Building Success: A Guide to Establishing and Maintaining a Psychological Health and Safety Management System in the Federal Public Service

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Message from the Technical Committee

We are pleased to present our third report to the Steering Committee on Mental Health in the Workplace.

Since the release of our first report in December 2015 and our second report in April 2016, there has been tremendous support for addressing mental health in the workplace, including the Federal Public Service Workplace Mental Health Strategy. Released in June 2016, the strategy advances the work of the Joint Task Force and requires federal public service organizations to develop and implement action plans on mental health. The strategy also outlines support for enterprise-wide efforts, such as the creation of a Centre of Expertise on Mental Health in the Workplace. The virtual presence of the centre was launched in February 2017, and work continues to engage stakeholders and to develop a repository of best practices to support organizational efforts.

To further support organizations, the Technical Committee has prepared this report to guide organizations in developing and implementing a Psychological Health and Safety Management System.

Originally signed by:

Bob Kingston
Caroline Curran
Brenda Baxter
Shirley Friesen
Sandra Guttmann
Hilary Flett
Jerry Ryan
Denis St-Jean
Helene Paris
Jean-Pierre Lamarche
Stephanie Priest

Introduction

Background

In the first report to the Steering Committee on Mental Health in the Public Service, the Technical Committee outlined the following vision for the federal public service:

  • To create a culture that enshrines psychological health, safety and well-being in all aspects of the workplace through collaboration, inclusivity and respect. This obligation belongs to every individual in the workplace.

In support of this vision, the second report outlined key parameters for establishing a Psychological Health and Safety Management System (PHSMS) in the federal public service. According to the National Standard of Canada for Psychological Health and Safety in the Workplace, a PHSMS focuses on the identification and mitigation of hazards that can affect the psychological health and safety of employees in the workplace. A psychologically healthy and safe workplace is defined as follows:

  • A psychologically healthy workplace is one where every reasonable effort is made to promote the mental health of employees.
  • A psychologically safe workplace is one that allows no significant harm to employees’ mental health in negligent, reckless or intentional ways and where every reasonable effort is made to protect the mental health of employees through harm reduction strategies based on due diligence.

The second report also recommended that Assembling the Pieces: An Implementation Guide to the National Standard for Psychological Health and Safety in the Workplace be adapted for the federal public service environment. The document (Assembling the Pieces) is a step-by-step implementation guide written for all employers in Canada for establishing a PHSMS.

Approach

As part of the process to create a customized guidance document for the federal public service, the Technical Committee consulted with stakeholders to better understand promising practices as well as areas where gaps remained. As observed, many organizations have implemented practices, processes and procedures that form part of a PHSMS, and the Technical Committee sought to build on these efforts.

The Technical Committee noted the following:

  • Organizations need to understand the underlying issues upon which to act and implement solutions
  • An effective PHSMS requires a culture change, including the engagement of employees, with the support of authentic and visible champions
  • Joint governance and collaboration within organizations is the foundation for building a PHSMS  

Following the consultations, this guide was developed to help federal organizations plan, develop, maintain and update a PHSMS.

About the guide

This guide should be read in conjunction with the Technical Committee’s first two reports. The two reports provide valuable background information for implementing a PHSMS, and each chapter of this guide identifies recommendations from the reports, to help contextualize the information. This guide may be read in conjunction with Assembling the Pieces, which provides additional guidance, tools and resources.

It is recognized that organizations may be at different stages in establishing a PHSMS. Although the steps outlined in this guide should be implemented in sequential order, specific context may be a determining factor during implementation. Organizations may also need to tailor the steps to address their specific circumstances.

The establishment of a PHSMS will require a significant culture shift in the federal public service and an ongoing and visible commitment to ensure continuous improvement over time. This guide is a work in progress and is expected to evolve over time. Users are encouraged to provide feedback, including their successes and challenges, to the Centre of Expertise on Mental Health in the Workplace.

Chapter 1: establishing the foundation for a PHSMS

Introduction

This chapter describes the steps to establish the foundation for a PHSMS:

  1. Step 1: establish a Joint Sub-Committee on Mental Health (JSCMH)
  2. Step 2: jointly identify one or more champions
  3. Step 3: jointly determine the project sponsor
  4. Step 4: jointly develop the JSCMH’s terms of reference
  5. Step 5: jointly develop an initial communications strategy

This chapter provides guidance for implementing the following recommendations of the Technical Committee:

  • Appoint a Psychological Health and Safety Champion(s) at a senior level through an inclusive selection process, which includes consultation with bargaining agents/employees (from the first report)
  • Establish a joint governance structure to support the psychological health and safety management system within the organization, including the selection of psychological health and safety champions (from the second report)

This chapter may be read in conjunction with Chapter 1 of Assembling the Pieces (Building the Foundation), which provides additional guidance, tools and resources.

Context

Traditionally, occupational health and safety (OHS) has focused on identifying and assessing physical hazards in the workplace. However, employers and employees also have an obligation to support a psychologically safe workplace, including the identification and assessment of psychological hazards in the workplace.

Lessons learned by other public sector and unionized employers indicate that success in building a PHSMS is directly linked to the extent to which the PHSMS is co-developed by management, employees and unions. Consultations with federal public service organizations have also noted that co-development and collaboration among stakeholders can have a positive impact on the implementation of mental health-related initiatives.

