Here is a webinar we lead for ASSP on Covid-19 recently. The webinar discusses how organizations can use occupational health and safety management system audits and the corrective action process to respond to Covid-19 challenges.
Leadership commitment to a management system is critical to its performance. Encouraging support is sometimes challenging. The management review process required by ISO management system standards can help gain leadership commitment.
Do’s and Don’ts
Coordinate management review with management other business review meetings. Conducting “management review” during regular business review meetings gives the sense that the management systems is part of the overall business. Management reviews conducted infrequently and apart from the other important business management meetings leads to a silo-ed perception of the management system.
Make management review value added. Ensure the information being presents is actionable by leadership. Give them a few choices for recommendations with supporting information and ask them to decide. They will appreciate your opinion and recommendations to help make decisions.
Do the Math and Have Backup.
Defend your recommendations for improvement with cost and return on investment information. Showing leadership how the management system helps save and even makes money, contributes to their support and commitment.
Take Good Notes
Recording leadership decisions during the management review helps ensures follow-up. Records of management review are also evidence of their leadership commitment, especially during audits.
Timely Management Review Follow-up
Follow-up on management review recommendations in a timely fashion and report on progress at the next management review opportunity. This will enhance leaderships perception of the management system, their support and commitment.
Management Review Frequency
Most organizations perform periodic reviews of the business performance to make sure things are going along smoothly and to make any course corrections needed. Integrating the ISO system management review with these regular business review meetings will help ensure that:
- Management system performance issues are addressed in a timely fashion
- The management system is integrated with all other business processes
- Timely information is provided to leadership to help make important business decisions
Management Review Inputs
Management review meetings should not necessarily address all management review inputs during each meeting. Management review inputs that should be reviewed at every management review include:
- Follow-up from previous management reviews
- Status of actions from previous management reviews;
- Status of corrective actions and incident investigation
- Progress toward achieving objectives.
Management review inputs to be reviewed less frequently and as needed such as
- Customer Complaints and interested party concerns
- Changes including new compliance obligations
- Adequacy of resources
- changes in risks and how they are being addressed
- Audit results
Management Review Outputs
The purpose of management review is to ensure the management system is able to achieve it intended outcomes. The outputs of management review are an important part of the Act part of the Plan-Do-Check-Act continual improvement cycle. It is where leadership has the opportunity to review the information generated in the “Check part of the PDCA cycle and intervene (Act) and continually improve the management system
Records of management review are the notes of the meeting (output notes). They are required by all ISO management system standards. Outputs are what leaderships asks the organization to do to improve performance. These records are also excellent evidence of leadership commitment during third party audits.
The goal of management review is to provide information to leadership that it can act on. Planning and conducting good management reviews will enhance leaderships opinion and support of the management system.
The ISO High-Level Structure (HLS) is the basis for all management system standards and is now being revised by ISO. These changes will affect all management system standards. Users of ISO management system standards such as ISO 14001, 9001 and 45001 will need to evaluate how these changes will affect the organizations ISO management systems.
Introduced in 2012, the HLS was created to help better integrate quality, environmental and health and safety management systems. Prior to its introduction ISO 9001 had a different structure that ISO 14001 that complicated integration of the management core processes such as corrective action and management review. The HLS solved that problem. The revision introduced a new name for the HLS and it is now called Annex L, Appendix 2.
The revision will also introduce guidance on use of the HLS for standard writers and users. This guidance is called Annex L, Appendix 3. Both Annex L, Appendix 2 and 3 will be combined as a table.
Appendix 2 is in the final stages of an initial “limited” revision and not yet available to the public. Appendix 3 is in mid-stage revision and should be approaching the final stage later this year.
Here are a few of the most important changes to Annex L, Appendix 2 from the “limited” revision:
Definition of Risk
A lengthy debate is ongoing within ISO about if a revision to the definition of “Risk” is needed. “Risk” is currently defined in the HLS as “the effect of uncertainty”. Some within ISO argue that a better definition is “the effect of uncertainty on objectives“.
Others fear that the addition of the words “on objectives” to the definition of risk will cause confusion in standards like ISO 9001, 14001 and 45001. They believe this because these standard have a specific requirement to create measurable “objectives” within the management system.
The debate over the definition of risk has lead to several proposals including eliminating the definition of risk entirely from the HLS. A subgroup has been assigned the task of sorting this difficult issue and the results will be reflected in a future revision of the HLS. For now however the definition of “risk” will remain as it is in the HLS.
