Audit of Occupational Health and Safety

Executive summary

Audit overview

This audit aimed to assess whether Health Canada (HC) and the Public Health Agency of Canada (PHAC) have an established Occupational Health and Safety (OHS) program that complies with legal and policy requirements. The scope included an assessment of the processes in place to support OHS requirements from April 1, 2019, to July 31, 2023, including the establishment of governance and management oversight.

It should be noted that OHS activities during the audit's scope were affected by the COVID-19 pandemic. To reflect the changing work environment during the pandemic, the audit team used the last full year of available data to assess compliance with annual legislative requirements. More recent developments were considered and added to the report where relevant.

Good practices

We found that the Health Canada (HC) and Public Health Agency of Canada (PHAC) OHS Policy Committees were generally established and operating in accordance with Part II of the Canada Labour Code, herein referred to as the "Labour Code". We also found evidence of regular monitoring and reporting of OHS activities.

In addition, we found that training programs were developed to address OHS requirements outlined in the Labour Code, and that the Corporate Occupational Health and Safety Program, herein referred to as the "Program" or COHSP, had made efforts to promote awareness of required training through internal communication channels and virtual sessions.

Lastly, we found that OHS facility requirements related to fire protection, safety signage, and personal protective equipment (PPE) were generally met, and that most buildings were well maintained.

Opportunities for improvement

We acknowledge the difficulty of implementing OHS activities during the COVID-19 pandemic, given HC and PHAC's changing needs and the new realities of a hybrid work place. Nonetheless, we found that oversight bodies were not fully compliant with Labour Code requirements and noted gaps in the membership and activities of some Work Place Health and Safety Committees (WPHSCs). We also found that documentation outlining roles and responsibilities was outdated and lacked regular review, and that roles and responsibilities for incident reporting and compliance and enforcement were unclear for some groups across HC and PHAC.

In addition, we found that training did not fully comply with the legal requirements outlined in Part II of the Labour Code. Of note, we found that some training material was outdated or unavailable, there were low participation rates for existing courses, there were differences in availability of OHS training from one branch to the next, and there was a lack of compliance and enforcement for completion of mandatory courses.

Lastly, some facilities did not fully meet OHS requirements for first aid kits, posts to OHS bulletin boards, annual inspection requirements, and emergency preparedness procedures and plans. We noted inconsistencies across HC and PHAC buildings, with some facilities and WPHSCs providing more robust oversight than others. We also found that there were opportunities to improve OHS guidance in the context of hybrid work.

Introduction

A strong OHS program is crucial to ensuring a safe and healthy working environment and reducing the risk of accidents, injuries, and illnesses. This not only protects employee well-being, but it also enhances productivity, reduces absenteeism, and promotes a supportive and productive work environment.

To ensure that all federal employees have access to safe and healthy working environments, the federal public service's OHS framework is governed by several key policies and laws. These include Part II of the Labour Code, the Canada Occupational Health and Safety Regulations (COHSR), and the Treasury Board (TB) Directive on Building Emergency and Evacuation Teams (BEETs).

As employers, HC and PHAC are responsible for establishing, implementing, and maintaining processes that promote safe working conditions and comply with health and safety requirements. As such, HC and PHAC must ensure compliance across the 138 facilities that they manage in Canada. This extends to approximately 15,000 workers dispersed throughout the National Capital Region and regional offices.

At HC and PHAC, the Program, which falls under HC's Corporate Services Branch (CSB), handles these responsibilities under the Shared Services Partnership Agreement. To this end, the Program established HC and PHAC OHS policies in 2015 that outlined OHS responsibilities and compliance commitments.

The Program also oversees various committees. These include the HC and PHAC OHS Policy Committees, which are committees comprised of an equal number of senior management and employee representatives that provide strategic advice on OHS issues and policy implementation. The Program is also responsible for providing advice, guidance, training, and support to the various WPHSCs mandated by Part II of the Labour Code. These work place committees address specific OHS issues, participate in work place inspections and investigations, and maintain accident records for their respective facilities.

Given that the Program has not previously been audited for HC and PHAC, this audit aimed to assess potential risks to the health and safety of HC and PHAC employees by conducting physical walkthroughs at a sample of HC and PHAC facilities and laboratories. It also aimed to assess compliance with OHS legislation, regulations, and policy requirements, as well as consider additional complexities created by hybrid work arrangements since the onset of the COVID-19 pandemic. Of note, the audit team used the last full year of available data to assess compliance with any annual legislative requirements. Though developments after this date were considered, they were not used to draw conclusions on compliance with legislative requirements.

