective actions and follow-up.

Strength: Documentation reviewed indicating that

standardized investigation report form is in place.

The Employee Incident / Injury Reporting and

Investigation form systematically records all details

information according for incident investigation

process. The form is comprehensive, health care

oriented, user friendly, and includes a good level of

detail.


documentation


71


7.5 Have the persons conducting

investigations been trained in

investigation techniques?

(0-15 points)

12



Check training records of those persons

required to conduct investigations, and

interview them to confirm training received is

appropriate to conduct investigations.

If trained investigators are brought in, full

points may be awarded. Proof must exist.


of positive indicators using any combination

of documentation and interview results.


documentation indicated that key employees have

received incident investigation training. Training

records indicated that two training sessions for

incident investigation had been held on site in

2010. Interviews verified that key employees have

received incident investigation training.

Recommendation: 41% of interviews indicating

that many of employees unaware of who has

received the training on investigation techniques. It

is suggested to ensure that incident investigation

training is completed by all persons in leadership

positions. This will ensure that all persons who may

conduct incident investigations and have to

complete the report forms are knowledgeable

about investigation techniques and root cause

analysis. It is further suggested to communicate the

training to the staff.

12 0out of 15 points were awarded based on an

average of 59% positive indicators from the

interview responses and reviewed documentation.


72


7.6 Are workers involved in the

investigation process?

(0-10 points)

2

3

Verified by review of investigation

documentation and employee interviews.

There must be evidence of worker

involvement in investigation to score points.

Involvement should include more than the

injured worker or witnesses.





Strength: 61%employees interviewed indicated

that workers are involved in the investigation

process through, during staff/ team meetings, as

witnesses or through other informal interactions

with their Supervisors or Managers.

Recommendation: Only 35% of reviewed

documentation indicated that workers, other than

an injured employees or witness, are involved in

the investigation process. This is mainly

documented in some of the sampled staff / team

meeting minutes, which indicated that incidents

were discussed. It is unclear from these

documents, however, if the workers were just made

aware of the investigation results, or if they have

actual participation and input into the investigation

process.

It is suggested to involve some key employees in

the investigation process, and to document this on

the report forms, as well as on any applicable

meeting minutes. Workers could be involved during

staff / team meetings or as part of a regular

incident review and discussion during local JWHS

committee meetings. This will ensure that a

balanced perspective has been taken into

consideration during the investigation, resulting in a

more thorough investigation being conducted


reviewed documentation, and 3 out of 5 based on

the interview responses.


73


7.7 Do investigations focus on:

a) Identifying root causes?

(0-10 points)

b) Recommending corrective action?

(0-10 points)

4

4

Verified by reviewing completed

investigation report forms.


of reviewed investigation reports that focus

on identifying root causes and

recommending corrective action.

Recommendation: Only 40% of sampled incident

investigation reports properly identified direct,

indirect and root causes, and had appropriate

recommended corrective actions documented. It is

suggested that thorough root cause analysis is

applied to all investigations to determine the most

effective preventative measures, and that this be

properly and fully documented in the investigation

reports or other attached information. It is further

suggested to ensure that all recommended

corrective action be also properly and fully

documented on the investigation report forms. This

ensures that investigations result in the most

effective recommendations to prevent recurrence,

and that these recommendations can be tracked

more effectively.

4 out of 10 points were awarded for the

identification of root causes, and 4 out of10 for the

recommended corrective actions.

7.8 Are supervisors held responsible and

accountable for the investigation

process?

(0-10 points)

10

Verified by review of investigation

documentation and by employee

interviews.






97% of employees interviewed indicated that

supervisors and managers are held responsible

and accountable for the investigation process.


of positive indicators from interviews and reviewed

documentation


74


7.9 Are investigation reports reviewed and

signed off by management?

(5 points)

5

Verified by reviewing completed

investigation reports.

The report must be signed off by the

manager at least one level above the person

responsible for the area.

Points are awarded if at least 90% of

investigation reports being reviewed and

signed off by management.

