Municipal Health and Safety Auditing


General

What is a health and safety audit?

It is a way to check the health and safety management system (program). This is done by conducting

  • documentation reviews,
  • interviews with staff, and
  • observational tours.

Why conduct health and safety audits?

  • To identify program strengths and make suggestions for improvement
  • To ensure continuous improvement of processes and monitor for consistency across all aspects of the operation
  • To promote/enhance a municipality’s health and safety culture and employee awareness
  • COR certification and maintenance through the PIR program

Is an audit the same as an inspection?

No – auditors are not looking for specific hazards in the workplace, instead, they focus on the “system”.

Definitions

What is an "auditor"?

An individual certified by a Certifying Partner to conduct health and safety audits.

What is "documentation review"?

A validation method used in a health and safety audit, designed to determine if an employer has the required processes, policies, and procedures in place, and if adequate records are being kept.

Who is considered to be a "manager"?

A person who directs (and/or supervises) the affairs of a business, office, or organization.

Who is considered to be a "senior manager"?

The most senior person(s) accountable for the operation under the scope of the audit.

What is meant by the term "supervisor"?

A person in charge of or directing the activities of workers. Supervisor is a function, not necessarily a job or job title.

Who is a "worker"?

Any person engaged in a job who is not a manager or supervisor. This may include volunteers.

Auditor Training and Maintenance

Who can conduct municipal health and safety audits for PIR/COR?

Only AMHSA-certified auditors can conduct audits of participating member municipalities for PIR/COR. AMHSA uses the peer audit system (employee of audited municipality or a peer from another municipality or a consultant auditor).

What training is required to become an AMHSA-certified auditor?

Successful completion of:

What if I'm certified through another Certifying Partner?

Auditors certified through other Certifying Partners will no longer have the opportunity to challenge our auditor certification process. If you are a certified auditor through another CP, you will be given credit towards the Health and Safety Management Systems Course, but be required to attend the 2-day “Health and Safety Management Systems – Audit” course and conduct an auditor qualification/certification audit.

Once certified, how do I maintain my auditor certification?

Auditor certification is valid for 3 years. To renew:

  • Auditors must perform a minimum of 2 audits over the 3-year period. These audits must pass quality assurance.
  • Successful completion of the 1-day Audit Refresher course (with or without the optional second day of audit tool training) or 2-day Audit course is required to renew certification.

What happens if my AMHSA auditor certification expires before I attend the Auditor Recertification course?

Auditors whose certifications have lapsed have 6 months from date of expiry to attend the 1-day Audit Refresher course or 2-day Audit course.

What happens if I don't perform the required number of audits in the 3-year period?

Auditors who do not pass quality assurance review of at least two audits in each three-year period must attend the 2-day Audit course and conduct a new qualification (certification) audit.

Auditor Qualification (Certification) Audits

When do I conduct my certification audit?

Although six months is allowed, AMHSA generally requires candidates to complete their certification audit within 3 months of course completion. It has been AMHSA’s experience that the longer candidates wait to perform their certification audit, the less likely it is to pass quality assurance review. We recommend auditors-in-training conduct their certification audit as soon as possible after passing the course.

What kind of audit do I conduct to become certified?

Auditor candidates must complete the entire audit process – they must correctly determine the number and range of people to interview and the sites to visit, based on the scope of the audit. They must use all verification techniques, and complete the entire audit tool. Auditor qualification (certification) audits can be either

  • the municipality’s official PIR internal audit for the year (full scope – entire municipality covered by the WCB code) or
  • a single department/area. If auditing a department, we recommend a scope large enough that at least 6 interviews are conducted by the auditor-in-training. This provides them with the experience of compiling the interview results and including positive response rates in the “I” justifications.

What do I submit to AMHSA with my certification audit?

The documents submitted to AMHSA will depend on the tool being used to conduct the audit.

  • 2016 Excel Audit Workbook
    • Audit Workbook
    • Current organizational chart
    • Signed Code of Ethics
  • eCompliance Audit Tool
    • Audit Tool Report
    • eCompliance .eca file
    • Current organizational chart
    • Signed Code of Ethics
  • 2010 Excel Audit Tool
    • Audit Tool
    • Summary Score Sheet
    • Executive Report
    • Organizational Charts
    • Tables 2 and 3
    • Interview Summary Sheet
    • Pre-audit letter, meeting agenda, and minutes
    • Close-out meeting agenda and minutes
    • Signed Auditor Code of Ethics

How do I ensure I've Completed Table 2 - Determining Interviews correctly?

Table 2 is used by the 2010 Excel Audit tool to determine a representative interview sample. Auditor candidates are encouraged to get approval of their interview sample before conducting the audit. Simply email (shannon@amhsa.net) or fax (780.417.3940) your request and completed Table 2 to AMHSA – attention Shannon Thomas.

What if I have questions as I conduct my certification audit?

Call or email your assigned audit analyst:

External Audits

When must municipalities have external audits?

External audits are required to attain a COR certification, and every three years to maintain a COR. For example:

  • 2014: passed first external audit, received COR
  • 2015: need to conduct first internal audit
  • 2016: need to conduct second internal audit
  • 2017: need to pass another external audit

How are arrangements made for external audits?

