a way categorize and sort documentation within four levels which are:
Level I is the highest level that contain OH&S policies, and in some cases a policy manual. In large organizations, these are often referred to as “corporate level” documents that all business units must follow.
Level II documents are typically procedures that address specific activities such as lock‐out‐tag‐out, eye‐wash, and respiratory protection requirements and processes such as competency, planning and monitoring /measurement. When beginning to implement an OHSMS, organizations find that most of their documents are level II procedures (or process descriptions). It is typically the case that level II documents are also referred to “corporate” level documents: however, these can vary between business units.
Level III documents are specific guidelines, work instructions, and standard operating procedures and are typically unique to a plant or business unit. These documents define how an activity or process will occur.
Level IV documents are records used to either manage the system or are outputs from it. These can be, for example, forms/templates, training presentations, or monitoring records that are generated to provide artifacts of conformance with the standard.
FIGURE 7 Management system pyramid.
FIGURE 8 Gap analysis example.
7.4 Gap Analysis
After characterization of existing systems and processes is complete, conduct a gap analysis. This is typically an assessment of current state versus the desired future state such as conformance with an OHSMS standard. A gap analysis provides information on the degree to which specific OHSMS requirements are currently in place or being met, and the extent to which they integrated in the organization's business and operational processes. In some instances, it may be clear that an element is not at all present and associated activities are not being performed. In other instances, it may be the case that an element's requirements are being partially fulfilled. Finally, there may be complete fulfillment, but actions have not been documented. Whichever the case, the gap analysis is an important step in gaining an understanding of what actions need to be taken for development and implementation.
Documentation of gap analysis activities can serve to demonstrate continual improvement activities, if needed, for system certification certification (Figure 8).
7.5 Development
There are numerous ways to begin development of an OHSMS within an organization. Regardless of the approach, the characterization of existing business processes and OH&S policies and procedures, as well as the gap analysis described above needs to be done to inform the development steps.
If a formal MS (e.g. ISO 45001) standard is being used or followed, consideration needs to be given to its specific requirements. For instance, ISO 45001, has a focus on process(es) and not just procedures or programs.
One way to begin the development of the OHSMS is to create a grid with the management system elements, or requirements on one axis, and the management system document pyramid (Figure 7) on the other with its four levels. The cells of this grid can then be populated with information about the existing OH&S policies, procedures, and processes. A strategy can then be developed to populate all cells in the grid, as needed for conformance. This approach does not imply that procedures should or need to be developed, rather that if they exist, identifying them is valuable, and if they don't, to consider whether it would be helpful to, or to simply create a simple document that describes a (the) process in play for a particular cell in the grid.
Beyond identifying policies, procedures, and processes, important initial activities include conducting a risk (and opportunities if following ISO 45001) assessment to determine the OH&S risks (and opportunities) and other risks impacting the OHSMS that subsequently establish the foundation from which performance objectives are created and operational controls and actions are put in place.
Organizations typically begin addressing an OHSMS requirements starting with the first section and moving on in a linear fashion, or they begin with an element where there is a current need, or an element where is alignment with other initiatives in the organization. For instance, if there is a need to improve the audit function, the OHSMS checking, evaluation, or corrective action section may be the first place to start. Or if there are leadership initiatives in the organization, OHSMS elements associated with leadership and management commitment may be a fruitful place to begin. What's important to keep in mind is that the elements of an OHSMS are generally interconnected with each other. That is, if starting with leadership, think about aspects of worker engagement, competencies, governance and performance metrics and how that shapes leadership activities.
Regarding auditing, consideration should to be given to how the OHSMS's internal auditing needs (requirements) will interact, be performed, coexist, etc. with existing compliance audit functions. It is common for organizations to integrate the OHSMS and traditional compliance audit functions.
7.5.1 Support Team
The size of the organization will dictate the size of the implementation team needed. Safety and health staff team members will need assistance from human resources. A senior manager sponsor is a positive addition to the team. A representative from each facility (business unit, functional unit, etc.) in the organization should be identified and invited to participate. The implementation of a management system requires skills beyond traditional safety and health expertise. Consider the involvement of people from diverse functions in the organization. Engaging diverse participants in the implementation team will support integration and systems management of health and safety within and throughout the organization.
7.6 Rollout
Moving from the development of the OHSMS and its processes, policies and procedures, to its rollout can take place in increments over a period of time. This can range from months to years depending upon an organization's existing OH&S program maturity and organizational culture.
With OH&S risks and legal and other requirements identified, operational controls and associated elements are implemented. These include updating or putting in place
Training programs
Hazard controls following the hierarchy of controls
Preventive and corrective action
Procurement and contracting systems
Communication mechanisms
Checking/evaluation actions (auditing, incident investigation, etc.)
Associated with all of these activities is documentation that verifies actions, or as required by a standard.
Goals and Milestones. It is important to establish how implementation will be measured. One suggestion is to conduct a gap analysis early in the process and use progress reports to measure the completion of individual components or elements that fill the gap between what has preexisted and the desired final system components. Circulate the initial goals and milestones to the implementation committee members and others in the organization. Consider both outcomes (leading indicators) and output measures (trailing indicators).
Communication.