Strength: 98% documentation reviewed indicating

that all sampled investigations reports were

reviewed and signed off by management.


documentation

7.10 Are completed investigation reports /

results shared with employees?

(0-10 points)

5



Documentation could be health and safety

meeting minutes, investigation reports

posted on bulletin boards, notes on

investigation reports. Results shared should

not contain personal information pertaining to

the affected parties.





Recommendation : Only 24% of documentation

reviewed and 39% of interviews indicated that the

results of incident investigations are shared with

employees through staff/team meetings, notes in,

emails communication books, , or verbal

interactions. Most of the interviews and

documentation reviewed indicated that most of the

time investigation results were not shared at all or

only in uncertain terms with very little detail. It is

suggested that investigation results are routinely

shared with potentially affected staff, to ensure

their awareness of the situation and opportunity for

feedback regarding the recommended corrective

actions. Such communications should include an

incident description, identified causes, and

corrective actions taken This is not considered to

be confidential information since it includes no

names or personal details, and will only ensure that

meaningful information is conveyed to summarize

the investigation and inform affected employees.

2 out of 5 points were awarded based on the reviewed documentation, and 3 out of 5 based on the percentage of positive interviews


75


7.11 Are corrective actions taken to prevent

recurrence?

(0-15 points)

12

Verified by interviewing employee and

observing corrective action where

applicable.


of corrective actions implemented.

Strength: 61% of employees interviewed and 92%

of observations indicated that corrective actions are

taken after an incident to prevent recurrence.

Recommendation: 10% of sampled corrective

actions were observed to not be implemented. In

addition, 39% of employees interviewed were

unsure if corrective actions were taken after an

investigation to prevent recurrence. It is suggested

to conduct proper follow up after each investigation

to ensure that all required corrective actions have

been fully implemented to prevent recurrence. It is

further suggested to communicate the investigation

outcome, including the recommended corrective

actions, and the implementation status of these

actions to all affected employees. This will ensure

that staff in each work area is aware of positive

actions being taken, and any changes that may

impact them.

12 out of 15 points were awarded based on an

average 79% of positive indicators from

observations and interviews



76

Audit Score

Total points possible: 125 - Points not applicable (N/A) = Total points 97 Total Points scored = 97

(divided by)

X 100 = FINAL SCORE 78 %

Total points = 125


77

8. Program Administration



78


8.1 Is there a system to ensure:

a. Health and safety issues are

communicated with employees?

(15 points)

b. Feedback on health and safety

issues from employees?

(15 points)

c. Follow-up on health and safety

issues?

(15 points)

15

15

15

Verified through review of documentation

and employee interviews (e.g. newsletter,

records of safety meetings, records of

toolbox meetings, bulletins, hazard

identification and assessment records,

suggestion boxes, etc.).

a. Identify how employees are advised of

health and safety issues, and confirm this

is being done.

b. Identify how employees are enabled to

offer feedback on health and safety

issues, and confirm employee awareness

of the system.

c. Identify how follow-up is done, and

confirm that employees are aware of it.




Strength: 100% of reviewed documentation

indicated that a system is in place to communicate

health and safety issues with employees, provide

feedback opportunities, and ensure follow up on

health and safety issues. 98% of employees

interviewed confirmed that health and safety issues

are regularly and effectively communicated. 100%

of employees felt that they were enabled to offer

feedback and input on any issues raised, and 92%

stated that health and safety issues are

consistently followed up on. Health and safety

issues are communicated and addressed during

JWHS committee meetings, staff / team meetings,

education sessions, as well as via memos, memo,

emails, hazard assessment reviews, OHS boards

and through interactions with educators and

members of the OHS department.


that all health and safety concerns and issues are

adequately followed up on, including

communication of any actions taken to the affected

staff. This will increase the overall awareness of

the health and safety management processes,

worker participation and input, and reinforce that

such participation leads to improved health and

safety of the work place.


on the percentage of positive indicators exceeding

the required 70%.


79


8.2 Does the employer have a system to

control contractor health and safety?

(0-5 points)

5


interviewing contractors.