Step 1: establish a Joint Sub-Committee on Mental Health (JSCMH)

An effective PHSMS requires a joint sub-committee on mental health to provide leadership and oversight and should comprise all stakeholders from across the organization.

The Joint Sub-Committee on Mental Health (JSCMH) can be established under the National Union (or Labour) Management Consultation Committee or the OHS committee. Key stakeholders within the JSCMH should include employer, employee, human resources and bargaining agent representatives, champions, as well as representatives from areas of interest, including audit and evaluation, management, OHS, employment equity groups, and Values and Ethics. The JSCMH is responsible for overseeing the development of a PHSMS and requires a champion and a project sponsor to support the allocation of human and financial resources. The JSCMH should be accountable to the deputy head, who is responsible for the health and safety of the organization’s workforce.

Depending on the size, culture and complexity of an organization, additional layers of co-governance and oversight may be required beyond the JSCMH. These could involve committees such as the Regional Union-Management Consultation Committee, the Regional Labour-Management Consultation Committee, and local health and safety committees.

Step 2: jointly identify one or more championsFootnote 1

Champions are to be identified through a joint union-management process, with input from individuals across the organization. As the face of the vision, champions play an important role in engaging unions and employees at all levels and in raising awareness of the importance of psychological health and safety. Champions need not come exclusively from management levels, but should be individuals who are credible, can speak openly and sincerely about the issue, and are dedicated to advancing psychological health and safety in the workplace.

Step 3: jointly determine the project sponsor

To support the work of the JSCMH and champions, departments and agencies need to identify a project sponsor in their organization. A project sponsor is an individual in a senior leadership position who has the authority to allocate human and financial resources to support the PHSMS. A champion and sponsor may be the same individual.

Step 4: jointly develop the JSCMH’s terms of reference

Given that the introduction of a PHSMS may require a significant culture change, it is critical that the supporting governance structure be clearly defined. The terms of reference need to clearly state that development of the PHSMS is a collaborative initiative between management, employees and bargaining agents and that the decision-making process is aligned with the practice of the National Joint Council committees and the council’s approach to co-development.

To support engagement with employees and transparency, the terms of reference should also indicate how the JSCMH works and how decisions will be communicated to employees.

Step 5: jointly develop an initial communications strategy

All organizations need to develop an initial communications strategy. The key objectives of this strategy are to:

  • make employees aware of the federal public service’s vision for psychological health and safety in the workplace
  • outline the steps that the JSCMH will take to engage employees
  • highlight the process for the JSCMH to identify the factors affecting the psychological health and safety of the organization’s workforce

This strategy needs to be co-developed with bargaining agents and disseminated to all employees.

Summary

Before conducting a psychological hazard analysis of the organization (Chapter 2 of this guide), the following steps must be completed:

  1. Step 1: establish a Joint Sub-Committee on Mental Health (JSCMH)
  2. Step 2: jointly identify one or more champions
  3. Step 3: jointly determine the project sponsor
  4. Step 4: jointly develop the JSCMH’s terms of reference
  5. Step 5: jointly develop an initial communications strategy

Chapter 2: conducting a workplace psychological hazard analysis

Introduction

This chapter describes the steps to conduct a workplace psychological hazard analysis:

  1. Step 1: train staff to undertake the workplace psychological hazard analysis
  2. Step 2: jointly conduct an evaluation of the organization’s workplace psychological hazards
  3. Step 3: jointly identify and evaluate programs, policies and workplace practices that may affect psychological health and safety
  4. Step 4: jointly assess data to identify problem areas, and develop recommendations for the next steps

This chapter provides guidance for implementing the following recommendations of the Technical Committee:

  • Educate, train and equip individuals, managers, and Occupational Health and Safety Committees/representatives, enabling them to adopt the Vision (from the first report)
  • Departments should conduct an assessment of risks and potential threats to workplace psychological health and safety to inform a continual review process, including assessment, identification, remediation, and further review (from the first report)
  • Ensure that OHS committees are equipped with essential training to fulfill their duties (from the second report)
  • Identify psychological health and safety factors through workplace assessments to inform continuous improvement (from the second report)

This chapter may be read in conjunction with Chapter 2 of Assembling the Pieces (What Are Your Opportunities?), which provides additional guidance, tools and resources.

Context

It is important to create a PHSMS that addresses organizational challenges, problems and opportunities as they arise and that manages responses and subsequent actions. Modifying the organization’s existing hazard prevention program to include psychological health and safety may reduce the likelihood of duplication and support change management goals. Hazard analysis, for the purpose of identifying and addressing opportunities and gaps, is a critical component in adapting and improving the effectiveness of the PHSMS.

According to early adopters of the National Standard of Canada for Psychological Health and Safety in the Workplace, broad and inclusive discussions within the organization were critical to successful alignment with the standard. Such change initiatives also noted that effort should not be focused solely on product-driven “plan” and “act” activities, but also on process-oriented “do” and “study” activities (Figure 1).

Figure 1: plan, do, study and act (PDSA) improvement cycleFootnote 2
Plan, do, study and act (PDSA) improvement cycle. Text version below:
Figure 1 - Text version

The figure is a circle that is divided into four equal parts. The parts are labelled as follows, clockwise from the top left:

  • Plan
  • Do
  • Study
  • Act

On the outside of the circle and in line with each quadrant are four arrows symbolizing repetition of the cycle.

To the right of the circle, the following text appears:

The PDSA cycle allows for rapid development and improvement of program components.