Criterion 1 – Governance

Context

The regulations in Part II of the Labour Code require that a health and safety policy committee, previously known as a departmental OHS committee, be established for any federal department or agency with 300 or more employees. The Labour Code also requires that a work place health and safety committee be established for any building with 20 or more employees, while buildings with fewer than 20 employees only require a health and safety representative. Given the number of employees working for HC and PHAC during the audit scope, a health and safety policy committee was required for each of HC and PHAC, though it should be noted that the two committees met jointly. In addition, 40 buildings were identified as requiring work place health and safety committees.

What we expected to find

We expected to find that oversight bodies for OHS governance were in place at HC and PHAC, and that committee membership was in line with the requirements in Part II of the Canada Labour Code. We also expected that roles and responsibilities were well-defined, documented, and communicated, and that committees discussed relevant OHS issues in a timely way, while also actively monitoring work place incidents, monthly inspections, and other relevant OHS information to provide effective oversight in line with legislative requirements.

Why it matters

Oversight bodies for OHS are key to fostering a safe and healthy working environment. This is because they streamline activities across the organization, provide oversight and accountability for OHS activities, and promote compliance with relevant legislation. The essential role of governance bodies is reflected in Part II of the Labour Code, which legally requires HC and PHAC to have certain committees in place for OHS oversight.

Key findings

Roles and responsibilities

We found that the HC and PHAC policies on OHS provided detailed roles and responsibilities for the establishment and operation of OHS activities. The policies defined the roles of stakeholders at various levels, including those of the Program, senior management, OHS committees, Responsible Building Authorities (RBAs), managers, and employees. Detailed roles and responsibilities of key stakeholders were also outlined in another internal roles and responsibilities document, though this document was not formally approved during the audit scope. In addition, the roles and responsibilities of the health and safety policy committee members were outlined in Terms of Reference (ToR) documents, in line with legislative requirements.

However, we found that the HC and PHAC policies on OHS were significantly outdated. Of note, the policies had not been reviewed since their initial approval in 2015, despite a review requirement of once every three (3) years. As of June 2024, updated policies had been drafted and were pending approval. We noted that roles and responsibilities in the updated policies would be limited to those of senior management, with the responsibilities of stakeholders and committees to be defined in separate documents.

Similarly, we found that the Terms of reference (ToRs) for the OHS Policy Committees were not reviewed or updated regularly during the audit scope. We also found that 67% of sampled WPHSCs had ToR documents that outlined member roles and responsibilities. This number dropped to 52% when only work place health and safety committees that had updated their ToR at least once every two (2) years were included. However, we found that both the HC and PHAC OHS Policy Committee ToRs were updated in January of 2024.

In addition, we found that there was room for improvement in the communication of OHS roles and responsibilities across HC and PHAC. For instance, interviews revealed that there was some miscommunication on requirements for incident reporting and the training courses required for OHS committee members.

OHS committee operations

HC and PHAC OHS policy committees

We found that the HC and PHAC OHS policy committees were generally established and operating in accordance with Part II of the Labour Code. For instance, there was evidence that the committees met quarterly in 2020, 2021, 2022, and 2023 to discuss OHS issues, as required by legislation. We also found that the committees were executing the duties listed in the Labour Code, as evidenced by meeting records. This included participating in the development of policies and programs, overseeing incident monitoring, inspections and investigations, and participating in implementing OHS processes. In addition, the HC and PHAC OHS policy committees generally kept records of their meetings, as required by the Labour Code.

Work Place Health and Safety Committees (WPHSC)

While most WPHSCs were established in accordance with Labour Code requirements, there were gaps in data availability and compliance. Of note, we could not determine whether 8 of the 40 facilities with 20 or more employees had a WPHSC in place, due to data limitations. In addition, two (2) of the 21 sampled facilities were missing co-chair representatives in their WPHSC, as required by the Code.

We also found that although operating requirements were met for the majority of WPHSCs, there were a few instances of non-compliance. For example, 17 of 20 (85%) sampled committees met at the required frequency in 2022, and 19 of 21 (90%) WPHSCs met at the required frequency in 2023. In addition, we determined that work place OHS committees performed some of the duties listed in Part II of the Labour Code, but that duties related to monitoring of PPE, supporting and promoting the implementation of a Hazard Prevention Program (HPP), and assisting in investigations of hazardous substance exposure were not well established.