Documents could be minutes of toolbox,

health and safety committee meetings, unit

or team meetings, where applicable.

If contractors are not utilized this question is

not applicable.


of positive indicators, using any combination

of documentation and interview results.


documentation indicated that a process is in place

to control contractor health and safety while on site.

Contractors must complete the contractor

orientation prior to starting work, which outlines

health and safety requirements, emergency

response procedures, locations of emergency

response equipment and first aid. Interview

indicated that Contractors receive a tour of the

facility or area they are to work in. In addition,

contractors are required to sign in, adhere to the

required standards and procedures and use all

required PPE. Also, interviews verified that

Contractors are required to follow all permit

requirements, and are monitored by facility

maintenance or other Covenant Health staff.

Full points were awarded based on the average

95% of positive indicators from interviews and

reviewed documentation

8.3 Does management participate in the

planned health and safety meetings?

(5 points)

5


To award points there must be documented

evidence of management participation.

Strength: Meeting minutes indicated that

management participated regularly in all unit /

department meetings, general staff meetings /

forums, as well as in site and local JWHS

committee meetings.


documentation

8.4 Are records of health and safety

meetings kept?

(10 points)

10


Records to review include attendance

records, agendas, minutes, etc.

Strength: All meetings minutes include OHS

members and staff meetings minutes are kept

consistently at sites.


documentation


80


8.5 Are records pertaining to the

organization’s health and safety system

kept for a minimum three-year period?

(10 points)

10


records (e.g. hazard assessment records,

inspection reports, training records,

investigation reports, etc.)

If the employer’s system has not been in

place for 3 years, records should be

available since the start up of the health and

safety system. (If less than 1 year’s worth of

documentation is available for review, the

auditor must make note of this.)

Strength: Documentation review indicated that all

records pertaining to the organization’s health and

safety management system are retained for a

minimum of three years. This includes policies and

procedures, hazard assessments, inspection

reports, investigation reports, statistics, training

records, etc.


documentation.

8.6 Are health and safety statistics

maintained?

(10 points)

10


Identify the type of statistics maintained by

the employer (e.g. frequency rate, severity

rate, cost per claim, audiometric stats,

pulmonary stats, air quality, blood levels, first

aid, etc.).

If the employer’s system has not been in

place for 3 years, records should be

available since start up of the health and

safety system.

Strength: documentation reviewed indicated that

Health and safety statistics are maintained for each

site which include:

Statistics and Accident Prevention Report

spreadsheets included the total number

incidents reported, hazardous situations, first

aid requirements, health care, lost time

injuries, and days lost for the current month

and year to date, as well as the same

information for the previous year.

WCB summaries include number of claims,

claim costs, etc.

Full points awarded based on the documentation

reviewed


81


8.7 Are records or statistics analyzed to

identify trends and needs?

(10 points)

10


Identify examples of the statistics being

analyzed, and any trends/needs identified by

the employer.


records and statistics analyzed to identify trends

needs.

Examples of identified trends include the following:

The Statistics and Accident Prevention Report

spreadsheets compare the numbers of

incidents and injuries of the current month and

year to date to the same time period of the

previous year for each site.

The WCB Account / Industry Synopsis report

evaluates the number of injuries reported,

frequency rates, severity rates, average claims

cost, total number of claims, duration bands for

lost time claims, types of accidents, age

groups involved, nature of the injury, body

parts injured, etc.


documentation

8.8 Is the health and safety system

evaluated at least annually through the

use of an audit process?

(5 points)

5

Verified by review of previous audits.

This could include internal or external audits.

If this is the employer’s first health and safety

audit, this question is not applicable (n/a).

Strength: The Both sites Health and safety

management system is evaluated annually through

the participation in the COR audit process. An

internal COR audit was conducted towards the end

of 2013.


documentation


82


8.9 Has an action plan been developed as

a result of the previous audit?