Plan: decide what to do

Do: undertake the work

Study: look at the results

Act: make adjustments

Implementing a PHSMS requires an assessment of the organization, beginning with a psychological health and safety hazard analysis to determine the starting point, or baseline. The analysis may identify hazards to be addressed on a priority basis, to support psychological health and safety in the workplace.

Step 1: train staff to undertake the psychological workplace hazard analysis

Occupational health and safety (OHS) committees play a key role in prevention, identification and mitigation of health and safety hazards, as well as other key stakeholders, including:

  • co-chairs of the OHS policy committee
  • co-chairs of the Joint Employment Equity Committee
  • diversity workplace networks, chairs and champions
  • co-chairs of regional and national labour management committees
  • champions for workplace mental health
  • human resources planners
  • OHS policy experts
  • human resources data analysts
  • disability management practitioners
  • conflict resolution specialists
  • auditors and evaluators
  • union representatives
  • support service providers (for example, Employee Assistance Program, Peer Support Network)

Organizations need to trainFootnote 3 all persons involved in the assessment of psychological hazards. At a minimum, this training is to include task-related hazard analysis, environmental hazard analysis and workplace inspections. More information on the types of analysis is provided in Step 2. The goal of the training is to equip individuals with the knowledge, skill set and tools to conduct an initial evaluation and to plan for ongoing measurement and evaluation of any new or existing programs.

Information on training requirements for OHS committees is provided in subsection 20.18 of the National Joint Council Occupational Health and Safety Directive and in Part 3 of the Policy Committees, Work Place Committees and Health and Safety Representatives Regulations.

Step 2: jointly conduct an evaluation of the organization’s workplace psychological hazards

Hazard analysis involves the identification and assessment of hazards and risk factors for the purpose of eliminating or mitigating those hazards. This step describes the types of hazard analysis, the hazard analysis process, and data sources.

  • What is a psychological hazard?
    Any potential source of psychological harm to an employee.
  • What are psychosocial risk factors?
    Elements of the work environment, management practices and organizational dimensions that characterize psychological risks to health.

Types of hazard analysis

Organizations are to undertake the following:

Task-related hazard analysis (or job hazard analysis) involves an assessment of both psychosocial and physical hazards. The assessment is conducted by breaking down a single task into sequential steps, which are then analyzed for hazards through different perspectives (for example, physical, chemical, biological, mechanical, ergonomic and psychological), to provide a comprehensive and systematic way of classifying hazards.  An example of a task-related hazard assessment may include the work of a paramedic and associated physical dangers, as well as trauma or stress.

Environmental hazard analysis involves an assessment of the work environment by examining various influential workplace characteristics. The characteristics may vary by workplace, and should be selected so as to provide a comprehensive view of the organization. The 13 psychosocial factors identified in the National Standard of Canada for Psychological Health and Safety in the Workplace provide a valuable overview of workplace characteristics. An example of an environmental hazard assessment may include the work associated with a trade advisor in a politically unstable country, where the job duties may not be considered hazardous, but the physical location of the work is.

Hazard analysis process

Organizations are to undertake the following process:

1. Identify the task or environment to be assessed. Conduct a preliminary review of critical data sources and an assessment of priorities. The review may include well-known problem areas or a general assessment of the workplace.
2. Task-related: break the task into reviewable steps.
Or
Environmental: select the critical lens or characteristics for examining the workplace.
Determine whether the hazards relate to the work steps themselves, the situation in which the work is performed, or both.
3. Determine the hazards associated with each step or characteristic. Provide evidence to inform decisions about identified hazards, including identification of potential consequences.
4. Recommend actions to eliminate, mitigate or protect against the hazards. Implement evidence-based recommendations, and define the monitoring process. This may require additional expertise.

Data sources

Existing sources of information to conduct an evaluation of psychological hazards in the workplace may include Employee Assistance Program data, Public Service Employee Survey data, and turnover rates. Other sources of information are listed in Appendix B.

Organizations may determine their own workplace characteristics and assessment processes and may be guided by existing practices and tools, including the Guarding Minds @ Work (GM@W) system. GM@W is an off-the-shelf assessment and survey tool to accompany the National Standard of Canada for Psychological Health and Safety in the Workplace. GM@W provides the worksheets to conduct an environmental psychological hazard analysis, using the 13 psychosocial factors to identify psychological risk factors in the workplace. Psychological risk factors may need to be added or removed to capture the workplace context.

The GM@W organizational assessment sheets may help identify demographic factors where an additional assessment may be required, including individual characteristics (such as experience, education, gender, gender identity, age and culture), work-related characteristics (such as operational and policy requirements), as well as specific occupations (such as correctional officers, coast guard employees or nurses working in the North). In addition, there are other sources of data to be considered, including those required by law (section 19.3 of the Canada Occupational Health and Safety Regulations and clause 4.3.5 of the National Standard of Canada).

Diversity and inclusion

Diversity and inclusion are integral to the National Standard of Canada for Psychological Health and Safety in the Workplace. Organizations should proactively encourage participation of all persons protected under Employment Equity and Human Rights legislation, at all stages of the OHS process. Organizations should also ensure that there is a clear understanding of how employment equity, diversity and inclusion considerations will factor into the analysis and associated recommendations.

Step 3: jointly identify and evaluate programs, policies and workplace practices that may affect psychological health and safety

It is important to identify specific programs, policies and procedures in the organization that may affect psychological health and safety and to analyze them using the same process and tools described in Step 2. For each program, policy or procedure, specific psychological risk factors can be considered, in addition to relevant data generated by the program, policy or procedure.

