CHAPTER 15: MONITORING, MEASUREMENT, ANALYSIS AND PERFORMANCE EVALUATION

15.1 General (ISO 45001, Clause 9.1)

OH&S performance can be termed as the effectiveness of all those measures that are implemented to prevent injury and ill health to persons at the workplace. These measures constitute all the processes and arrangements defined in an organisation’s OHSMS, such as OH&S objectives, identification of hazards, assessment of risks, application of controls, handling of emergency situations, communication with interested parties, training of personnel, compliance with legal requirements, conducting audits, taking corrective actions, conducting management reviews, etc.

Having established an OHSMS, an organisation is required to measure, monitor and assess the effectiveness of its systems and processes. These actions are necessary for an organisation to determine the following:

•How well is the OHSMS achieving its intended outcomes? If it is not, there is a need to identify shortcomings and take actions to eliminate them.

•Is the OHSMS and the OH&S performance continually improving?

•Is the organisation in compliance (or otherwise) with legal and other requirements to which it subscribes? There may be a need to take measures to eliminate non-compliance if any, and to ensure that the organisation remains compliant with regulatory requirements at all times.

•Are the organisation’s OH&S objectives being met?

•Are the incidents of injury and ill health being reduced?

•Are the OH&S concerns of workers and other stakeholders being addressed?

15.2 Requirements (ISO 45001, Clause 9.1.1)

In order to create an effective monitoring, measurement, analysis and performance evaluation system, an organisation must establish, implement and maintain processes that can perform these four functions. The monitoring, measurement, analysis and performance evaluation processes must address the following aspects:

•What are the performance parameters that need to be measured and monitored? How will they be measured and monitored, and who will be responsible for doing so?

•What is the frequency or occasions at which these parameters shall be measured and monitored?

•The parameters that need to be measured and monitored proactively and those that need to be measured and monitored reactively need to be identified. Hazard identification is a proactive measure, while incident investigation is a reactive measure. Likewise, giving training and awareness is a proactive measure, and measuring the number of incidents and accidents is a reactive measure.

•The processes must define how the organisation will measure and monitor its compliance to legal and other applicable requirements. The frequency, responsibility and associated documented information must also be defined.

•The processes must define how the organisation shall measure and monitor the effectiveness of its hazard identification and risk assessment activities. This may be evident reactively by the OH&S incidents that take place. It is however also possible to conduct proactive or ongoing hazard identification activities to measure the effectiveness of the hazard identification process.

•An organisation must establish processes to measure and monitor the effectiveness of the operational controls implemented to reduce or eliminate the OH&S risks. Periodic inspection, maintenance or testing are some of the measures to confirm if the applied controls have not been degraded and are still effective.

•An organisation must define how it shall measure and monitor its progress (or the lack of it) towards achieving its OH&S objectives. The defined mechanism should include method, frequency and responsibility for undertaking these tasks. OH&S objectives are typically measured against the time frame defined in management programmes.

•An organisation shall define a calibration system for instruments used for measuring and monitoring so that the results obtained are reliable.

•An organisation should also define how it will analyse, evaluate and communicate the results of its measuring and monitoring processes.

15.3 Health monitoring and surveillance

Health surveillance is a process involving a range of strategies and methods used to systematically detect and assess the early signs of adverse effects on the health of workers exposed to health hazards. Health surveillance may also be needed to determine the fitness of employees who carry out special tasks such as working at height or working in confined spaces.

It is necessary for an organisation to ensure that it establishes a health surveillance programme appropriate to the site’s significant medical and occupational health risks. Coupled with an occupational illness reporting system, data can be collected and analysed to detect early signs of ill health or adverse health impacts on employees. Hence a good health surveillance programme will help in taking proactive measures against potential ill health events.

The objectives of a health surveillance programme may be summed up as:

•Protecting the health of individual employees by detecting, as early as possible, adverse changes that may be caused by exposure to hazardous substances and environments.

•Identifying and implementing specific surveillance requirements for employees requiring statutory health surveillance.

•Identifying tasks that involve chemicals and other hazardous substances that can be harmful to health if not properly controlled. For some chemicals, biological monitoring can be used to indicate how effective control measures are, and how much of the chemical has entered the body. Biological monitoring involves measuring the chemical or its breakdown products in urine, blood or breath. People exposed to hazardous chemicals risk health problems, including respiratory disease, occupational asthma, skin conditions, hypersensitivity or in some cases, cancer. Employers have a legal responsibility to ensure health monitoring is provided to a worker if the worker is carrying out ongoing work that involves using, handling, generating or storing hazardous chemicals.

•Collecting and analysing data to determine trends, taking proactive actions and applying suitable controls.

•Demonstrating fitness to undertake specific tasks where specific health criteria needs to be met.

A sample occupational health surveillance programme can be found in Appendix H.

15.4 Performance indicators and criteria

Measurement is an essential aspect of the PDCA cycle. ‘If you don’t know where you’re going, you’ll end up someplace else,’ the famous quote by Yogi Berra clearly suggests the need for constantly evaluating one’s OH&S performance. An organisation must therefore define the criteria and the indicators used to evaluate the effectiveness of its OH&S performance. Some examples of proactive or leading performance indicators used by an organisation are listed below:

•Review risk assessments for all departments and activities at least once every year.

