Procedure overview
1 Purpose
This document provides the Framework for the Safety Management System (SMS) used to manage Health, Safety, and Wellbeing across the University, in compliance with the Work Health and Safety Act 2011 (Qld), Work Health and Safety Regulations 2011, ISO 45001:2018 Occupational Health and Safety Management Systems, Work Health and Safety Codes of Practice, and other relevant Standards.
2 Scope
This Procedure applies to all Employees, Students, Contractors, and Visitors engaged in university-related activities. It covers all University Sites and Workplaces, including campuses, remote workspaces, fieldwork, and virtual environments, both within Australia and overseas. It applies to all activities managed or influenced by the University.
3 Procedure Overview
The SMS Framework is based on AS/NZS ISO 45001: Occupational Health and Safety Management Systems - Requirements with guidance and use, which applies the iterative process of Plan-Do-Check-Act. It aligns with the University's Work Health and Safety Governance Procedure and Work Health and Safety Policy.
Planning allows Workplace Health and Safety (WHS) Risk, opportunities, objectives, and processes to be assessed and determined. The planned processes are then implemented. Monitoring and measurement are conducted to check that the intended outcomes are being achieved, followed by further actions to achieve continual WHS performance improvement.
This framework is considered in the context of the University being a complex high-reliability organisation, where people create safety under dynamic, uncertain, and complex conditions.
Figure 1: AS/NZS ISO 45001: Occupational Health and Safety Management Systems process
4 Procedures
4.1 Understanding the organisation and its context
The University's SMS has been developed in a time of significant global change, where the higher education sector is being impacted by a range of social, technological, economic, environmental and legislative drivers. It aims to support our Strategic Plan and aligns with our Core Strategies - Education Plan, Research Plan and the People Strategy, understanding to truly shift Safety Culture we must invest in our people.
4.2 Leadership commitment and planning
The University is dedicated to advancing beyond a compliance-centric approach, embracing a holistic health, safety, and wellbeing framework. This approach not only ensures Employee safety, environmental protection, and regulatory compliance but also reflects our commitment to a value proposition that benefits all stakeholders and the environmental systems they interact with. The University requires those responsible for any activities on University campuses and any other locations where activities are undertaken to consider safety as part of their day-to-day business and ensure they are familiar with and fulfil their obligations, so far as is reasonably practicable.
4.3 Consultation
Under the Workplace Health and Safety Act 2011 the University has duties in relation to consultation, cooperation, and coordination with workers and shared duty holders, so far as is reasonably practicable. The University is committed to understand the needs and expectations of workers and other interested parties, build stronger relationships, foster trust and collaboration, and ultimately achieve our health and safety objectives and compliance with legal and regulatory requirements.
This includes ensuring mechanisms are established, communicated, implemented and maintained within the accountability area for workers and shared duty holders to participate, be represented, communicated with and consulted with regarding workplace health and safety. The mechanisms must be consistent with the requirements of safety legislation and support consultative processes outlined in the University's Work Health and Safety Policy and Work Health and Safety Communication and Consultation Procedure.
4.4 Legal requirements
The University integrates health, safety, and wellbeing into all University operations through a structured SMS. To ensure legal compliance and a safe environment, the University:
- Identifies all relevant health and safety laws and standards.
- Maintains access to an up-to-date list of these legal requirements.
- Evaluates compliance regularly and addresses any non-compliance.
- Monitors changes in legislation and updates procedures accordingly.
- Documents all related activities and keeps records per University protocols.
- Trains staff to ensure awareness and understanding of applicable legal obligations.
4.5 Elements of the University SMS
The University SMS Framework consists of four key elements, facilitating a standard approach, effective implementation and communication of health and safety policies and procedures, compliance with regulatory requirements, and continuous improvement of the University's health and safety performance. They are:
- Governance
- Assurance and Compliance
- Risk Management
- Capability and Culture.
4.5.1 Governance
Governance establishes the foundation for WHS decision-making, accountability, and strategic alignment. Key Components:
- Leadership Commitment: Senior management actively leads WHS initiatives and integrates safety into strategic planning.
