Audit of PWGSC Compliance to Acts, Regulations, Policies and Directives Related to Health and Safety Concerns - First Aid (2008-715)

Final Report

November 19, 2009

Table of Contents

• MAIN POINTS
• INTRODUCTION
• FOCUS OF THE AUDIT
• OBSERVATIONS
  • Department unable to demonstrate that first aid attendants have been designated and certified in all workplaces.
  • First aid attendants are not fully aware of their roles and responsibilities.
  • First aid kits, supplies, stations and records are not properly maintained.
  • Significant shortage of Workplace Health and Safety Committees/Representatives particularly in the National Capital Area.
  • The Departmental First Aid Policy was recently revised.
• CONCLUSION
• MANAGEMENT RESPONSE
• RECOMMENDATIONS AND MANAGEMENT ACTION PLAN
• ABOUT THE AUDIT

MAIN POINTS

What was examined

i. First aid is the emergency primary treatment or care that conforms with the recommended practice of the St. John Ambulance or Canadian Red Cross Associations, and is provided by the Department in response to an injury or illness of an employee arising out of or in the course of employment. In general, the purpose of first aid is to ease the victim's pain and anxiety and to prevent deterioration of his or her condition. In extreme cases first aid may be required to prevent death before medical assistance can be obtained. A recognized provider such as St. John Ambulance, the Canadian Red Cross, or Rescue 7 generally issues first aid certification to individuals. During their training, first aid attendants are taught skills that help them think, react and improvise in an emergency situation with a series of simple techniques that can be performed with minimal equipment.

ii. In Canada, the provision of first aid facilities and health services is legislated by the Canada Labour Code Part II. The legislation is supported by the Canada Occupational Health and Safety Regulations, which identifies, in much greater detail, specific requirements to ensure a safe and healthy workplace. This includes provisions for first aid attendants, training, supplies, stations, treatment records, communication of information, and transportation. Federal departments are also guided by the Treasury Board Occupational Health and Safety Directive, which enhances the legislated first aid requirements for delivery in federal departments. The Directive, like the legislation, is considered a minimum standard that may be exceeded by a department's occupational health and safety program. The essence of this legislation is that management is responsible to create and support a safe workplace.

iii. Public Works and Government Services Canada (PWGSC) has 18 departmental policies related to occupational health and safety. Departmental Policy 016 pertains specifically to first aid and outlines the roles and responsibilities of key stakeholders and establishes a code of practice to ensure that first aid is available to all employees.

Why it is important

iv. Every organization will, at some time or another, have to deal with first aid emergencies. Even in workplaces that seem safe, such as offices, emergencies can still happen. Therefore, it is critical to be prepared at all times to quickly and effectively deal with these situations.

v. By performing simple first aid procedures and following certain guidelines, it may be possible to:

• Save lives (in the case of injured or ill persons);
• Reduce the chance of permanent damage (e.g. prompt flushing of the eyes with water after a chemical splash can prevent blindness);
• Help prevent an injury from becoming more serious (e.g. cleaning and bandaging a cut can help prevent infection and further problems);
• Minimize the length and extent of medical treatment; and
• Reduce time lost from work.

vi. It is also important to ensure individuals have been identified and trained in first aid procedures and necessary first aid supplies and equipment are available, and in a serviceable condition, so that in the event of an emergency, persons delivering first aid have ready access to all necessary tools and are competent in their use. In addition, employers must create and maintain an accurate written record of all work-related physical injuries or sudden occurrences of illness experienced by employees while at work. These records should be kept as prescribed. Maintaining adequate treatment records are essential if further investigation into a particular incident is required. They can also be used to identify incident trends and possible areas for improvement with respect to health and safety.

What we found

vii. The level of compliance of PWGSC first aid practices with acts, regulations, policies, and directives related to health and safety needs improvement in the following areas:

• Records of first aid attendants' names, locations and certification status are incomplete and outdated and monitoring over certification status is not always done in a consistent manner;
• First aid stations, kits, supplies and records are not always properly maintained; and
• Workplace Health and Safety Committees/Representatives are not designated as required, particularly in the National Capital Area.

viii. In addition, although the Departmental policy on first aid was recently revised, some remaining gaps with the Treasury Board Occupational Health and Safety Directive were identified.