Monitoring and reporting

We found some evidence of regular monitoring and reporting of OHS activities. For example, the Program established a reporting process for work-related incidents, and incident-related data was discussed during OHS policy committee meetings. In addition, the Corporate Occupational Health and Safety Program (COHSP) agreed to hold regular meetings with one high-risk branch to share aggregated incident data with senior management. However, interviews uncovered miscommunications and lack of clarity on the responsibilities and expectations for the incident reporting process. For instance, manual incident tracking led to inconsistencies in data collection from one branch to the next. Furthermore, delayed reporting of incidents to senior management for the aforementioned high-risk branch sometimes meant that errors were not identified in a timely way.

In addition, we found evidence that the Program monitored monthly inspection data from WPHSCs, and that this data was presented at joint annual HC and PHAC OHS policy committee meetings. Of note, annual reports to the Labour Program were submitted by all HC WPHSCs and 15 of 17 (88%) PHAC WPHSCs in 2021. All HC and PHAC committees submitted annual reports on time in 2022. This suggested that the OHS policy committees and the Program received timely information for effective monitoring.

However, we found room for improvement in oversight for assuring compliance with mandatory work place inspections. Mandatory work place inspection rates were low in 2021, with a completion rate of 55% at HC and 29% at PHAC. We found evidence that inspection rates climbed to 43% in 2022 and 64% in 2023, which suggests that the OHS policy committees and the Program received timely information for effective monitoring. However, established inspection objectives were not consistently achieved. In addition, there was generally limited evidence of compliance and enforcement activities, and we noted opportunities to strengthen oversight in this capacity.

Conclusion

Overall, we found that oversight bodies were partially compliant with requirements outlined in the Labour Code. Although most policy and work place OHS committees were established and operating as required, we identified gaps in the membership and activities of some WPHSCs. In addition, we found that documentation outlining roles and responsibilities was outdated and lacked regular review. Lastly, we found deficiencies in annual reporting, as well as a lack of clarity in roles and responsibilities, namely those related to incident reporting and compliance and enforcement.

Recommendations

Recommendation #1 (high priority)

The Assistant Deputy Minister (ADM) of the Corporate Services Branch (CSB) should ensure that the roles and responsibilities of OHS oversight bodies are clear, documented, and communicated to ensure alignment with legislative requirements and promote standardization across HC and PHAC.

Recommendation #2 (medium priority)

The ADM of CSB should establish a formal process to review the HC and PHAC OHS policies and regularly update them.

Criterion 2 – OHS Training

Context

Part II of the Labour Code requires that members of policy and work place committees receive prescribed OHS training and be informed of their OHS responsibilities.

What we expected to find

We expected to find that OHS training materials were developed, reviewed regularly, and communicated to key stakeholders to ensure alignment with Labour Code requirements. We also expected that the contents of OHS training materials effectively conveyed roles and responsibilities, and that monitoring was done to ensure compliance with mandatory training requirements.

Why it matters

A lack of OHS training increases the risk of work place accidents, injuries, and illnesses. Not only are these at odds with the concept of a safe and healthy working environment, but they can also lead to decreased productivity and increased absenteeism, which may prevent HC and PHAC from meeting their operational and strategic objectives.

Key findings

We found that training programs were developed to address the OHS requirements outlined in the Labour Code. We also found that the Program provided access to courses and promoted awareness of required OHS training for committee members and key stakeholders. For instance, there was evidence that the Program had implemented successful reform projects and held virtual OHS training sessions across HC and PHAC. In addition, we found that some laboratory-specific training was in place for branches whose employees performed laboratory work.

However, we identified several areas for improvement within the organization's training programs. These include outdated training materials, lack of compliance with Workplace Hazardous Materials Information System (WHMIS) annual training review requirements, a lack of standardization across branches, and insufficient training for OHS compliance and enforcement.

For instance, the list of mandatory OHS training at HC and PHAC had not been endorsed by the OHS policy committees during the audit scope, and we found that two (2) mandatory courses were either no longer available on the learning platform, or no future sessions were planned. This may have impeded employees' understanding of required training and prevented them from taking necessary courses. However, we noted that a new training standard was endorsed in June 2024, indicating renewed efforts to promote required training for OHS policy committee and WPHSC members.