•Ensure OH&S equipment is inspected/tested at the frequency determined for each equipment.

•Conduct at least two complete and four partial emergency drills every year.

•Ensure each manager conducts at least two ‘deep compliance’ inspections every month.

•Each supervisor should conduct at least four ‘behaviour safety contacts’ every month.

•OH&S objectives are measured/monitored every quarter and a progress report is sent to the Chief Executive.

•Every driver undergoes a ‘defensive driving’ training session once every six months.

•Every employee is given equipment hazards and postural hazards training at least once every year.

•Number of near-miss incidents reported every quarter.

•Number of hazards identified and reported every month.

•Safety committee meetings are held at least once every two months.

•A number of design changes are made to address identified OH&S risks over the life of a project.

•At least two internal OH&S audits to be conducted every year for all departments and functions of the organisation.

•Legal and other requirements to which an organisation subscribes are measured and monitored for compliance once every six months.

•Number of ‘toolbox talks’ conducted during a defined period.

•Number of proactive health, fume, dust, light or noise surveys carried out every year.

•Compliance with health surveillance programmes.

The reactive measures or lagging indicators of OH&S performance relate to the outcomes of measurement and monitoring of events that have already taken place. Although ‘outcome’ indicators are important, they generally reflect the results of past actions. It is also possible for outcome indicators to hide potential risks. For example, having a low incidence of injury does not necessarily mean that adequate safety systems and controls are in place. Reactive performance indicators could be accidents, incidents, nonconformances or events that occurred in a given time period, such as:

•Number of lost time accidents (LTAs);

•Number of restricted work cases (RWCs) or first-aid cases because of minor injuries;

•Work-related ill health cases, injuries and fatalities;

•Vehicle collisions and other losses, such as damage to property;

•Number of fires or emergencies;

•Number of OH&S system-related nonconforming situations identified; and

•Number of corrective actions taken.

15.5 Measuring and monitoring equipment

It is normal for an organisation to use a number of instruments or measuring devices to measure and monitor its OH&S performance. These could be instruments such as decibel meters, temperature or pressure gauges, volt meters, dosimeters, dust monitors, weighing scales, air flow meters, accelerometers, lux meters, gas leak and emission detectors, etc. Organisations need to ensure that a calibration system is established for calibration of such measuring instruments. The following simple steps could enable the implementation of an effective calibration process:

•Make a list of all OH&S measurement and monitoring equipment held by the organisation and the location where they are installed;

•Give a unique identification number to each equipment;

•Define a frequency of calibration for each equipment;

•Calibrate measuring equipment at the defined frequency. The calibration process involves comparing the readings of a device under test with the readings obtained from a standard instrument of known accuracy;

•Apply identification labels to indicate the last date of calibration and the next due date; and

•Retain calibration certificates and other documented information on calibration.

15.6 Measuring and monitoring plan

The measurement and monitoring activities described above must follow a well-considered plan. Often referred to as a ‘measurement and monitoring plan’, it forms the core of the OH&S measuring and monitoring process. A measurement and monitoring plan is often a summary of what equipment or OH&S parameters are measured, at what frequency and who has the responsibility for carrying out this task. A typical measuring and monitoring plan would include the following pieces of information:

•Proactive and reactive performance parameters, also called Key Performance Indicators (KPIs), which have been determined for measuring and monitoring;

•Responsibility for measurement, monitoring and analysis of each KPI;

•Procedures used for measurement, monitoring and review;

•Process and frequency of measurement or monitoring of KPIs;

•Process, frequency and responsibility for inspection and testing of operational controls;

•Process, frequency and responsibility for calibration of measuring and monitoring equipment;

•Process, responsibility and frequency for monitoring the extent to which OH&S objectives have been achieved;

•Process, responsibility and frequency for review of compliance with OH&S regulatory and other requirements;

•Process, responsibility and frequency for internal OH&S audits; and

•Documented information to be retained for each of the above activities.

A sample measuring and monitoring plan can be found in Appendix N.

15.7 Evaluation of regulatory compliance
(ISO 45001, Clause 9.1.2)

Meeting regulatory and other requirements to which an organisation subscribes is its first and foremost obligation. An organisation must be in complete compliance with regulatory requirements at all times. Hence an organisation is required to establish, implement and maintain appropriate processes for evaluating regulatory compliance on an ongoing basis. These processes must define the following aspects relating to the evaluation of regulatory compliance:

•The legal and other requirements that an organisation subscribes to;

•The responsibility, method and frequency at which the organisation shall evaluate the extent to which it complies with the applicable regulatory and other requirements;

•The actions to be taken if the organisation fails to meet the legal or other applicable requirements to which it subscribes;

•How the organisation shall keep itself abreast of the latest regulatory requirements, including knowledge and implications of the latest changes; and

•Retaining documented information of the results of compliance with legal and other requirements.