- Policy Development: WHS policies are developed under the University's Policy Framework and reflect the University's safety values.
- Strategic Planning: WHS goals are embedded in the University Strategic Plan, Education Plan, and Research Plan.
- Roles and Responsibilities: Defined in the Work Health and Safety Governance Procedure, ensuring clarity across all levels—from Council to individual workers.
4.5.2 Assurance and compliance
This element ensures the SMS is implemented effectively and meets internal and external requirements. Key Components:
- Internal Audits: Conducted by various levels of the organisation to assess compliance and identify improvement as per Work Health and Safety Audit Schedule.
- External Audits: Independent reviews validate system maturity and effectiveness.
- Monitoring and Reporting: Performance Indicators (lead and lag) are tracked via SafeTrak and Power BI.
- Corrective Actions: Findings from Audits and Incidents are addressed through structured action plans.
4.5.3 Risk management
Risk Management is a structured and proactive process for identifying, assessing, controlling, and reviewing health and safety Risks across University activities. Key Components:
- Hazard Identification: Hazards are identified through inspections, Audits, Incident reports, and staff input.
- Risk Assessment: Conducted prior to work using the University's Safety Risk Matrix; documented in SafeTrak.
- Control Measures: Selected using the Hierarchy of Controls; prioritising elimination and engineering solutions.
- Approval and Implementation: Risk assessments are approved based on Risk level; controls must be implemented and verified before work begins.
- Monitoring and Review: Controls are reviewed regularly and after Incidents or changes; effectiveness is tracked in SafeTrak.
4.5.4 Capability and culture
This element focuses on building WHS Competency and fostering a positive Safety Culture. Key Components:
- Training and Competency: Mandatory and role-specific Training ensures staff are equipped to manage WHS Risks.
- Employee and Student Engagement: Workers participate in consultative forums and provide feedback on WHS matters.
- Safety Culture: Promoted through leadership, recognition, and transparent communication.
- Communication: WHS updates, alerts, and lessons learned are shared via newsletters, toolbox talks, and digital platforms.
4.6 Operational
The SMS Framework supports the WHS Policy by providing mandatory minimum requirements to systematically manage health and safety Risks.
The University Policy Framework establishes categories of policies and sets out requirements and standards for each step of the development and review process. Records must be kept for each stage of the policy and procedure development process in accordance with the University Policy Framework.
Key Components of the University Safety Policy Framework
- Work Health and Safety Policy
- Developed under the University's Policy Framework and approved by the Vice-Chancellor and President, and the University Council.
- Provides high-level direction on safety principles and responsibilities.
- WHS Procedures
- Developed under the University's Policy Framework and approved by the Vice-Chancellor.
- Based on legislative requirements and Codes of Practice.
- Define mandatory minimum requirements for managing health and safety Risks.
- Compliance is mandatory.
- Work Health and Safety Schedules
- Subordinate to Procedures.
- Provide detailed Information on specific activities or requirements.
- Enhance readability and usability of Procedures.
- WHS Plans
- Part of the University SMS Framework.
- Based on legislative requirements and Codes of Practice.
- Define mandatory minimum requirements for managing health and safety Risks.
- Responsive to regulatory changes.
- Endorsed by the University Safety Consultative Forum.
- Compliance is mandatory.
- WHS Guidance Material
- Published when further supporting material is requested.
- Available on the University Website or UConnect.
- For Information not mandatory.
This framework ensures a consistent and efficient approach to managing health and safety Risks across the University.
4.7 The University SMS
The University's Safety Management System (SMS) comprises four key elements, each designed to align with the ISO 45001 standard for Occupational Health and Safety.
| Element | Procedure |
| Element 1 - Governance |
|
| Element 2 - Risk Management |
|
| Element 3 - Compliance and Assurance / Performance Evaluation and Monitoring |
|
| Element 4 - Capability, Culture and Wellbeing |
|
| Operational - Key Risk Procedures |
|
5 References
Nil.
6 Schedules
This procedure must be read in conjunction with its subordinate schedules as provided in the table below.