In addition, we found that OHS training completion rates were low for committee members. For instance, only 124 of 286 (43%) WPHSC committee members had completed the mandatory course "Canada Labour Code, Part II: An Overview" during the audit period. Similarly, 12 of 59 (20%) OHS policy committee members completed this course during the audit scope. We noted that sessions on work place safety and prevention services were provided to OHS policy committee members by an external provider in 2020, though only 19 of 29 (62%) committee members at the time were identified as having fully completed this training. This indicated that data on mandatory training was being collected, but that there were no clear deliverables for ensuring completion.

Lastly, interviews demonstrated a lack of consistency across HC and PHAC branches, particularly for groups that required additional OHS training because of their activities. Of note, interviewees mentioned gaps in the OHS training provided. While some interviewees felt that OHS training was appropriate, others noted a lack of its integration into onboarding procedures for new staff. Some also noted a lack of training on specific topics, such as laboratory spills, respirator use, and consideration of site-specific factors.

Conclusion

Overall, we found that some OHS training was in place during the audit scope, but that it did not fully comply with the legal requirements outlined in Part II of the Labour Code. We identified outdated or unavailable training materials, low participation rates for existing training courses, a decentralized approach to OHS training, and a lack of compliance and enforcement for the completion of mandatory courses.

Recommendations

Recommendation #3 (high priority)

The ADM of CSB should establish a process to ensure that mandatory training is reviewed and updated regularly, and that training is promoted, tracked, and enforced as required by the Canada Labour Code.

Criterion 3 – Facilities and emergency preparedness

Context

According to the Labour Code, federal government facilities are expected to comply with several occupational health and safety (OHS) requirements. These include communicating OHS legislation on bulletin boards, conducting building maintenance, placing hazard safety signage in prominent locations, providing PPE and first aid equipment, having Building Emergency and Evacuation Teams (BEETs) on site, and conducting regular inspections and drills. Part II of the Labour Code also states that any work place with 50 or more employees requires an updated emergency evacuation plan that caters to all employees, including those requiring special assistance.

In addition to legislative requirements outlined in the Labour Code, the Corporate OHS Regulations require the implementation of regular emergency management meetings and emergency drills at government facilities. At the department and agency levels, these activities are led by Responsible Building Authorities (RBAs), who are mandated by HC and PHAC OHS policies to perform several emergency management functions that ensure employee safety.

What we expected to find

We expected to find that emergency management processes were defined and communicated to staff in alignment with legislative requirements. We also expected to find that OHS requirements were implemented at HC and PHAC facilities, and that these were operating as intended to foster a safe and healthy working environment. However, we noted the difficulties associated with conducting OHS activities in the hybrid work environment spurred on by the COVID-19 pandemic, and we considered this during our assessment.

Why it matters

It is important that HC and PHAC facilities remain safe working environments in order to mitigate any legal risks and maintain employee health and safety in the work place. In addition to standard OHS requirements, emergency preparedness in HC and PHAC buildings is crucial to ensuring that employees can remain safe during emergency situations.

Key findings

By conducting walkthroughs at 20 sampled HC and PHAC facilities, the audit team determined that fire protection equipment met requirements at 14 of 20 (70%) facilities, that hazard safety signage was available at 12 of 20 (60%) sampled facilities, and that PPE was generally provided to employees when needed. We also found that 17 of 20 (85%) sampled buildings were well maintained, with some exceptions. These included the presence of contaminants, such as pests, and improper storage or clutter of old or surplus items, such as electronics, office furniture, office equipment, and cables.

Despite the fact that requirements were generally met, we found that some facilities were not fully compliant with Labour Code requirements. For example, we observed that OHS resources and requirements were not consistently posted on bulletin boards at 8 of 20 (40%) sampled facilities, and that 12 of 20 (60%) sampled facilities had expired first aid equipment. In addition, we found deficiencies in evacuation plans and annual inspections. Of note, only 7 of 20 (35%) sampled facilities were able to provide evacuation plans or equivalent documentation, and only 7 of 19 (37%) applicable sampled WPHSCs completed the 12 required annual inspections in 2021 and 2022. However, we noted that 43% of all HC and PHAC WPHSCs conducted all required inspections in 2022, and that 64% of committees conducted all required inspections in 2023. This indicated that there were improvements regarding inspection frequency from 2021 to 2023, in line with the return-to-office direction.

In addition, we found opportunities to improve guidance on procedures for BEETs in facilities. We noted the exclusion of BEETs in the OHS policy, leading some teams to create their own approaches to emergency management. Templates and documents were inconsistent from building to building, leading to a lack of emergency preparedness standardization across HC and PHAC. However, evidence of emergency drills was provided by 16 of the 20 sampled facilities. Although we found inconsistencies in annual evacuation drill reporting, 80% of sampled facilities were able to meet the annual drill requirements laid out in the TB Directive on BEETs.