Management Response

Management accepts the findings of the audit report on the PWGSC first aid program.

Corporate Services, Policy and Communications Branch will act on the three recommendations identified in the audit report by implementing the attached management action plan.

Recommendations and Management Action Plan

Recommendations and Management Action Plan Recommendation 1: The Assistant Deputy Minister, Corporate Services, Policy and Communications Branch should ensure that the appropriate number of first aid attendants are designated and trained by maintaining up-to-date records and monitoring certification status.

Management Action Plan 1.1: Revise Departmental Policy 016 – First Aid. This action has been completed.

Management Action Plan 1.2: Maintain a directory of workplaces and a list of first aid attendants for each workplace, which includes the name of all attendants, the type of certification held, certification status, and location. In the National Capital Area, information on first aid training delivered is found in the Integrated Training System maintained by Human Resources Branch. This list of first aid attendants will be updated by December 31, 2009; the location, type of certification held, and certification status will by identified by January 30, 2010; and the list of PWGSC workplaces with the list of first aid attendants will be updated by April 2010. The directory will be maintained on a monthly basis, starting April 2010.

Recommendation 2: The Assistant Deputy Minister, Corporate Services, Policy and Communications Branch should periodically communicate to stakeholders, and particularly first aid attendants, Workplace Health and Safety Committees/ Representatives, and Regional Managers, their detailed roles and responsibilities with respect to first aid including responsibilities for maintaining first aid stations, kits, supplies and treatment records.

Management Action Plan 2.1: Include the revised roles and responsibilities in Departmental Policy 016. This action has been completed.

Management Action Plan 2.2: Recognize all designated first aid attendants for their contribution and remind them of their roles and responsibilities in regards to Departmental Policy 016 through an e-mail or communiqué. This will be done yearly, starting June 2010.

Management Action Plan 2.3: Include information on the roles and responsibilities of first aid attendants in the training program for first aid attendants by December 31, 2009.

Management Action Plan 2.4: Update the roles and responsibilities of the Workplace Health and Safety Committee Members/ Representatives in the Workplace Health and Safety Committee Members/ Representatives Training Program to reflect the revised Departmental Policy 016 – First Aid by November 30, 2009.

Management Action Plan 2.5: Recognize the members of the health and safety committees and representatives of their contribution and remind them of their roles and responsibilities in regards to Departmental Policy 016 through e-mail or communiqué. This will be done yearly, starting June 2010.

Recommendation 3: The Assistant Deputy Minister, Corporate Services, Policy and Communications Branch should ensure that the required number of Workplace Health and Safety Committees or Representatives have been designated.

Management Action Plan 3.1: Maintain a directory of the workplaces and the required / established Workplace Health and Safety Committee members/ required / appointed representatives for each one of these workplaces in each region. This will be done every six months, starting April 2010.

INTRODUCTION

1. This audit project was approved as part of the 2008-2011 Risk-Based Multi-Year Audit and Evaluation Plan.

2. In Canada, every employer has a legislated responsibility to provide a safe and healthy workplace for employees, and to reduce the incidence of occupational injuries and illness. Additionally, under the September 2000 revisions to the Canada Labour Code Part II, managers can now be held personally responsible and liable for unsafe working conditions.

3. In general, the purpose of first aid is to ease the victim's pain and anxiety and to prevent deterioration of his or her condition. In extreme cases first aid may be required to prevent death before medical assistance can be obtained. A recognized provider such as St. John Ambulance, the Canadian Red Cross, or Rescue 7 generally issues first aid certification to individuals. During their training, first aid attendants are taught skills that help them think, react and improvise in an emergency situation with a series of simple techniques that can be performed with minimal equipment. The results of monitoring of first aid incidents can provide valuable insight into preventative measures that can be taken. Further the consideration of first aid related issues by the Workplace Health and Safety Committees/ Representatives could also support preventative actions.

4. The Canada Labour Code Part II, the Canada Occupational Health and Safety Regulations and the Treasury Board Occupational Health and Safety Directive require all federal government departments to establish health and safety programs to address occupational issues. To complement the legislation, PWGSC has established 18 departmental policies related to various components of occupational health and safety to help protect the health and safety of its some 12,000 employees who are employed in all regions across Canada.