(10 points)

10

Verified by review of previous audits.




an action plan had been developed as a result of

the previous audit. There are 3 areas (employee’s

education, work place inspection and hazard

assessment) and several items for each area on

the action plan and all items of 3 areas have been

addressed. Several of item action plan had been

not completed.


documentation


83


8.10 Has the action plan been implemented?

(0-15 points)

12

Based on items in the action plan, verify

implementation by observation, review of

documentation, or employee interviews.


of items in the action plan (refer to question

8.9) implemented to date.



Strength: 100% documentation review and

observations indicated that the key action item

areas from the previous audit have been

addressed to date.

Recommendation: 80% of reviewed

documentation and observations indicated that the

action plan specific OHS initiatives have been

implemented. Although 70% of employees

interviewed were aware of previous audits and

stated that audit results were shared. It is

suggested to ensure that an action plan is

developed and systematically implemented over

the next year. It is further suggested to ensure all

employees are aware of audit process and action

plan results. This can be done by discussing the

audit with the employees through the OH&S

meetings and Staff meeting, and also posting

action plan on OHS board.

12 out of 15 points were awarded based on the interview responses, and positive indicators from reviewed documentation and observation .


Audit Score


(divided by)


Total points = 125


84


85

Observation Report Audit Question What To Look For Location(s) Notes

1.3 Is the policy readily available to

employees?

Health and safety policy may be

posted on bulletin boards, in

lunchrooms, reception areas, or may

be accessible on computers or inside

safety manuals that are readily

available to employees.

90% of observations indicated that the

Health and Safety Policy is readily available

to employees at all sites. The policy was

observed to be posted in key areas

throughout the facilities, as well as in OHS

binders available in specific units

/departments

1.10 Is the relevant health and safety

legislation readily available at work

sites?

Copies of Occupational Health and

Safety legislation (federal, provincial,

municipal) appropriate to the operation

of the work sites should be present on

site. Some examples could be:

- Occupational Health and Safety

Act

- General Safety Regulations

- Chemical Hazards Regulations

- First Aid Regulations

- WHMIS

- TDG


Alberta Occupational Health and Safety Act,

Regulation, and Code were readily available

to employee by means of the computers.

Several employees that were asked about

their access to the legislation during the

tours weren’t also able to demonstrate how

they can find the legislation on line. There

wasn’t any current hard copy of Alberta

OH&S Legislations on both sites.


86

Audit Question What To Look For Location(s) Notes

3.1 Have hazard controls been

identified and implemented:

Engineering?

Personal Protective Equipment

(PPE)?

Engineering and personal protective

equipment controls outlined in the

hazard assessment documents must

be observed. The engineering

controls could be ventilation, guarding,

substitution, isolation, noise control,

etc.

The personal protective equipment

controls could be hard hats, steel-toed

boots, gloves, respiratory masks, etc.

90% of observations indicated that

appropriate hazard controls have been

identified and implemented in the various

work areas.10% of observations indicated

that some required hazard controls were not

identified or not consistently implemented.

These included

Hazards of Cytotoxic drugs have been missed in the Care units and hazard assessment.

Some of the controls for Violence Hazards

Have been missed in the dementia care

units.

Employees are not using Proper mask

N95within the care units.

Personal Protective Equipment (PPE) are

not readily available to employees within the

care units.

Employees are not using proper PPE when

they are using O2 cylinders.

Some of control been missed food services

and hazard assessment , These included :

Non Slip Mat ( food services) are not used

within slippery areas,


87


3.3 Are employees using controls

developed for identified health and

safety hazards?

Auditor to physically observe

employees using the engineering,

administrative, and personal protective

equipment controls identified and

approved in the hazard assessment

documents.


employees are using the developed hazard

controls. These included:

Engineering controls:

Trolleys, Pallet jacks, Carts, Dolly, Keyboard

trays ,Mobile lifts for safe patient handling (

care unit), Ergonomic Chair/stools ( all

unit/department ), Emergency eye wash

stations, appropriate carts for transport of

clean and dirty dishes ( food services

),appropriate carts for moving food and

supplies (food services), machines have all

required safeguards (food services ), hood

and ventilation ( Food services), Storage

Cabinets and Shelves (facilities), etc.