Each year AMHSA notifies municipal CAOs of their status in the audit cycle. If the second internal was conducted in the previous year, this year an external audit will need to be conducted and passed (check with your auditors or health and safety coordinator). General process for external peer audits:

  • Written request for external audit is sent to AMHSA by June 15th
  • AMHSA finds auditors to conduct your audit and provides contact information
  • AMHSA informs you of which municipality your auditors will audit and provides contact information
  • Municipal contacts confirm specifics directly with the auditors

If your municipality is hiring a consultant to conduct its external audit (not participating in the peer process), inform AMHSA.

How do I request an external audit?

Submit your request in writing to Shannon@amhsa.net including

  • Municipality name and mailing address
  • Contact person, telephone, fax, email
  • Scope of audit (number of sites and employees)
  • Names of auditors on staff
  • Month preferred to have audit requested

How does AMHSA decide which municipality audits where?

We try to match up municipalities of similar size that are located near each other, to the best of our ability. This is dependent on which municipalities are participating in the external peer audit process each year. Cross-audits are not allowed. The same auditors will not be asked to perform two consecutive external audits on a municipality.

Who is responsible for external audit expenses?

The municipality being audited pays travel expenses – accommodations, meals, and travel costs ($/km), etc. The employer of the auditor is responsible for the auditor’s salary. AMHSA recommends discussing expense reimbursement before the audit takes place.

How should we prepare for the external auditors?

Communication is key! The auditors will require up-to-date information about the employees (managers, supervisors and workers) and sites. The auditors will need a quiet place to work and conduct interviews, and assistance scheduling interviews. AMHSA recommends gathering as much of the documentation as possible for the auditors to review on their first day on-site. The less travel involved for the auditors, the quicker the audit will be completed. Make sure you provide maps of the locations of the municipal sites that the auditors will be visiting on their observational tours, and an escort if necessary.

What is required to pass an external audit?

External audits must score at least 80% overall, with no less than 50% in any element. The auditor must also pass QA review for the audit to be processed for PIR.

What is the external peer audit system?

External audits are conducted by auditors from outside the municipality who are certified to conduct audits using the AMHSA Municipal Health and Safety Audit Tool. In most cases the auditors used will be certified auditors from another municipality (peer audits). This means that usually auditors from another municipality will conduct the external audit on your municipality and your auditors will conduct an audit on another municipality.

Quality Assurance Reviews

What happens once an auditor submits an audit to AMHSA?

All audits are reviewed by AMHSA audit analysts for auditor quality using a Partnerships-approved review tool. Auditors must score at least 80% on the QA review and correct all critical issues for the audits to be processed. Auditors are contacted and given a deadline by which they must submit their revisions. Once all revisions are made, AMHSA submits the information to Alberta Labour and the audit is processed for PIR. The municipality receives its PIR refund in the spring.

What happens if I don't score at least 80% on my quality assurance review?

You will be given one chance to revise and re-submit your audit, and it will be reviewed and re-scored. If it still fails, the audit will not be processed and submitted to Alberta Labour and WCB-Alberta. Note that this will result in the loss of a municipality’s COR in the case of internal or external PIR audits.

What is AMHSA looking for during the quality assurance review?

The QA Analysts look for fatal flaws, and ensure the audit report is complete - all auditor notes, strengths, and suggestions follow AMHSA’s auditing guidelines. Analysts also check that there are no scoring issues, no contradictions between questions and elements, and that the audit reports accurately reflect the results and are professional. 

Fatal Flaws

Timelines

  • 45 days (maximum) for on-site work, followed by
  • 45 days (maximum) to submit report for QA after last day on site
  • Revisions – 20 days per round of changes

Sampling

  • Representative interview sampling – meets or exceeds minimum, reflective of all departments, levels, shifts, and number of years of experience
  • Representative site sampling – meets or exceeds minimum, representative of all areas of operations, sites with differing numbers of workers, locations, and hazards. Main office and shop must be included in every audit

Boilerplating

  • Copying all or a portion of an audit for one employer and re-using it for another employer, making very few changes in the process
  • Can happen if the audit from one year is copied and re-used in a subsequent year

How do I avoid revisions?

Review your audit before submitting it to AMHSA for quality assurance review. Ask yourself the following questions before submitting your audit:

  • Have I followed the question guidelines?
  • Have I used the correct validation method?
  • Have I followed the scoring guidelines?
  • Are my Justification Notes complete?
  • Have I addressed all deficiencies with suggestions for improvement? 
  • Did I include Concluding Comments?
  • Have I included 1-2 program-level Strengths for each element?
  • Do Strengths include how they benefit the organization?
  • Do my Suggestions for Improvement describe a change to the system?
  • Do Suggestions include how making the change will benefit the health and safety management system?

Who should I contact if I have questions about my quality assurance review or revisions?

Contact your audit analyst:

Where can I find more information about quality assurance?

  • FAQs are available on the Alberta Labour website
  • AMHSA’s quality assurance review form is located in the Audit course binders and available for download here
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