5. Departmental Policy 016 - First Aid was approved on January 24, 1996 and was recently revised. The objective of this policy is to ensure that first aid is available to all PWGSC employees. The policy supplements the legislation by outlining a code of practice as well as the roles and responsibilities of key stakeholders regarding the provision of first aid. The fact that the policy was under review was taken into consideration when deriving the audit criteria.

6. Within PWGSC, the Corporate Environment, Health and Safety Directorate, in collaboration with management, unions and employees, develops and implements the departmental environment, health and safety program. With respect to first aid, the Director, Corporate Environment, Safety and Health is responsible for monitoring the health and safety program to ensure that all legislated and departmental requirements regarding first aid are met and for assessing the effectiveness of the departmental first aid program. The Director also provides advice and guidance to Branch Heads and to Regional Directors General; and liaises, on behalf of the Department, with regulatory bodies and central agencies on related matters. In addition, the Director provides functional guidance to the Regional Managers responsible for Health and Safety.

7. Regional Managers responsible for health and safety (Regional Managers) assist the Director, Corporate Environment Health and Safety, by maintaining up-to-date lists of the names, certification status and location of first aid attendants; and by monitoring their qualifications to ensure that their first aid training certification remains valid. The Regional Managers report to their respective Regional Directors and Regional Directors General, and not to the Director, Corporate Environment, Health and Safety. The Regional Managers are also responsible for: determining priorities relating to first aid training; investigating requests for special training and/or equipment for first aid services; and monitoring to ensure that records of first aid treatment are inspected at three-month intervals by the Workplace Health and Safety Committees/Representatives.

8. Workplace Health and Safety Committees are a mandatory requirement under the Canada Labour Code Part II for workplaces with 20 or more employees; Representatives are required for workplaces with 19 or fewer employees. The Code awards Committees/Representatives with several powers and duties to participate in and resolve workplace health and safety issues. Within PWGSC, Committees/ Representatives are responsible for inspecting first aid records at three-month intervals to verify their proper maintenance; and monitoring first aid stations to ensure that they are properly identified, equipped and maintained. These committees also play a key role in safety prevention by: participating in the development and implementation of programs to protect the employees safety and health; setting up and promoting programs to improve employee training and education; making recommendations to management for accident prevention and safety program activities; and monitoring the effectiveness of safety programs and procedures. Although not a requirement of the committee, given their responsibilities they are well placed to review treatment records for trends.

9. Managers in Charge of Worksites and Supervisors are responsible for designating at a minimum two first aid attendants per work location to ensure that at least one first aid attendant is available at all times to render first aid to employees during working hours.

10. First aid attendants (attendants) are PWGSC employees who volunteer to provide first aid along with their regular day-to-day duties. Once designated as attendants by their managers, they undergo the training needed to provide emergency first aid required for their workplace. Each practicing attendant must hold, at a minimum, recognized and valid first aid and cardiopulmonary resuscitation (CPR) training certifications. This training provides attendants with skills to react quickly in an emergency situations including: shock, unconsciousness, fainting, choking, cardiovascular emergencies, and severe bleeding with a series of simple techniques that require minimal equipment. According to a report received from the Human Resources Branch, in the National Capital Area over 1,700 PWGSC employees, including many attendants, have been trained in first aid over the last five fiscal years. Attendants are the Department's first responders and administer emergency primary care within the scope of their competence and refer employees to a medical treatment facility when the attention of a physician is required. Attendants maintain a first aid register and record each injury or illness occurring in the course of employment that requires first aid treatment. They also ensure that first aid kits, supplies and related equipment are kept in good working order so they are available if and when they are required. Finally, they are responsible for documenting details about the incident in first aid reports, which could be used to monitor for potential dangers and trends.

FOCUS OF THE AUDIT

11. The objective of this internal audit was to determine whether first aid practices at PWGSC are compliant with relevant acts, regulations, policies, and directives related to health and safety.

12. During the preliminary survey phase of the audit, a risk assessment was conducted to identify which areas of health and safety should be considered during the examination phase. As a result of this assessment, we determined that the focus of the audit would be on key aspects related to first aid practices within PWGSC.