Expected Outcomes Vs Results
The previous version of the HLS used the term “expected outcomes” to describe the results organizations should expect from its ISO management system. Some users found the term “expected outcomes” confusing so it has been changed to “expected results”. The change was also made to simplify translation to other languages.
The old HLS used the term “outsourced processes”. Manufacturers sometimes send their products to other organizations who perform specialized processes like heat treating or electroplating. This relationship between organizations was called “outsourcing” in the previous version of the HLS. The concept of “outsourced processes” however does not apply as well to other disciplines such as environmental management or health and safety management systems.
The term “external provider” is now being used in place of outsourced process. This change has been made in response to several comments that found the term “outsource” unclear. The use of external provider clarifies that outsourced, contracted, and purchased products, services and processes all need to be controlled by the management system.
The use of the terms “maintain” and “retain” to describe what needs to be done with certain types of documents in the management system has been replaced with the term “shall be available”. This change has been made to avoid confusion between maintaining and retaining documented information. This change is not expected to impact organizations with mature document control process and management systems.
This part of the HLS has been substantially reorganized. The title of 9.2.1 was changed to General and 9.2.2 Internal Audit Program has been added. This change has been made for ease in understanding. Now the two distinct concepts covered in the paragraph (what an audit program entails and what should be considered when establishing an audit program) are listed separately.
Effects of the Annex L, Appendix 2 and 3 Revisions (Whats Next?)
The revision of Annex L is not expected to have a significant immediate effect on ISO standards or ISO management system audits. The revisions will not requires revision of any of the ISO management system standards until these standard are revised and updated as required by ISO. However, organizations in the process of implementing an ISO management system or integrating a new discipline specific standard such as ISO 45001 into an existing management system structure, should anticipate that these changes will appear in future revisions of ISO management system standards.
A long-time professional college “The Honorable Scott Weyburn”, recently posted an interesting question focusing on benefits of ISO 9001 registration. I posted a response that prompted Scott to ask for more so here it is. Here is a link to Scott’s post which you might want to read first.
Understanding the Problem
The cause of the problem is easy to understand but difficult to correct. In my three decades performing nonfinancial audits for CBs if have found the CB customers primary interest is in sending a signal of sustainability to customers and other interested parties. Improving sustainability performance is subordinate to that perceived imperative. As a result, the organization focuses on passing the audit, not on having an effective management system. Investment is in readying for the audit not on the resources of an effective system. This is partially due to naivety and a lack of readiness in leadership in the organizations.
It is also due to financial tension within the organization. Investing in audit readiness only cost less than skillful implementation of an effective management system. Leadership calculates “If all I want is certification for messaging and developing a MS with that goal is cheaper than an effective system, why would I invest in an effective system?”. Leaderships misunderstanding is almost excusable considering the misrepresentation bombardment from CB’s and AB’s that their certifications and accreditation’s are evidence of system effectiveness.
Audit Services as Commodities
Another reason the certification process is failing is organizations seeking certification services perceive them as a commodity to be purchased from the lowest bidder. They do not understand certification audits are a professional service where auditor and CB competence are critical to obtaining a return on their certification investment.
To be competitive CB’s in the past would reduce the number of audits days and thereby reduce the cost of their service over their competitors. IAF implemented MD-5 to try to control this audit day downward trend. MD-5 is a complex system for determining audit days that was of some help early on. However, as time went on CBs recognized that the only way to be competitive was to reduce the day rates for auditors. Subsequently there has been a continuing downward spiral in compensation of qualified auditors, especially for contract auditors with no employment benefits.
Many experienced auditors like myself have subsequently reduced the number of audits we perform for accredited CBs doing only enough to remain competent for purposes of certification. The CBs now rely on inexperienced, inexpensive, and often incompetent auditors to perform audits on their behalf.
ABs Playing a Role
The ABs have also found themselves in a difficult financial conundrum. There has been much consolidation in the CB business reducing the ABs revenue streams. They recognize the threat to their clients, that major findings of auditor incompetence would bring, and are reluctant to issue meaningful nonconformities that compel change. The incentives created by the ABs for CBs to improve their performance are more prescriptive and lead to “lipstick on a pig” corrective actions that exacerbate the problem.