As the first step in the review, policies and procedures that have direct links to psychological health and safety should be considered, such as the following:

  • Policy on the Duty to Accommodate Persons with Disabilities
  • Employment Equity Policy
  • Policy on Harassment Prevention and Resolution
  • Telework Policy
  • Directive on Performance Management
  • Directive on the Performance Management Program (PMP) for Executives

This review must be conducted from a psychological health and safety perspective. It is recommended that the policy be broken down into its various components.

Step 4: jointly assess data to identify problem areas, and develop recommendations for the next steps

The most influential and reliable data sources should be selected to monitor and measure success as the initiative proceeds. The quality, timeliness and reliability of the data will determine their value for analysis and could affect the quality of the decisions that are based on this data. Data sources are to be readily available to support ongoing monitoring.

Privacy questions may arise when assessing available data sources. In addition, access to disaggregated data and information may be limited to specific interest groups, and applicable privacy requirements are always to be adhered to.

Ensure that the recommendations for preventive measures comply with legal requirements (section 19.5 of the Canada Occupational and Safety Regulations) and address identified and analyzed hazards, in the following order of priority:

  1. elimination of the hazard
  2. reduction of the hazard
  3. provision of personal protective equipment, clothing and devices (which could include suitable electronic devices or training in some cases)
  4. administrative controls

It is also important to note that technical experts should be consulted to determine the feasibility of potential solutions, as well as the ability to monitor implementation using existing data.

Summary

Before developing the PHSMS implementation strategy (Chapter 3 of this guide), an organizational assessment must be undertaken:

  1. Step 1: train staff to undertake the workplace psychological hazard analysis
  2. Step 2: jointly conduct an evaluation of the organization’s workplace psychological hazards
  3. Step 3: jointly identify and evaluate programs, policies and workplace practices that may affect psychological health and safety
  4. Step 4: jointly assess data to identify problem areas, and develop recommendations for the next steps

Chapter 3: developing the PHSMS implementation strategy

Introduction

This chapter describes the steps to develop the PHSMS implementation strategy:

  1. Step 1: create a training plan
  2. Step 2: develop a communication plan
  3. Step 3: establish a resourcing plan
  4. Step 4: build an evaluation plan
  5. Step 5: build a change management plan
  6. Step 6: prepare for critical events
  7. Step 7: develop a work plan

This chapter provides guidance for implementing the following recommendations of the Technical Committee:

  • Ensure appropriate resources are available to develop, implement, and support a comprehensive engagement strategy (from the first report)
  • Develop and implement a joint employer/employee communication strategy that includes, but is not limited to promoting active engagement and ongoing commitment…, engaging every individual in the workforce and enshrining psychological health and safety in all occupational health and safety communiques, programs and activities (from the first report)
  • Jointly develop and implement strategies for employee engagement, communication and promotion (from the second report)
  • Ensure adequate resources (staff and funds) and infrastructure (from the second report)

This chapter may be read in conjunction with Chapter 3 of Assembling the Pieces (What Are Your Objectives?), which provides additional guidance, tools and resources.

Context

Before building a PHSMS, it is important to complete the hazard analysis (Chapter 2) to gain a thorough understanding of the factors affecting psychological health and safety in the workplace. Given the significant culture shift associated with the implementation of a PHSMS, a well-developed plan and strategy for implementation are needed.

Planning enables the organization to prioritize its work-related psychological health and safety hazards, risks, legal requirements, management system gaps, and opportunities for improvement. Organizations should amend key procedures and processes identified as being in conflict with any of the 13 psychosocial factors, with attention given to the management of change and critical events.

Organizations are to establish objectives and targets and organizational requirements based on the hazard analysis and are to confirm the governance and ongoing management of the PHSMS. Thus, before beginning the planning process, it is imperative to jointly review the joint governance structure with unions and employees, confirm the terms of reference of all committees involved in building the PHSMS, and communicate the governance to all employees.

This chapter describes the key steps in the planning process. All the data and information that was gathered in the hazard analysis will help determine the essential elements of the strategy.

Step 1: create a training plan

As indicated in Chapter 2, training plans should be based on the organization’s hazard analysis. Organizations that have already implemented the National Standard of Canada for Psychological Health and Safety in the Workplace typically identify three areas for training and development:

  1. Knowledge and understanding of mental health and mental illness

    Not all employees need to become experts in identifying and treating individuals with mental illness. However, providing the opportunity for employees to develop an understanding of mental health and mental illness has many benefits, including de-stigmatization and access to tools for employees to recognize early warning signs and to implement coping mechanisms.

  2. Knowledge and understanding of the 13 psychosocial factors that impact the workplace

    Training in this area provides information about factors in the workplace that influence psychological health and safety. It provides guidance on how to eliminate, reduce and protect against hazards that potentially cause psychological harm and how to enhance factors that promote psychological health.

  3. Knowledge and understanding of mental wellness practices

    The National Standard of Canada for Psychological Health and Safety in the Workplace highlights the role that each employee plays in promoting psychological health and safety in the workplace. Equipping employees to manage their own health and well-being can contribute to a more positive work environment. Training in the areas of stress management, team-building, mindfulness, healthy eating and resiliency training can form part of this knowledge and understanding. 