13. The key aspects related to first aid examined during this audit included whether: first aid attendants are designated; first aid training, supplies and stations are provided; and first aid records and reports are maintained in accordance with the requirements of the Canada Labour Code Part II, the Canada Occupational Health and Safety Regulations, the Treasury Board Occupational Health and Safety Directive, and Departmental Policy 016 - First Aid.

14. The audit also examined whether Departmental Policy 016 was aligned with the above-mentioned acts, regulations, and directives and whether oversight was present to ensure that monitoring is consistently performed.

15. The Canada Labour Code Part II and the Treasury Board Occupational Health and Safety Directive define a workplace as "any place where an employee is engaged in work for the employee's employer." Because this definition of "workplace" is so broad, it had to be defined slightly differently for audit purposes to enable the auditors to choose a sample. As such, a workplace was defined as a floor of a building, or separate locked part thereof, where PWGSC employees are engaged in work for the Department. We examined a risk-based sample of 55 workplaces in the National Capital Area and the Atlantic Region that are occupied by PWGSC employees. From this sample, we inspected a total of 83 first aid stations to determine if they were appropriately identified, equipped and maintained; if their first aid kits, supplies and related equipment were in a serviceable condition; and if treatment records were maintained as prescribed.

16. In addition, we interviewed 29 attendants to determine if they were fully aware of their roles and responsibilities. Attendants were randomly selected for interview in the National Capital Area and the Atlantic Region. Interviews were also conducted in all regions with the Regional Managers responsible for health and safety (known as the Area Manager in the National Capital Area) regarding their roles and responsibilities and procedures for providing first aid training.

17. More information on the audit objective, scope, approach and criteria can be found in the section "About the Audit" at the end of the report.

OBSERVATIONS

Department unable to demonstrate that first aid attendants have been designated and certified in all workplaces.

18. Attendants play an important role in the workplace because they are the Department's first response when an employee is injured or becomes ill during the course of employment. These individuals are trained to provide emergency treatment and care to employees to preserve life, prevent further harm and promote recovery. In addition to providing first aid, attendants also have the responsibility to ensure that first aid kits, supplies and related equipment in their workplace are in good order to respond effectively to injuries or illnesses when needed. Furthermore, they are responsible for maintaining treatment records to document incidents requiring first aid.

19. Having accurate lists of attendants serves two purposes: first, it enables the Department to ensure that the minimum number of attendants have been designated at each worksite; second, it allows the Department to ensure that attendants are properly trained, and thus well prepared to provide first aid. In general, we found that the documentation kept regarding the designation and certification of attendants was incomplete and/or inaccurate.

Designation of first aid attendants

20. Departmental Policy 016 requires that a minimum of two employees per work location be designated as attendants to ensure that at least one is available during working hours. While designating attendants is the responsibility of managers and supervisors of the worksite, Regional Managers are responsible for maintaining up-to-date lists of the names, certification status and the location of the attendants.

21. We expected that the Department had accurate lists of attendants to demonstrate that they are designated as required.

22. We requested lists of attendants from each Regional Manager; however, in general the lists did not contain all of the required information and in some instances the information was outdated. In addition, although the Regional Manager indicated there are over 100 worksites in the National Capital Area, we were only provided with a list of attendants for the main building occupied by PWGSC.

23. When we compared the lists we received from the Regional Managers to a list of buildings occupied by PWGSC, some discrepancies were found. This made it difficult to determine whether two attendants had been designated at all locations where PWGSC employees are engaged in work for the Department. In addition, we found some people on the list who were designated as attendants even though they were not attendants and others that no longer worked in the same location or no longer worked for the Department. Due to this, we were unable to determine whether or not at least two attendants have been designated per worksite.

Certification of first aid attendants

24. Departmental Policy 016 requires attendants to hold recognized and valid first aid and cardiopulmonary resuscitation (CPR) certifications. First aid certificates expire three years from the date of certification at which time a refresher course must be taken. In the Department, the cost of first aid courses is funded centrally for designated attendants through the Corporate Environment, Safety and Health Directorate. In the National Capital Area, first aid training is secured and scheduled by the Human Resources Branch. In all other regions first aid training is secured and scheduled locally by the Regional Managers responsible for Health and Safety.