These are tough problems to solve that cannot be wrestled to the ground overnight. The financial assurance industry addressed similar problems with Sarbanes–Oxley Act of 2002 as well as in the Accounting Standards Codification issued by the Financial Accounting Standards Board (FASB). The best chance of fixing the underlying problems with assurance in the non-financial sector is to enact similar legislation which is unlikely to happen in the foreseeable future.
Exemplar Global certified ISO 14001:2015 lead auditor course in the modular Training Provider and Examiner Certification Scheme (TPECS) format. This courses is also delivered in a convenient virtual format. providing greater flexibility and reduced cost to students.
About the Course
The Exemplar Global certified ISO 14001:2015 EMS lead auditor courses are presented over a two week period 4 hours per day Monday thru Thursday. In the first week students take the ISO 14001:2015 Environmental Management System content (EM) . The EM content is delivered from 8:00am to 12:00pm each day of class.
The first two days of the second week of the class is the Auditor content (AU). The second two days of the second week is the Team Leaders content (TL). A test is administered after each course module.
|Course Module||Dates Offered||Times|
|ISO 14001 – EM||July 6-9, 2020|
August 3-6, 2020
|Auditor – AU||July 13-14, 2020|
August 10-11, 2020
|9:00am – 1:00pm|
|Team Leader – TL||July 15-16 2020|
August 12-13, 2020
|9:00am – 1:00pm|
Certified by Exemplar Global
- Understand environmental terms and definitions
- View the ISO 14001:2015 requirements from an auditor’s perspective
- Plan, manage, and schedule an audit program
- Identify, understand, and manage environmental aspects and impacts
Understand the requirements of ISO 14001:2015 to be able to conduct a successful audit. The course includes hands-on workshops to prepare you for real-life auditing situations. You’ll learn to manage the audit process and complete reporting..
This is a four-day, instructor-led classroom course. There are written tests on each of the competency units on days 2, 3, and 4. Days 1 and 2 will cover ISO 14001:2015 along with a corresponding competency exam. Day 3 will cover management systems auditing (AU) along with a corresponding competency exam. Day 4 will cover leading management systems audit teams (TL) along with a corresponding competency exam.
Who Should Attend
Those responsible for planning and scheduling an internal audit program for ISO 14001:2015 and those who must perform audits to ISO 14001:2015, environmental, suppliers, managers, or anyone interested in conducting first-party, second-party, or third-party audits.
All attendees are required to bring their own copy of the ISO 14001:2015 Environmental Management Systems – Requirements. Copies will not be provided for you.
- Describe the ISO 14001 Environmental Management System (EMS)-Requirements standard and development process
- Describe the intent and requirements of ISO 14001:2015
- Determine the evidence needed to demonstrate conformity to ISO 14001:2015
- Apply the process approach and Plan-Do-Check-Act (PDCA) methodology
- Identify aspects and impacts
- Apply the principles, processes, and methods of auditing
- Demonstrate the activities involved in preparing for an audit
- Determine an effective audit in the context of the auditee’s organizational situation
- Apply effective audit skills and practice personal behaviors necessary for an effective and efficient conduct of a management system audit
- Establish and plan the activities of an audit team
- Manage the audit process
- Prepare the audit report and perform an audit follow-up
June 4, 2020
1:00 PM – 1:30 PM – Central Time
The purpose of this brief webinar is to discuss the advantages of using internal audits and corrective actions to check that an organizations Covid-19 program is effective. The webinar explores how organizations can use ISO 45001 management system tools to respond to new challenges from the Covid -19 pandemic.
As the economy reopens organizations are being required to establish new programs and controls to minimize the spread of the virus among employees. Internal audits combined with corrective action programs help organizations establish and operate effective Covid-19 programs rapidly.
The webinar covers the following topics:
- Identifying Covid-19 compliance obligations
- Risk assessment methods for determining which Covid-19 Risk to addressed
- Establish operational controls for Covid-19 risks to employees
- When and how often to audit the Covid-19 program
- How to safely conduct Covid-19 audits
- How to effectively address Covid-19 internal audit findings through corrective action.
- Report the results of Covid-19 audits and corrective action to leadership
Kevin Lehner is a member of the US Technical Advisory Group (US-TAG) to ISO 45001: He is an expert and represents the US-TAG at international meetings. He recently traveled to Kigali, Rwanda to attend the 9th international meeting of TC 283 (interview with Martin Cottam in Kigali). Kevin is a certified lead auditor conducting ISO 45001 audits for clients including accredited ISO 45001 certification bodies.