It is also important to note the following when developing a training plan:

  • One size does not fit all

    As an example, Bell Canada, an early adopter of the National Standard of Canada for Psychological Health and Safety in the Workplace, launched an extensive Anti-Stigma Brown Bag Lunch series. The series was available across Canada, and feedback from attendees was very positive. However, as part of the formal evaluation, the implementation team realized that none of the employees who were out “working on the lines” had access to the training during their work day. The revelation resulted in Bell stepping back and developing other training options.

  • Avoid a focus on checking the box

    Assembling the Pieces describes the value of training grids that outline recommended training based on the roles and responsibilities of employees. Training grids let organizations effectively track the training that has been delivered. However, all too often, the focus can turn into checking the box to indicate that the training has been completed, even though the actual effectiveness of the training is not evaluated, or the training is not be aligned with the key objectives of the organization.

Step 2: develop a communication plan

According to Assembling the Pieces, “there are few things that will be more integral to your PHSMS than communications.” Building a PHSMS involves managers, employees and unions, so it is important that the communication plan be developed jointly. In addition, given the complexity of the work settings, it is critical to:

  • communicate actions and plans frequently
  • explain how aligning with the National Standard of Canada for Psychological Health and Safety in the Workplace will have a positive impact in the workplace
  • take a multi-prong approach when disseminating the message
  • review language to ensure a positive tone inclusive of all employees; an effective communications strategy for a policy analyst may not be suitable for a coast guard employee or a diplomatic courier. The message may also need to be adapted to reach out to employment equity groups in the organization.

Step 3: establish a resourcing plan

The resourcing plan is a list of all requirements to achieve stated objectives, targets and timelines. For example, financial resources may be required for awareness training, or a consultant may be required to conduct focus groups with employees.

The resourcing plan is the financial cost of carrying out all of the actions that have been identified and the associated human resource requirements needed to successfully implement the PHSMS. It is important to separate these costs and requirements so that the overall implementation strategy can be evaluated when complete. It is also important to ensure that the total resources do not exceed the budget or workload constraints.

Step 4: build an evaluation plan

It is important to determine what components are to be measured and how to assess whether actions are achieving the desired objectives. It may take two or three years before there are measurable results. Having short-term targets that can be measured and communicated to senior management and employees is important to maintain commitment and participation. The evaluation plan should clearly identify the commitments that are being measured, the individuals who will provide input, and short-term and long-term objectives.

Step 5: build a change management plan

Organizations change and adapt based on external and internal environmental factors. A critical component of a strong PHSMS is the development of a process that allows the system to react to change.

The purpose of change management is to ensure that individuals are motivated and able to appropriately perform new roles required due to the implementation of a new business strategy. A change management plan outlines the set of activities to help employees transition from their present way of working to new ways of working. It focuses on people and organizational factors that will drive or impede change throughout the organization.

Step 6: prepare for critical events

Floods, fires, earthquakes or other potentially catastrophic events are scenarios that a larger organization may already have planned for, to ensure that they can continue to operate and service their clients.

According to the National Standard of Canada for Psychological Health and Safety in the Workplace, there also needs to be a process to ensure that the psychological health of workers is considered and protected as much as possible in the planning stage or in the crisis stage of any critical event. An assessment of the potential psychological effects on employees must be done as part of the planning stage, and the critical event needs to be managed in such a way that psychological risks to employees are mitigated or reduced as much as possible. The associated reporting requirements are included in Part II of the Canada Labour Code.

Step 7: develop a work plan

To support the implementation strategy, it is imperative to develop a work plan for the first three years. When developing a work plan:

  • focus on two or three main priorities. It may be advantageous to focus on fewer priorities and do them well than to tackle too many things at once and not be able to accomplish the organization’s goals.
  • don’t get lost in the details. Start at the beginning and develop a multi-year plan with key milestones, and continuously review and adjust. Look for opportunities to align with the organization’s planning cycle.
  • set realistic expectations. It takes time to foster culture change, and it is important to manage expectations and to be patient as the journey progresses.

Summary

Organizations need to review and confirm the governance of the PHSMS and then develop an implementation strategy consisting of the following steps:

  1. Step 1: create a training plan
  2. Step 2: develop a communication plan
  3. Step 3: establish a resourcing plan
  4. Step 4: build an evaluation plan
  5. Step 5: build a change management plan
  6. Step 6: prepare for critical events
  7. Step 7: develop a work plan

Chapter 4: conducting a joint management review of the PHSMS

Introduction

This chapter describes the steps to implement a joint management review of the PHSMS:

  1. Step 1: review incident reporting
  2. Step 2: monitor performance
  3. Step 3: conduct a joint management review of the PHSMS

This chapter may be read in conjunction with Chapter 4 of Assembling the Pieces (Implement the Plan), which provides additional guidance, tools and resources.

Context

During and after implementation of a PHSMS, it is essential to continue with quality improvement activities and to regularly assess progress. This chapter focuses on lessons learned by early adopters of the National Standard of Canada for Psychological Health and Safety in the Workplace. Assembling the Pieces also provides many tips for successful implementation.

To support quality improvement and review activities, build on the work developed in Step 4 of Chapter 2 in order to determine how to track, measure and monitor progress. The information gathered from investigating and reporting incidents and other monitoring data will provide the foundation for evaluating the efficacy of the PHSMS. Key elements of the monitoring and improvement process are obtaining feedback and input on a continuous basis.