25. We expected to find that the Department could demonstrate that all those who have been designated as attendants, have been certified and re-certified as prescribed.

26. Human Resources and Skills Development Canada maintains a list of first aid organizations that have submitted first aid course materials to the Minister of Labour and were subsequently approved to deliver first aid courses in accordance with the Canada Occupational Health and Safety Regulations. Federal departments are required to use providers from this list when providing mandatory training to attendants, but may use other providers to provide additional, or supplementary, first aid training. This ensures that the subjects and techniques taught are consistent with the requirements of the Regulations. In general, the Department, regardless of region, is delivering training using providers from this list. However, in one section of the Quebec Region a provider that is not on this list, but is included on a provincial list of first aid organizations approved by the Commission de la santé et de la sécurité du travail (CSST), is being used to deliver mandatory first aid attendant training. Subsequent to the examination phase of this audit, the Québec Region submitted a formal request to Human Resources and Skills Development Canada to approve the first aid courses delivered by the organization. A response from Human Resources and Skills Development Canada is pending, but should the organization's first aid courses not be approved, an alternative provider will be sought.

27. Maintaining health and safety training records is a legislated requirement of the Canada Labour Code Part II. In PWGSC all departmental training, including first aid training, must be recorded into the Integrated Training System maintained by the Human Resources Branch. The Integrated Training System is used to record and report on training provided to PWGSC employees. We compared the lists of designated attendants provided by the Regional Managers against a report generated by the Integrated Training System of people who had taken first aid training in the last 5 fiscal years. Some discrepancies were found between the lists where those designated as attendants did not appear on the Integrated Training System report as having taken training. The accuracy of reporting information generated by the Integrated Training System has been discussed within the Department and alternate reporting methods are being investigated.

28. As per Departmental Policy 016, Regional Managers and the Training and Development Directorate, Human Resources Branch, are responsible for monitoring certification expiry. We noted that monitoring performed by the Regional Managers regarding the status of training certification varies greatly across the regions and that no oversight exists to ensure that monitoring is done consistently and with due diligence. In addition, in the National Capital Area, the Training and Development Directorate uses first aid course attendance reports to project training needs three years into the future, but does not specifically track first aid certification status and qualifications to ensure they are current. Of the 29 attendants interviewed, 26 held current certification and the majority felt that they had received their training and/or refresher course in a timely manner. However, without accurate records outlining training received by designated attendants, the Department may not be able to satisfy its legislated and departmental reporting requirements. Therefore, we were unable to determine whether or not all those designated as attendants hold current certification.

First aid attendants are not fully aware of their roles and responsibilities.

29. Given their critical role in the workplace, attendants must also be fully aware of their roles and responsibilities as outlined in Departmental Policy 016 to effectively deliver first aid across the Department. The policy gives attendants responsibilities above and beyond being trained in providing emergency first aid to injured or suddenly ill employees such as ensuring the good order of first aid kits, supplies and records. By exercising their responsibilities, attendants can ensure that any necessary supplies will be available to them, should they need to provide first aid, and that there is a proper record of any incident that occurred.

30. We expected to find that all those designated as attendants are aware of their roles and responsibilities outlined in Departmental Policy 016.

31. We found that attendants are not advised about their specific roles and responsibilities as outlined in Departmental Policy 016 (such as ensuring the good order of first aid kits, supplies and records) when accepting responsibility for the position. Of the 29 attendants interviewed, the majority of those interviewed were not aware of Departmental Policy 016. As a result, the attendants were unsure what their roles and responsibilities as a designated attendant were. Although the majority of the attendants had valid training certification and were confident in their ability to provide first aid, many did not know that they are responsible to inspect their first aid kits and maintain treatment records. Consequently, many attendants did not discharge their duties as required, which contributed to areas of non-compliance with regards to first aid kits, supplies and records.

First aid kits, supplies, stations and records are not properly maintained.

32. Requirements for the provision of first aid kits, supplies, stations, and the maintenance of first aid records are outlined in the following key policies: the Canada Occupational Health and Safety Regulations; the Treasury Board Occupational Health and Safety Directive; and PWGSC Departmental Policy 016.