Register for this Webinar
WDNR Green Tier Internal Audits
The WDNR Green Tier program requires participants to conduct periodic “outside” EMS audits to check that the system is functionally equivalent to ISO 14001:2015. By law, the minimum frequency of these audits is once every three years for Tier 1 participants and annually for Tier 2 participants.
Many organizations choose to perform WDNR Green Tier audits more frequently than prescribed by the Green Tier law. Longer than a year between audits result in increased risk to the organization. Postponing an annual physical from your doctor increases the risk that a medical condition will becoming a bigger medical issue.
WDNR Green Tier audits also provide important information to leadership. Reviewing Green Tier audit findings during management reviews allows leadership to evaluate how the EMS is functioning and if it is achieving the intended results. Leadership may miss important information when it reviews the results of audits only every three years.
Organizations that invest in their WDNR Green Tier audit program have better performing EMS’s and get a better return on their EMS investment. ISO 19011:2018, Guidelines for auditing management systems provides guidance for organizations wishing to improve their EMS audits. This guidance includes:
- How to establish audit programs
- How to conduct audits and report audit results
- What competencies auditors need to possess
- How to evaluate auditor competence.
Using the results of WDNR Green Tier Audits
WDNR Green Tier EMS audits evaluate audit criteria against audit evidence. Performing WDNR Green Tier audits ensures that “what should be is” and “what should not be is not”. Examples of audit criteria are requirements of Green Tier functional equivalence, compliance obligations such as permit requirements or requirements such as WDNR universal waste and hazardous waste regulations. They can also be internal requirements the organization has set for itself.
A robust EMS audit process and procedures coupled with effective corrective action process to address audit findings is critical to the effectiveness of am EMS. If the audit process or the corrective action process is weak the EMS may not be able to achieve the intended results of the EMS.
WDNR Green Tier Audit Corrective Actions
Green Tier audits are fundamental to superior environmental performance, but audits alone do not make changes that improve performance. Audits simply identify conformance and nonconformance to the requirements of Green Tier and the organizations internal requirement for the EMS.
Audits can be good news or bad news. If an organization is performing audits and find nothing but “good news” that is not especially noteworthy to leadership. Things are going along well, according to plan, and there is no identified need for action. When audits find nonconformances or bad news, this is good news to leadership because the audit has identified things that need to be fixed.
If organizations are either not performing effective audits or no audits at all this is bad news for leadership. Leadership has no way of knowing if the EMS is performing as planned. “No news” is bad news.
Audit nonconformance findings are good news and a source of EMS performance improvement. Audit nonconformances are not evidence of failure or reason to find fault. Doing so will create fear of the audit process within the organizations and increase the difficulty in gaining employees trust and cooperation with the audit process.
To benefit from the results of audits organizations also need to fix the nonconformance problems the audits discover. Performing audits and then being unable to correct the problems discovered is often a bigger problem than not performing audits at all. An example is an audit of regulatory compliance status that discovers a potential noncompliance. Uncorrected findings later discovered in a regulatory agency compliance audit could result in enhanced “knowing and willful” criminal penalties. Finding a potential noncompliance problem and not fixing it is worse than not finding it in the first place. To reduce risk, organizations need to take corrective action on audit findings in a timely fashion.
Some organizations struggle to get traction on their corrective action process for two primary reason.
- A clear process or workflow for performing corrective action has not been defined and or communicated by the organization.
- The organization has not established a systematic way to keep track of and report on if and how the nonconformance are being addressed.
WDNR Green Tier Audit Corrective Action Workflows
Corrective action workflows for audit nonconformance should be a team effort. Teams should follow several sequential steps collaboratively and reach consensus on each stage in the workflow. The last stage of the workflow is verification of effectiveness of the corrective action.
This team approach is similar to the collaborative product design process used by industries to develop products. The design process has desecrate points in the process called gates. Design teams agree that each step was completed before the design process can progress through the gate to the next stage
The purpose of this design review workflow is to ensure the design process is proceeding in a systematic fashion and to minimize the potential for design flaws that will become apparent in the production or use stage of product or service.
Figure 1 is an example of a corrective action workflow with approval gates and stages.