Step 1: review incident reporting

Organizations should already have an incident reporting system. The Canada Labour Code requires that employers report, at a minimum, on any hazard, and stresses the need to prevent such situations in the future.

The National Standard of Canada for Psychological Health and Safety in the Workplace recommends that incident reporting and investigation processes and procedures should be captured using existing reporting tools. An incident reporting system may be integrated within a more complex system of OHS incident reporting. It might also be a regulatory reporting requirement or an insurance reporting vehicle, such as a Workers’ Compensation reporting requirement.

The National Standard of Canada for Psychological Health and Safety in the Workplace also states that  organizations must establish and maintain procedures for reporting and investigating work-related psychological health and safety incidents such as psychological injuries, illnesses, acute traumatic events, fatalities (including suicides), and attempted suicides. These requirements may pose a challenge while protecting employee confidentiality and privacy. Existing incident reporting systems should be reviewed to ensure confidentiality and to determine whether changes to the process are needed. The incident reporting process must be carefully planned to ensure that it is secure, private and accessible only to individuals who are approved by the organization and meet the legislative and regulatory requirements for handling confidential information.

Step 2: monitor performance

Measuring and monitoring performance through a formal review system provides the ability to forecast future progress and implement adjustments and allocate necessary resources as required. It is important to assess progress toward intended outcomes and to measure the extent of improvement in overall psychological health and safety. This step is a critical aspect of a successful PHSMS and can be an area that is overlooked.

The frequency of monitoring performance is not specified in the National Standard of Canada for Psychological Health and Safety in the Workplace and is to be determined by each organization based on current management practices and the complexity of the PHSMS being implemented. Monthly, quarterly and annual review cycles may be required for different aspects of a PHSMS. For example, a monthly progress review could focus on targets, objectives, processes and policies. A quarterly review could be scheduled once the PHSMS implementation phase is complete, followed by an annual review of the overall progress relative to the baseline.

During the performance monitoring process, suggestions and ideas for continuous improvement or corrective actions should be developed jointly, through the preventive and corrective action processes established for the PHSMS, and should be used to adjust objectives and targets.

Step 3: conduct a joint management review

The final element of the monitoring component of the PHSMS is a joint management review of the PHSMS, consisting of a formalized, complete high-level system review. The review is to be conducted by senior joint leadership and ensures ongoing monitoring of relevant policies, procedures, results, and deficiencies. The joint management review of the PHSMS is a cumulative and ongoing process that supports the continuous improvement of the system.

The review may focus on trends, the identification of problems with the PHSMS, and identification of the factors that result in potential gaps in the system. Recommendations for improvement may lead to changes to the PHSMS, including the organization’s policies, objectives, targets, procedures, practices, and the allocation or reallocation of human and financial resources. A time frame should be established for the implementation of action plans arising from management review. The impact should be monitored, and the effectiveness of any changes should be evaluated.

Management reviews can be guided by a checklist that outlines the elements for review and includes a comments section to record necessary actions. Decisions and actions for continuous improvement or corrective measures are to be made through the preventive and corrective actions and by adjusting objectives and targets.

Summary

Implementation of a PHSMS is based on the PDSA improvement cycle (Chapter 2) and involves the following steps:

  1. Step 1: review incident reporting
  2. Step 2: monitor performance
  3. Step 3: conduct a joint management review of the PHSMS

Conclusion

The National Standard of Canada for Psychological Health and Safety in the Workplace indicates that improving the psychological health and safety of the workplace requires a shift from a primarily output-focused environment to a more inclusive and people-focused environment.

The establishment of a PHSMS, as described in this guide, is an important tool for achieving this shift and transforming the following vision into reality:

  • To create a culture that enshrines psychological health, safety and well-being in all aspects of the workplace through collaboration, inclusivity and respect. This obligation belongs to every individual in the workplace.

A workplace environment that effectively supports psychological health and safety issues contributes to a high-quality and high-performing federal public service.

Appendix A: steps to a successful PHSMS

Figure 2: Steps to a successful PHSMS
Steps to a successful PHSMS. Text version below:
Figure 2 - Text version

The figure is a rectangle that is divided into four equal parts. The parts are labelled as follows, clockwise from the top:

  • Establishing the foundation for a PHSMS
  • Conducting a workplace psychological hazard analysis
  • Developing the PHSMS implementation strategy
  • Conducting a joint management review of the PHSMS

In the middle of the rectangle is a circle that is divided into four quadrants. The quadrants are labelled as follows, clockwise from the top:

  • Establish
  • Analyze
  • Plan
  • Review

The quadrant labelled “Establish” has an arrow pointing to “Establishing the PHSMS.”  This part of the rectangle lists the following steps:

  1. Establish a Joint Sub-Committee on Mental Health (JSCMH)
  2. Jointly identify one or more champions
  3. Jointly determine the project sponsor
  4. Jointly develop the JSCMH’s terms of reference
  5. Jointly develop an initial communications strategy

The quadrant labelled “Analyze” has an arrow pointing to “Conducting a workplace psychological hazard analysis.” This part of the rectangle lists the following steps:

  1. Train staff to undertake the psychological workplace hazard analysis
  2. Jointly conduct an evaluation of the organization’s workplace psychological hazards
  3. Jointly identify and evaluate programs, policies and workplace practices that may affect psychological health and safety
  4. Jointly assess data to identify problem areas, and develop recommendations for the next steps

The quadrant labelled “Plan” has an arrow pointing to “Developing the PHSMS implementation strategy.” This part of the rectangle lists the following steps:

