Procedure overview
- 1 Purpose
- 2 Scope
- 3 Procedure Overview
- 4 Procedures
- 5 References
- 6 Schedules
- 7 Procedure Information
1 Purpose
To establish a systematic and consistent approach for monitoring, evaluating, and improving Work Health and Safety (WHS) performance across the University of Southern Queensland (UniSQ), ensuring effective implementation of the University Safety Management System (SMS) Framework, continuous improvement, legislative compliance, and alignment with the University's strategic goals.
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 University is committed to fostering a safe, healthy, and supportive environment for all Employees, Students, Contractors, and Visitors engaged in university-related activities. This procedure outlines the framework for monitoring, evaluating, and improving WHS performance across the University. This procedure incorporates the Plan-Do-Check-Act (PDCA) cycle to support continuous improvement and ensure adaptability in managing WHS performance.
This procedure aligns with the Work Health and Safety Act and Regulations 2011 (Qld).
4 Procedures
4.1 Roles and responsibilities
All University Members share responsibility for promoting a proactive safety culture. This involves complying with WHS policies, managing risks, and reporting incidents. Embedding safety into daily operations requires clear communication, training, and collaboration. Strategic oversight and resource allocation support a resilient WHS system aligned with the University's goals and legal obligations.
For further information on specific roles and responsibilities, refer to the Work Health and Safety Governance Procedure.
4.2 Workplace Health and Safety (WHS) Data Set
The University's WHS Data Set is structured into four key groups of Performance Indicators, incorporating both lead and lag measures to evaluate the effectiveness of the University SMS. Lead indicators are proactive measures that assess system maturity and preventative efforts, while lag indicators reflect outcomes and historical performance:
Group 1: Incident and Risk Control KPIs (Lag Indicators)
These indicators reflect the outcomes of Risk management activities and the effectiveness of existing controls. They are retrospective in nature and help assess performance based on past events:
- Number and type of incidents - Monitoring reported incidents to identify trends, recurring issues, categorise incident types, and highlights high-risk areas or activities.
- Psychosocial - in addition to incident data, sources may include unplanned leave, turnover, number of unplanned leave days, complaints, Employee survey results, number of complaints and amount of overtime.
- Lost Time Injury Frequency Rate (LTIFR) - Measures the frequency of injuries resulting in time lost from work, indicating the severity and impact of incidents.
Group 2: WHS Assurance and System Implementation KPIs (Lead indicators)
These indicators measure proactive efforts and the implementation, effectiveness and maturity of the University SMS system:
- Completion of safety audits and inspections - Tracks the number of scheduled audits and inspections completed, including the closure rate of identified corrective actions.
- Number of Risk assessments completed - Measures the volume and quality of Risk assessments conducted, along with the implementation status of associated control measures.
- Training and induction completion rates - Monitors participation in mandatory WHS training and induction programs to ensure workforce readiness and compliance.
- Safety Culture- Feedback is analysed to identify engagement trends and inform targeted interventions that strengthen safety awareness and participation.
- Consultative Forums - These forums meet regularly in accordance with their Terms of Reference (TOR) and serve as structured consultation platforms. They provide opportunities for workers and management to share feedback, and contribute to continuous improvement.
Group 3: Workers' Compensation and Rehabilitation KPIs (Lag Indicators)
These indicators assess the outcomes of injury management and return-to-work strategies, providing insight into the effectiveness of rehabilitation processes:
- Number and cost of WorkCover claims - Tracks the volume and financial impact of claims lodged.
- Average claim duration - Measures the time taken to resolve claims, indicating efficiency in injury management.
- Return-to-work success rates - Assesses the proportion of injured workers successfully reintegrated into the workforce.
Group 4: Legislative Compliance (Lag Indicators)
These indicators monitor the University's adherence to WHS legislation, standards, and regulatory requirements:
- Compliance with WHS legislation and mandatory Codes of Practice - Evaluates alignment with statutory obligations.
- Regulatory notices - Tracks formal notices issued by regulators, including improvement and prohibition notices.
- Audit findings related to legislative compliance - Reviews outcomes of internal and external audits focused on legal compliance.
Indicator data is reviewed regularly, as outlined in Section 4.5, to support informed decision-making and continuous improvement.
4.3 Audit Framework and WHS Assurance
4.3.1 Audit Framework
The Work Health and Safety Audit Schedule is overseen by the University HSW Team, with audit priorities determined based on Risk assessments, incident trends, and alignment with University's strategic objectives. System assessments are conducted to evaluate the effectiveness of the University's WHS controls and SMS. These assessments support continuous improvement, ensure compliance with legislative and internal requirements, and help mitigate health and safety Risks across the University.
The University applies a structured assurance model based on the Three Lines of Defence (refer to the University's Work Health and Safety Audit Schedule):
- First Line - Schools, Institutes, Organisational Units, and operational areas are responsible for conducting workplace inspections at least annually, or more frequently based on Risk level.
- Second Line - the HSW Team conducts scheduled audits to assess compliance with WHS legislation, internal procedures, and emerging Risk areas. Targeted deep dives are undertaken in high-risk areas based on data trends.
- Third Line - Independent assurance is provided through external WHSMS audits conducted every three to five years by Internal Audit or accredited external auditors. Specialist audits may also be commissioned to validate internal findings and assess the maturity and effectiveness of WHS practices.
4.3.2 WHS Assurance Activities and Performance Oversight
The following activities support the University's ongoing monitoring, evaluation, and improvement of WHS performance. These activities are designed to ensure compliance, identify Risks, and inform strategic decision-making through data-driven insights.
WHSMS and Legislative Compliance
- Conduct audits to assess alignment with university policies, the Work Health and Safety Act 2011, ISO 45001, and other applicable legislation.