Gates separate some of the stages in the corrective action workflow. The number of approval-gates in the corrective action process can vary depending on the organizations’ needs. Stages in the corrective action workflow can include:
Stage 1 – New (Contain and Assign)
Recognition of the problem is the first step in the corrective action workflow. Recognition can occur as the result of an audit or incident. How the workflow proceeds after recognition depends on the gravity of the problem or incident encountered. The team leader or gate keeper needs to quickly decide what type of problem it is such as:
- Easy to Fix – We understand the problem cause and we can just fix it because it is unlikely to recur
- Not so easy to fix – We do not fully understand the problem but believe that the cause and solution can be discovered without commitment of substantial resources at this stage.
- Difficult to fix – This type of problem needs significant resource (horsepower) to address it with skill.
The preliminary evaluation will determine the size and competencies of the team needed to address the problem.
The team should consider Immediate steps to contain the problem (stop the bleeding) and what that containment should be. Placing lables and dates on the universal waste containers corrects the audit finding.The person assigned to the corrective action task should not delay implementation.
Stage 2 – Investigate (Cause and Corrective Action)
Putting a band aid on the problem with a short-term correction alone will not address the underlying problem cause and the nonconformance is likely to recur. Determining the cause of a problem is necessary to find a solution that fixes the problem and prevents recurrence. The team should investigate why the problem happened in the first place.
Root cause analysis is a huge topic and there are many approaches to doing a cause analysis, but sometimes asking “why did that happen?” several times can help identify the underlying cause of the problem (5 why analysis). Other problems can be more complex and require more horsepower than a 5 why analysis can deliver. These types of problems may need more sophisticated cause analysis techniques such as Six Sigma (DMAIC), 8 Disciplines (8D) or others.
The root cause of the problem helps the team discover an effective corrective action that will prevent the problem from recurring. The team should reach consensus that the proposed corrective action is appropriate to the cause before the corrective action is implemented. This will improve the likelihood that the corrective action will fix the problem in a way that it will not happen again..
Corrective action solutions that are based on one individual’s perception of the root cause and how to fix that problem often oversimplify both the cause and the solution. The tendency is for individuals to hurry the process and close the nonconformance as quickly as possible. This leads to weak root cause analysis which in turn compromises the selection of an appropriate corrective action.
If the corrective action process is not monitored in a team setting the assignee is more likely to close out the issue (get it off their desk) as soon as possible. A team approach to the corrective action process that use approval-gates can help avoid this consequence. Approval-gates encourage robust cause analysis.
The following is an example of poor cause analysis and proposed corrective action for the audit finding that universal waste containers were not properly labeled and dated.
- Proposed Cause – “The employee had not been trained in how to properly package and label the universal waste”.
- Proposed Corrective Action: Train the employee in how to properly package and label universal waste.
This cause analysis simply repeats the finding. It does not describe why the problem happened in the first place and the proposed corrective action is more of a correction than a corrective action. Implementing this action will not ensure that the same problem does not happen again.
Root Cause Analysis
Figure 2 shows the results of a more appropriate cause analysis of the universal waste packaging and labeling nonconformance.
Once the root cause is identified an appropriate corrective action can be proposed that will prevent it from happening again.
Often there are several options for corrective actions that fix the problem in a way that it does not recur. Some might have potential to be extremely effective but are costly to implement. An example might be to outsource the universal waste management to a contractor that comes to the site daily to check that the universal waste is being management correctly. This is highly effective and can transfer some of the risk of universal waste management, but it is expensive to implement. Before the corrective action is approved the team needs to decide if the proposed corrective action is appropriate for the cause.
An appropriate corrective action decided by the team for this problem and cause might be something like:
- Leadership will direct the HR department to develop a training matrix that shows competence required for all jobs including temporary fill in positions.
- The HR department will develop a process(es) that require(s) employees to demonstrate competence to do a job before the employee can be assigned to that job including temporary fill-in positions.
The team should reach consensus that the proposed corrective action is appropriate for the root cause before it is implemented. Once approved the actions should be implemented without delay.
Stage 3 – Perform (Corrective Action Implementation)
The team implements the corrective action after it is approved by the team and its leadership. One individual can implement a simple corrective action quickly. Complex problem solutions may require development of a project plan that assigns team members tasks. Task assignee’s need to accomplished these task by established dates. The team monitors progress on the tasks and periodically reports to the team leaders.
Stage 4 – Verification of Effectiveness
Verification confirms that the agreed upon corrective action was implemented as planned. It also confirms that the corrective action implemented was effective and fixed the problem in a way that it will not happen again.