  1. Create a training plan
  2. Develop a communication plan
  3. Establish a resourcing plan
  4. Build an evaluation plan
  5. Build a change management plan
  6. Prepare for critical events
  7. Develop a work plan

The quadrant labelled “Review” has an arrow pointing to the quadrant labelled “Conducting a joint management review of the PHSMS.” This quadrant lists the following steps:

  1. Review incident reporting
  2. Monitor performance
  3. Conduct a joint management review

Appendix B: data sources

Data holdings in the public service are derived from a number of systems. The following is a suggested list of data sources and information to use in building an organization’s baseline for a PHSMS:

  • existing organizational policies and plans pertinent to psychological health and safety in the workplace
  • job descriptions and job demands analysis
  • aggregated administrative data, from various perspectives (for example, bargaining agent, management), such as:
    • centralized administrative data, including sick leave, turnover rates, and patterns of absence in the organization
    • Employee Assistance Program data and reports such as service utilization rates
    • Organizational Informal Conflict Management System data and reports such as the types of service offered and their utilization rates
    • long-term disability costs
    • principal diagnostic categories for long-term disabilities (for example, mental health)
    • claims data such as benefit utilization rates, disability relapse rates and workers’ compensation data
    • data on organizations
    • Return to Work or Stay at Work data, if available
    • accommodation data, such as average length of time to implement accommodation requests and satisfaction with accommodations provided
    • organizational usage of Injury on Duty Leave
    • the organization’s average time to report claims to the Workers’ Compensation Board
    • review of incident reports, worker complaints, investigations and health-risk assessment data
  • laws and regulations, including:
    • human rights
    • OHS acts
    • violence and abuse prevention in the workplace
    • labour laws
    • workers’ compensation
    • harassment
  • standards, codes and guidelines
  • worker engagement indicators and worker feedback (for example, surveys, including results from the Public Service Employee Surveys, participation rates in events and training activities)
  • reports from unions or worker groups on exposure or risk information
  • diverse perspectives (for example, mental illness, cultural differences), including those with personal experience of mental health issues and various cultures
  • results of organizational audits
  • industry- or association-established best practices
  • research

Appendix C: abbreviations and terminology used in this report

Abbreviations

JSCMH
Joint Sub-Committee on Mental Health
OHS
Occupational health and safety
PHSMS
Psychological Health and Safety Management System

Terminology

co-governance
Governance made up of both employer and employee representatives.
hazard identification and assessment
As described in section 19.4 of the Canada Occupational Health and Safety Regulations, a systematic way to identify and assess workplace hazards, including those related to psychological health and safety.
National Standard of Canada
A standard approved by the Standards Council of Canada. The designation of a standard as a National Standard of Canada indicates that it is recognized as the official Canadian standard in a particular subject area.
project sponsor
An individual (typically a manager or an executive) who has overall accountability for a project and who is responsible for ensuring that the project delivers the agreed business benefits.
psychological hazard
Any potential source of psychological harm to an employee.
Psychological Health and Safety Management System
An organizational management system consisting of policies, procedures, and practices put in place to assist organizations in creating a psychologically healthy and safe workplace.
psychologically healthy workplace
A workplace where every reasonable effort is made to promote the mental health of employees.
psychologically safe workplace
A workplace that allows no significant harm to employees’ mental health in negligent, reckless or intentional ways and where every reasonable effort is made to protect the mental health of employees through harm reduction strategies based on due diligence.
psychosocial risk factors (PRFs)
Elements of the work environment, management practices and organizational dimensions that increase the risk to health.
standard
A document that provides requirements, specifications, guidelines or characteristics that can be used consistently to ensure that materials, products and services are fit for their purpose.

Appendix D: works cited

CSA Group and Bureau de normalisation du Québec. CAN/CSA-Z1003-13/BNQ 9700-803/2013, Psychological Health and Safety in the Workplace: Prevention, Promotion and Guidance to Staged Implementation.

Mental Health Commission of Canada. Assembling the Pieces: An Implementation Guide to the National Standard for Psychological Health and Safety in the Workplace, 2014.

Technical Committee Report to the Steering Committee on Mental Health in the Workplace, September 2015.

Technical Committee Report to the Steering Committee on Mental Health in the Workplace, April 2016.

Appendix E: terms of reference for the Joint Sub-Committee on Mental Health (example)

Joint Sub-Committee of the Labour-Management Consultation Committee on Mental Health

Terms of Reference

1. Preamble

The [name of organization] and the bargaining agents are committed to fostering a collaborative relationship and recognize the usefulness of the Joint Sub-Committee of the Labour-Management Consultation Committee on Mental Health (the joint sub-committee) in conducting and evaluating psychological hazards in the workplace.

Consultation is based on full and timely disclosure, to the utmost possible extent, of contemplated actions by both parties.

The joint sub-committee will function in accordance with these Terms of reference.

2. Name of sub-committee

Joint Sub-Committee of the Labour-Management Consultation Committee on Mental Health

3. Principles

Open dialogue will be conducted in a respectful and professional manner, without fear of reprisal. Each party recognizes the vital role of the other and is committed to invest the time and effort to encourage the sharing of information in this forum. To be effective, the process must be based on honest and open communication by both parties and to listening to each other’s opinions and observations.