Administrative controls:

Office ergonomic breaks poster, Good

lifting technique, Proper bending/ lifting

technique, proper respiratory and hand

hygiene practices, Isolate area for infection

control within unit areas, appropriate

procedures for garbage and waste control,

the proper instructions and any training or

demonstrations, Warning signs, etc.

PPE controls:

Gloves, Gowns, , Steel toe boots, N95

masks, Hair nets, Variety of protective

Gloves ( facility), Nitrile Gloves, Ear plug

and Ear muff (Boiler room), Oven mitts, Cut-

Resistant Glove (kitchen), Face shields,

Goggles , safety glasses, etc.


88


3.5 Does management enforce the use

of engineering controls?

Look for compliance with engineering

control requirements (i.e. have safety

guards been removed). Non-

compliance may indicate non-

enforcement. When there is non-

compliance, note if management in the

area responds and enforces the use of

control.

St Michael's Health Centre

St. Therese Villa


management enforces the use of

engineering controls. Observations

indicated that employees are generally

using the required controls.

3.6 Does management enforce the use

of safe work procedures, rules and

work practices?

Look for compliance with safe work

procedures, rules and work practices.

Non-compliance may indicate non-

enforcement. When there is non-

compliance, note if management in the

area responds and enforces use of

control.


St. Therese Villa


management enforces the use of safe work

practices and procedures. Observations

indicated that employees are generally

using the required controls.

3.7 Is the required PPE equipment

available?

Auditor must observe that the PPE

identified and approved in the hazard

assessment document (refer to 3.1) is

readily available for employee use.


St. Therese Villa

Strength: 60% of observations indicated that

most of the required PPE is readily

available to employees at both sites and

work areas. PPE were kept in locking room

in the care units and weren’t readily

available to employees in the care Units.


89


3.8 Where PPE is used as a method of

control, are employees trained in

the use, care and maintenance of

the PPE?

PPE observed at the workplace should

be clean, properly stored, in good

condition, etc. Employees should be

able to explain how each article of

personal protective equipment is used

and how it is maintained.


St. Therese Villa

70% of observations indicated that employees are trained in the use, care, and maintenance of the PPE they are required to use. Observations noted that PPE was in good conditions, as well as the correct use and storage of PPE in the various work areas.

3.9

Is the use of PPE enforced? Look for compliance with PPE

requirements. Non-compliance may

indicate non-enforcement.


St. Therese Villa

76 % of observations indicated that

management enforces the use of required

PPE. Observations indicated that

employees are generally using the most of

the required controls.

4.7 Are deficiencies identified in the

inspection reports corrected in a

timely manner?

Auditor selects items from past

inspection checklists and physically

observes the workplace to confirm the

identified deficiencies have been

corrected.


St. Therese Villa

96% of sampled deficiencies identified in the

inspection reports have been corrected in a

timely manner


90


6.8 Do first aid supplies and facilities

meet legislation requirements?

Check to see whether the first aid kit is

clean, the right size and stocked

appropriately, and that the log book is

being used. Check to see whether the

first aid room is clean and maintained.


St. Therese Villa

Both sites visited had a good supply of #2

first aid kits, eyewash stations, spill kits, etc.

readily available. Although There are some

supplies and equipments available in the

both sites, facilities not meet all legislature

requirements. This includes, lack of the

designated first aid area, first aid kids #3 ,

first aid signage, first aid provider, etc.

7.11 Are corrective actions taken to

prevent recurrence?

Auditor selects some approved

corrective measures from the incident

investigation reports and visually

confirms they have been implemented.


St. Therese Villa

92% of sampled corrective actions were

completed and fully implemented.

8.10 Has the action plan been

implemented?

Auditor must get the action plan from

the previous audit and confirm

implementation of the action items.


St. Therese Villa


action plan specific OHS initiatives have

been implemented. There are 3 areas

(employees education, work place

inspection and hazard assessment) on the

action plan and all 3 have been addressed

with 1 of the 3 areas competed (work place

inspection).

Partnerships in Injury Reduction Audit...

Documents

Transcript of Partnerships in Injury Reduction Audit...