Corrective action verification is usually performed by internal or external auditors during regularly scheduled or other audits. Others in the organization or on the team can perform the verification but it is important that the verifier be independent to the implementation process or the area where the verification is occurring.
Stage 5 – Closed
Team can close the corrective action after it has been verified. The team may need to invest additional effort if the verification finds that the corrective action implemented did not fix the problem. The team may need to re-investigate the cause and to re-propose and implement another corrective action.
Communicating and Tracking Corrective Action Status
A significant stumbling block that organizations sometime encounter when addressing nonconformances is the absence of a method to communicate and track the status of completion of the corrective action. Information about corrective action status has traditionally been paper based or electronic. These systems assign a corrective action task to someone to investigate and complete.
The team leader passes the physical or electronic copy of the corrective form to team member responsible for investigating the cause and proposing a corrective action. Then the paper or electronic copy is passed to other team members to add information or it is returned to the team leader for review and approval.
Assignee’s can misplace paper or electronic copies of corrective actions. Paper-based tracking systems require large three ring binders to store the completed corrective action forms and associated supporting documentation such as pictures or other evidence of completion of the corrective action. Electronic documents are often individually stored in folders located on the organizations servers or in the cloud.
With paper-based systems, communicating the overall status of corrective actions to leadership requires a labor-intensive process of thumbing through the three ring binders and manually recording the status of the corrective actions. Individual documents stored on servers or in the cloud have similar problems. Sorting through individual folders and files takes time to to find important information about the corrective action program. Use of electronic spreadsheets can help here but create other problems that limit the effectiveness of this solution
Corrective Action Tracking Database Apps
Industry 4.0 revolution will soon fundamentally and significantly change almost all business. This revolution is helping organizations store data optimize equipment and operations using the cloud environment. Organizations will be able to access enormous amounts of information with a click. Affordable cloud-based applications that track corrective action progress progress of are now becoming available to all types of businesses. Some of these application are easy to use and allow quick access to trends that inform management decisions.
The heart of these cloud based applications are databases that organize and store information. They help communicate the status of corrective actions to team members and leadership. These applications make it easy to monitor the approval-gate process and communicate with team members via automated emailing functions when the status of a corrective action changes or is approaching a due date. Correcttrack.com is a cloud based application that helps organizations keep track of Green Tier audit findings and improve the effectiveness of the corrective action process.
WDNR requires Green Tier participants to periodically audit their Green Tier EMS. Audits confirm the organization has established and is operating a “Functionally Equivalent” EMS that results in superior environmental performance. They are the critical “checking” part of an effective functionally equivalent EMS. If performed with skill the audit results can provide important information that the organizations leaders need to determine if the EMS is achieving its intended results.
Ensuring the results of audits are addressed in a timely fashion is critical to an effective EMS. This is especially true for nonconformance and noncompliance audit findings because findings that go unaddressed or with poor corrective actions increase the risk to organizations than if audits had not been done at all.
The ISO 45001 Technical Committee TC 283 is meeting in Kigali, Rwanda the week of October 6-12, 2019. The meeting will start with a plenary of all attendees to update national members on TC 283 developments. Task Groups (TG) and Work Groups (WG) will meet independently to work out the contents of several new work items that in are in progress including:
- TG1 – Communications
- TG3 – Revision of the High Level Structure (Annex L Appendix 2 & 3)
- WG2 – Psychological Health and Safety at the Workplace
- WG3 – Implementation Handbook
The TG3 discussions on revision of the ISO High Level Structure will focus on issues that have been encountered by users of ISO 45001 with respect to:
- The definition of risk as it applies to an OHSMS
- The relationship between risk and opportunity and the traditional OH&S discipline specific terminology ‘Hazards and Risks’
- Outsourced processes and how these to the OH&s discipline.
Comments are welcome here on opinions of changes to the HLS that will benefit the discipline specific ISO 45001.
Note. I want to be clear upfront that my intention is not to discredit the contribution organized labor made to the development of ISO 45001:2018. The point I make here is that they had a significant impact on the requirements in certain sections of ISO 45001:2018. This fact may help inform users about the intent of the requirements for purposes of implementation and conformity assessment.
Clause 5.4 of ISO 45001:2018 discusses requirements for consultation and participation of workers and is the result of an interest groups desire to ensure their constituents were give certain rights to have influence over the organizations OHSMS. Organized labor got a symbolic win here for their constituents but does this additional language add value to the standard or simply create unnecessary complexity and confusion for users of the standard?