Lastly, we found that there were difficulties in recruiting BEET members and First Aid Attendants in the hybrid work context, especially given evolving TB direction throughout the COVID-19 pandemic. Given that the HC and PHAC OHS policies had not been updated since 2015 and did not include hybrid work considerations, COHSP adapted by training a higher ratio of employees than strictly required in order to ensure adequate coverage of these positions.

Conclusion

Overall, we found that the majority of facilities met OHS requirements around building maintenance, fire equipment, and hazard safety signage. However, we observed that the majority of sampled facilities had expired first aid equipment and insufficient resources posted to OHS bulletin boards, were non-compliant with annual inspection requirements, and had implemented insufficient emergency preparedness procedures and plans. We also noted inconsistencies across HC and PHAC buildings, with some facilities and WPHSCs providing more robust oversight than others. Lastly, we found that there were opportunities to improve OHS guidance in the context of hybrid work.

Recommendations

Recommendation #4 (High Priority)

The ADM of CSB should implement a robust monitoring system to track compliance with legal requirements on monthly inspections and emergency preparedness measures.

Recommendation #5 (High Priority)

The ADM of CSB should implement standardized emergency preparedness training and drill exercises for employees across facilities in accordance with the TB Directive on Building Emergency and Evacuation Teams.

Recommendation #6 (Medium Priority)

The ADM of CSB should review processes on emergency preparedness to assess their effectiveness in the new hybrid work place reality.

Appendix A

Audit objective

The objective of this engagement was to assess whether HC and PHAC had implemented key controls to ensure that the OHS program was established and operating in compliance with legal and policy requirements to support healthy and safe work environments.

Audit scope

The scope of this audit included an assessment of the processes in place to support OHS requirements, including the establishment of governance and management oversight. Key components included:

• the establishment and operation of local and organization-wide OHS committees;
• incident reporting program and resolution processes;
• training programs;
• investigations, regular inspections, and maintenance;
• operational monitoring;
• reporting tools and resources;
• roles and responsibilities; and
• emergency preparedness programs at organization facilities.

The audit did not assess the broader administration of the Public Service Occupational Health Program (PSOHP) or associated guidance for the whole of the Public Service.

The audit scope covered the period of April 1, 2019, to July 31, 2023.

Audit approach

The audit included, but was not limited to:

• Interviews with management, committee members, staff, and key stakeholders;
• Interviews and surveys with work place committee members chosen by judgmental sampling;
• Review of documentation, minutes, and published governance by the Program and key stakeholders;
• Policy Committee member interviews and surveys;
• Verification of records and logs kept by work place committees;
• Judgmental sampling for a review of training and awareness records and tracking;
• Data analysis of reporting tools (e.g., incidents, risks)
• Review of Lab Safety Manuals; and
• Walkthroughs of work places, including offices and laboratories, using testing checklists.

Statement of conformance

The Office of Audit and Evaluation conducted this audit engagement in compliance with the 2017 International Standards for the Professional Practice of Internal Auditing. The audit was also supported by an internal Quality Assurance and Improvement Program, thereby ensuring that the audit team collected sufficient and relevant evidence to address the audit criteria and to support audit conclusions.

Audit criteria

Audit criterion #1: Effective oversight bodies are established and operate in compliance with legal requirements.

Audit criterion #2: Occupational Health and Safety training and awareness programs are in place and comply with legal requirements.

Audit criterion #3: Occupational Health and Safety Facilities and Emergency Preparedness requirements are in place and comply with legal requirements.

Appendix B – Recommendation ratings

Recommendations are ranked to assist management in prioritizing their response to audit findings. These ratings are intended to assist with resource allocation in order to address identified weaknesses and help improve internal controls and operating efficiency. Please note that ratings are for guidance purposes only. Management must evaluate ratings provided by OAE based on their own experience and risk tolerance.

Recommendations are ranked according to the following definitions:

• High priority: Item should be given immediate attention due to the existence of either a significant control weakness, such as control not existing, or not being adequately designed, or not operating effectively, or a significant operational improvement opportunity.
• Medium priority: This is a control weakness or operational improvement that should be addressed in the near term.
• Low priority: This is a non-critical recommendation that could be addressed to either strengthen internal controls or enhance efficiency, normally with minimal cost and effort. Individual ratings should not be considered in isolation and their effect on other objectives should be considered.