7 Procedure Information
| Accountable Officer | Chief People Officer |
| Responsible Officer | Director (Health, Safety and Wellbeing) |
| Policy Type | University Procedure |
| Policy Suite | |
| Subordinate Schedules | |
| Approved Date | 16/2/2026 |
| Effective Date | 16/2/2026 |
| Review Date | 16/2/2031 |
| Relevant Legislation | |
| Policy Exceptions | |
| Related Policies | |
| Related Procedures | Work Health and Safety Communication and Consultation Procedure |
| Related forms, publications and websites | |
| Definitions | Terms defined in the Definitions Dictionary |
| Council means the governing body, the University of Southern Queensland Council....moreCouncil means the governing body, the University of Southern Queensland Council. A person employed by the University and whose conditions of employment are covered by the Enterprise Agreement and includes persons employed on a continuing, fixed term or casual basis. Employees also include senior Employees whose conditions of employment are covered by a written agreement or contract with the University....moreA person employed by the University and whose conditions of employment are covered by the Enterprise Agreement and includes persons employed on a continuing, fixed term or casual basis. Employees also include senior Employees whose conditions of employment are covered by a written agreement or contract with the University. Any collection of data that is processed, analysed, interpreted, organised, classified or communicated in order to serve a useful purpose, present facts or represent knowledge in any medium or form. This includes presentation in electronic (digital), print, audio, video, image, graphical, cartographic, physical sample, textual or numerical form....moreAny collection of data that is processed, analysed, interpreted, organised, classified or communicated in order to serve a useful purpose, present facts or represent knowledge in any medium or form. This includes presentation in electronic (digital), print, audio, video, image, graphical, cartographic, physical sample, textual or numerical form. The measures of activities the University is undertaking to achieve end results....moreThe measures of activities the University is undertaking to achieve end results. The Strategic Plan developed by the University, as required under Section 8(1)(a) of the Financial and Performance Management Standard 2019....moreThe Strategic Plan developed by the University, as required under Section 8(1)(a) of the Financial and Performance Management Standard 2019. A person who is enrolled in a UniSQ Upskill Course or who is admitted to an Award Program or Non-Award Program offered by the University and is: currently enrolled in one or more Courses or study units; or not currently enrolled but is on an approved Leave of Absence or whose admission has not been cancelled....moreA person who is enrolled in a UniSQ Upskill Course or who is admitted to an Award Program or Non-Award Program offered by the University and is: currently enrolled in one or more Courses or study units; or not currently enrolled but is on an approved Leave of Absence or whose admission has not been cancelled. The term 'University' or 'UniSQ' means the University of Southern Queensland....moreThe term 'University' or 'UniSQ' means the University of Southern Queensland. The person bearing the title of Vice-Chancellor and President, or as otherwise defined in the University of Southern Queensland Act 1998 , including a person acting in that position....moreThe person bearing the title of Vice-Chancellor and President, or as otherwise defined in the University of Southern Queensland Act 1998 , including a person acting in that position. | |
| Definitions that relate to this procedure only | |
| Audit A systematic examination to determine whether activities and related results comply with planned arrangements and whether these arrangements are implemented effectively. Competency The combination of skills, knowledge, and experience required to perform a task safely and effectively. Control Measure An action or device implemented to eliminate or reduce the risk associated with a hazard. Corrective Action Steps taken to eliminate the causes of an existing non-conformity or other undesirable situation to prevent recurrence. Hazard A source or situation with the potential to cause harm, including injury, illness, or damage to property. Incident An unplanned event that results in, or has the potential to result in, injury, illness, or damage. Risk The likelihood and consequence of a hazard causing harm. Safety Culture The shared attitudes, values, and practices that characterise an organisation's commitment to safety. Safety Management System (SMS) A formal, organization-wide approach to managing safety risks and ensuring the effectiveness of safety risk controls. It involves systematic procedures, practices, and policies designed to proactively identify hazards and manage safety risks. Training The process of providing employees with the knowledge and skills necessary to perform their work safely. | |
| Keywords | Safety Procedures, WHS, OHS, safety guidelines, leadership commitment, policy development, strategic planning, roles and responsibilities, continuous improvement |
| Record No | 13/575PL |