- Identify gaps in policy implementation, training, or Risk controls.
- Undertake internal and external reviews to validate system effectiveness and maturity.
Risk and Hazard Management
- Review the Risk Assessment Register and hazard records for completeness and control effectiveness.
- Analyse incident and hazard data to identify trends, emerging Risks, and areas requiring updated assessments.
Psychosocial and Organisational Risk
- Review Psychosocial Risk and Organisational Assessments
- Monitor implementation of the Sexual Harassment Prevention Plan.
- Monitor and evaluate the effectiveness of associated controls.
Emergency Preparedness
- Conduct regular inspections and audits to identify WHS Risks and verify corrective actions.
- Review emergency preparedness activities, including drills and response plan effectiveness.
Stakeholder Engagement
- Use feedback mechanisms (e.g. surveys, focus groups, HSR consultations) to evaluate engagement with WHS systems.
- Assess contractor compliance with the University's WHS requirements and legislative obligations through the Contractor Management Procedure.
4.4 WHS Performance Reporting and Management Review
To support continuous improvement and provide strategic oversight of University's SMS, performance is regularly reviewed and reported through the following mechanisms:
- WHS updates to the University and Portfolio Safety Consultative Forums.
- WHS Performance Reports provided to:
- Vice-Chancellor's Executive (VCE)
- Audit & Risk Committee (A&R)
- University Council as per the University reporting schedule.
- Annual performance report and management review submitted to the Vice-Chancellor's Executive (VCE), summarising system effectiveness, key trends, and strategic Risks.
4.5 Continuous Improvement
The University applies the Plan-Do-Check-Act (PDCA) cycle across all WHS system activities to drive continuous improvement. This approach supports proactive Risk management and system maturity through structured planning, implementation, monitoring, and corrective action.
Continuous improvement is embedded in day-to-day operations through stakeholder engagement, benchmarking, data-driven decision-making, and regular review of procedures. Employees are empowered to identify and act on improvement opportunities, reinforcing a culture of safety and wellbeing.
The PDCA methodology is integrated into the University's WHSMS Performance Indicators (Section 4.2), system assessments (Section 4.3), and reporting mechanisms (Section 4.4), ensuring a consistent and strategic approach to WHS performance management.
4.6 Record Keeping
Records must be managed in accordance with the University Records Management Policy and Procedure. This includes ensuring records are retained within a recognised University recordkeeping system and remain accessible for review, reporting, and compliance audits.
Relevant records include, but are not limited to, Incident and investigation records, Audit and inspection reports, Risk assessments and control implementation documentation, and Training and induction records.
4.7 Digital Tools and Systems
- SafeTrak: University's Risk Management System.
- Power BI Dashboards: Visualisation of WHS performance data and trends.
- ChemWatch: Chemical safety data management and compliance.
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 | |
| 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. The measures of activities the University is undertaking to achieve end results....moreThe measures of activities the University is undertaking to achieve end results. Sexual Harassment is any unwanted or unwelcome sexual behaviour which makes a person feel offended, humiliated or intimidated, or occurs in circumstances where a reasonable person would have anticipated the possibility that the other person would be offended, humiliated or intimidated by the conduct. Sexual Harassment can take many different forms. It can be obvious or indirect, physic...moreSexual Harassment is any unwanted or unwelcome sexual behaviour which makes a person feel offended, humiliated or intimidated, or occurs in circumstances where a reasonable person would have anticipated the possibility that the other person would be offended, humiliated or intimidated by the conduct. Sexual Harassment can take many different forms. It can be obvious or indirect, physical or verbal, repeated or one-off, and perpetrated by a person of any gender against people of the same or another gender. Sexual Harassment may include: staring or leering; unnecessary familiarity, such as deliberately brushing up against a person, or unwelcome touching; suggestive comments or jokes; insults or taunts of a sexual nature; intrusive questions or statements about a person's private life; displaying posters, magazines or screen-savers of a sexual nature; sending sexually explicit emails or text messages; inappropriate advances on social networking sites; accessing sexually explicit internet sites; requests for sex or repeated unwanted requests to go out on dates; behaviour that may also be considered to be an offence under criminal law, such as physical assault, indecent exposure, sexual assault, stalking or obscene communications. Sexual Harassment is not interaction, flirtation or friendship which is mutual or consensual. The term 'University' or 'UniSQ' means the University of Southern Queensland....moreThe term 'University' or 'UniSQ' means the University of Southern Queensland. Persons who include: Employees of the University whose conditions of employment are covered by the UniSQ Enterprise Agreement whether full time or fractional, continuing, fixed-term or casual, including senior Employees whose conditions of employment are covered by a written agreement or contract with the University; members of the University Council and University Committees; visiti...morePersons who include: Employees of the University whose conditions of employment are covered by the UniSQ Enterprise Agreement whether full time or fractional, continuing, fixed-term or casual, including senior Employees whose conditions of employment are covered by a written agreement or contract with the University; members of the University Council and University Committees; visiting, honorary and adjunct appointees; volunteers who contribute to University activities or who act on behalf of the University; and individuals who are granted access to University facilities or who are engaged in providing services to the University, such as contractors or consultants, where applicable. Any recorded information created or received that provides evidence of the decisions and activities of the University while undertaking its business. This is irrespective of the technology or medium used to generate, capture, manage, preserve and access those records....moreAny recorded information created or received that provides evidence of the decisions and activities of the University while undertaking its business. This is irrespective of the technology or medium used to generate, capture, manage, preserve and access those records. | |
| Definitions that relate to this procedure only | |
| Risk The likelihood and consequence of a hazard causing harm. | |
| Keywords | |
| Record No | 25/133PL |