The bargaining agents and the [name of organization] believe that an effective Labour-Management relationship is based on:

  • equality of the parties within the consultation process;
  • mutual trust and respect;
  • commitment to be constructive, fair and courteous in our dealings with each other;
  • emphasis on the value of all employees and consideration of their needs;
  • recognition and encouragement of employee contributions within the organization;
  • facilitation of constructive decision making and problem solving at the lowest possible level;
  • commitment to bringing interests to the table and applying those interests to guide evidence-based recommendations to the Labour-Management Consultation Committee; and
  • respect for the privacy of individuals, as applicable.
4. Purpose of the joint sub-committee

The purpose of the joint sub-committee is to provide expert and evidence-based analysis via a regular assessment of psychological hazards in the workplace. The exchange of information between management and employee representatives and within these groups will meet the privacy requirements outlined in the Privacy Act. This should enable employee representatives to be informed about aggregated data, policies, programs and working conditions, and to discuss these with management. Proposed changes to departmental policies, programs or working conditions that may affect psychological health and safety in the organization should be communicated to the Labour-Management Consultation Committee.

Such joint consultations ensure that the views of employee representatives are obtained and that managers give careful consideration to these views when making decisions.

5. Scope of the joint sub-committee

The joint sub-committee has no authority to amend the provisions of collective agreements or regulations affecting employees’ terms and conditions of employment. The specific details of an employee’s situation or condition shall not be discussed at this committee. Discussions shall only relate to the Organization as a department.

The joint sub-committee functions in a consultative and evaluative capacity. This does not imply unanimous or majority agreement, nor does it in any way interfere with management’s authority, its obligation to manage, or a union’s legal rights established by the Public Service Labour Relations Act or by a collective agreement. The objective is to communicate freely and to resolve problems through consensus rather than by vote.

The joint sub-committee will strive for consistency in approach in any decisions made that affect employees, so as to maintain uniform application of policies, programs and working conditions to the highest degree possible.

6. Suggested composition of the joint sub-committee

Co-chairs

The joint sub-committee will be co-chaired by a management representative and a bargaining agent representative. The co-chairs are responsible for conducting the meeting and establishing an environment that permits the free expression of opinion, without intimidation or fear of reprisal. 

The participating bargaining agents shall agree upon a co-chair.

Secretariat

The Secretariat will be provided by the Chief of Occupational Health and Safety, the Chief of Employment Equity or the Chief of any of the other human resources functions represented. In the absence of the Chief, a member of one of those units may act as secretary.

Management

  • Co-chair of the Occupational Health and Safety Policy Committee
  • Co-chair of the Joint Employment Equity Committee
  • Diversity workplace networks, chairs and champions
  • Co-chair of regional and national labour-management committees
  • Champions for workplace mental health
  • Human resources planners
  • Occupational health and safety policy experts
  • Human resources data analysts
  • Disability management practitioners
  • Conflict resolution specialists
  • Support service providers (for example, Employee Assistance Program, Peer Support Network)
  • Auditors and/or evaluators

Bargaining agents

All bargaining agents should be invited to participate. However, an additional seat should be allocated to the bargaining agent elected as co-chair of the joint sub-committee. 

7. Required training

All members of the joint sub-committee must have up-to-date training in workplace hazard analysis. 

8. Attendance

The meetings of the joint sub-committee will be held on the employer’s premises during working hours, at times determined by mutual agreement of the parties. Representatives will be given reasonable time, with pay, to prepare for and attend meetings and to carry out follow-up action.

Representatives of the joint sub-committee or other employees who are invited guests shall be protected against any loss of regular pay due to attendance at meetings.

9. Agendas items

Bargaining agent and management members will be responsible for providing agenda items to the secretary. These items must be provided in sufficient time to allow for the distribution of the meeting agenda and material to both parties at least one week before the scheduled meeting.

Joint sub committee members who submit agenda items to the secretary should also provide explanatory notes and/or pertinent documentation

Items not on the agenda may be discussed at the meeting with the approval of both management and bargaining agents.

10. Frequency of meetings

To be decided

11. Record of meetings

The secretary will prepare a written summary of items discussed, action taken and recommendations made. After the meeting, records of discussions will be sent within [insert number] weeks following the meeting to the co-chairs for review and signature. The secretary will have the records of discussions translated, distributed and posted as quickly as possible following signature. A copy of the signed record of discussions will be sent to the bargaining agents.

Joint sub committee members are expected to follow up on commitments identified in the minutes.

12. Use of official languages

Meetings shall be conducted in both official languages. Members of the joint sub-committee are encouraged to speak in the language of their choice. Agendas, meeting material and minutes will be provided in both official languages.

13. Quorum

There will be a requirement to have at least [insert number] of the [insert total number] bargaining agent representatives and [insert number] of the [insert the total number] of management representatives available for the meeting. Otherwise, the meeting may have to be cancelled or rescheduled.

14. Limitations

The joint sub-committee may make decisions and provide information only according to its delegated authority.

15. Amendments

These Terms of reference will be reviewed every two years and may be amended by mutual consent of management and the bargaining agents.

16. References

This document is to be read in conjunction with [insert name of document(s)] [and list other useful documents, such as other terms of reference or frameworks].

Co-Development Guidelines

Guidelines for Labour-Management Consultation Committee

[Insérer le nom de l’organisme]

Original signed [month] [day], [year].

© Her Majesty the Queen in Right of Canada, represented by the President of the Treasury Board, 2018,
ISBN: 978-0-660-24570-6

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