As an auditor my approach would be to check if the workers themselves believe that their opinions about the OHSMS have been considered in its development and implementation. The best way to do this is to ask them directly. Here is a line of questioning I would use to get objective evidence of conformity to the participation and consultation requirements in 5,4 of ISO 45001:2018.
My first question would be something like “Have you heard about the OHSMS here?”. The answer to this question helps me get a sense of the organizations general awareness of the existence of an OHSMS. You might have to rephrase the question to get them to understand what you are asking.
The next questions would be something like… Can you tell me about what you do as your job here and what you do to keep yourself safe from injury or ill health? A good answer would be something like… My job is to load railcars. I need to stand on top of the railcar and inspect it after it is loaded. I need to wear this fall protection harness when I am on the railcar in case I accidently fell off. The harness would break my fall and prevent or reduce my chances of injury.
The next question would go directly to participation and consultation and would be something like this. Did you participate in any of the planning part of the OHSMS giving leadership your opinion of your comfort level with safely performing you job. Another good answer would be something like…Yes, our entire crew participated in a hazard identification and risk assessment meeting where we went over all the job tasks and risks. We were asked if we felt safe doing these tasks given the safety procedures and equipment that was in place. One of the areas we raised as potentially unsafe was the absence of fall protection. Based on that, our leadership has provided us with these ladders, harnesses and showed us how to use them. I feel much safer now with this enhanced risk control.
Based on the results of this interview I would have good objective evidence that the intent of 5.4 had been achieved. If most other worker interviewed had a similar tale to tell I would feel comfortable in concluding that the organizations had meet the requirements of clause 5.4 of the standard.
Of course, this line if questioning could have gone in many other directions and the answers given may not have supported a finding of conformity to varying degrees. Auditors are certified and calibrated to make decisions during audits while considering all the evidence presented much like a judge does in a legal case. Auditors who focus on too much detail like expecting the auditee to produce evidence of each of the 21 individual requirements of 5.4 are missing the point and need to step back and look at the bigger picture.
Here is a question that was recently posed on the ISO 45001 LinkedIn Group page and our response.
ISO 45001…Looking at requirement 7.4.1 (d) “The organisation shall ensure that the views of external interested parties are considered in establishing its communication process(es).” Anyone have any thoughts on how they will address this requirement, bearing in mind that OHSAS 18001 required, where appropriate external interested parties…are consulted?
Our Response –
I assume when you ask “how will they address this requirement” you are referring to certification bodies (CB’s) performing 3rd party independent audits of the OHSMS. I suspect that the answer to this question will be largely determined by how the CB calibrates their auditors for what the CB considers adequate objective evidence of conformity. My hope is that the CB’s will take a liberal view of what is acceptable here and let the auditee decide who is an external party and what views need to be considered.
I think that this section of ISO 45001:2018 is unnecessarily confusing and will likely be a source of debate between organizations and their CB auditors. The High-Level Structure text for his section was limited to the following:
The organization shall determine the internal and external communications relevant to the XXX management system, including:
— on what it will communicate;
— when to communicate;
— with whom to communicate;
— how to communicate
As a member of the US-Technical Advisory Group I observed that organized labor strongly supported adding additional language in this section and suspect that the intent is that organized labors “views” are considered when establishing the communication process.
So if organized labor is part of an organizations structure asking them to express their views on communication and documenting those views would be a good place to start. These views can then be discussed with the leadership during management review and “considered” when establishing the communication process. Producing these records during and audit should help show CB auditors that “the views of external interested parties are considered in establishing its communication process(es)”.
If organized labor is not a consideration, then it gets a bit tougher. I would start with of list of who the organizations think might conceivably be consider an external interested party. These might include:
- Regulatory agencies
- Business associations
- The community
- Local politicians
- Worker family member and relatives
I do not believe the standard compels an organization to proactively seek out the views of all external interested parties. This would be overly burdensome and of little value to the effectiveness of the OHSMS. However, after compiling its list the next question should be, have any of these external parties expressed views on how we communicate externally about our OHSMS? If the answer is no, then it would be appropriate to state to the auditor that no external parties have express views on our external communication process.
If views have been express by any of those on the list this should also be documented and discussed in management review (also documented) regarding the result of the consideration of these external views. Lastly, if the CB auditor digs in heals here and expects extensive evidence in this section you will always have the option to appeal a finding the CB’s Executive Committee of the CB for relief.