33. In general, we found that first aid kits, supplies, stations, and records were not properly maintained. The areas where we observed non-compliance are outlined below.

First aid kits and supplies

34. First aid kits are to be located at each first aid station. A first aid kit is an approved container with approved first aid supplies. Some supplies are more commonly used by employees (such as band-aids and disinfectant), while others help guard against less common and unforeseen events (such as splints and eye shields). Having an adequately supplied first aid kit will ensure that, should an emergency arise, the necessary supplies are available to assist the attendant in providing first aid treatment to the injured or ill employee.

35. We expected to find that each first aid station is equipped with a first aid kit and that the kit contains the required first aid supplies.

36. Of the 83 first aid stations we examined all but one was equipped with a kit and required supplies. This is because the group had just recently moved to this location and the first aid kit was on order. However, none of the 82 kits we examined met the minimum supply requirements defined in Departmental Policy 016. We found that supply quantities were often insufficient or the supplies were unusable (e.g. expired, damaged, or no longer sterile). Although Departmental Policy 016 does not state who is responsible for ordering first aid supplies, attendants are responsible for inspecting the kits. Of the 29 attendants interviewed, 21 stated that they were aware of their office's procedure for ordering new supplies if required. However, 69 kits showed no evidence that the attendant had inspected it to ensure that the supplies were in good order.

37. Not providing first aid kits and supplies as prescribed poses risks that supplies would be unavailable in a timely manner during an emergency situation.

First aid stations

38. Each workplace must be provided with a first aid station. This is a place, other than a dedicated first aid room, where a first aid kit is located. Each station must be identified by appropriate first aid signage and have the prescribed emergency communication information posted in a prominent location at the first aid kit. Stations may either be located in the office of a first aid attendant, or in a central location such as an entrance to the workplace. An adequately identified and maintained first aid station is important because it allows employees to locate and obtain first aid assistance quickly and efficiently.

39. We expected to find properly maintained first aid stations that were identified by appropriate first aid signage and had the prescribed emergency communication information posted in a prominent location.

40. We examined 55 workplaces and found all of them had at least one first aid station as required. Some workplaces contained more than one first aid station, so we examined a total of 83 first aid stations. Of the 83 stations examined, 21 had no signage to indicate their location. In addition, although Departmental Policy 016 does not have any provision for signage on or above the offices of attendants, we observed that in some workplaces the standardized signs meant to indicate the location of a first aid station were placed on or above offices to indicate the location of a first aid attendant. However, the signs were sometimes on offices that did not belong to an attendant nor did they contain a first aid station.

41. Although Departmental Policy 016 contains a template for required emergency communication information, which includes attendant's names and locations and other emergency telephone numbers, it does not explicitly state who is responsible for maintaining and posting this information. We found that 48 stations did not have any emergency communication information posted in a prominent location at the first aid station as required by the Departmental Policy. Moreover, most of the existing emergency communications contained either insufficient or inaccurate information. We noted that telephone numbers for emergency services (e.g. ambulance, poison control centre) were often missing and information regarding attendants' names and locations was out dated.

42. The missing or inaccurate signage on or above first aid stations and offices combined with missing or out dated emergency communication information made it difficult to locate kits and attendants during on-site inspections. This could also cause confusion during an emergency situation.

First aid treatment records

43. Each first aid kit must contain a first aid register for the purpose of keeping treatment records. A first aid treatment record is a written entry of every injury or illness, occurring in the course of employment and requiring first aid treatment. Each record is to be kept for 10 years and must contain the following information:

1. The full name of the person receiving treatment;
2. The date, time and location of the occurrence of the injury or illness;
3. The date and time that the injury or illness was reported;
4. A brief description of the nature of the injury or illness;
5. A brief description of the treatment rendered and any arrangements made relating to the person treated, i.e. transportation required, escort, etc.; and
6. The signature of the first aid attendant or the person rendering first aid.

44. Maintaining adequate treatment records is the responsibility of the first aid attendant. These records may be of assistance if further investigation into a particular incident is required. They can also be used to identify incident trends and possible areas for improvement with respect to health and safety.

45. We expected to find that each first aid kit contains a first aid register and that attendants maintain treatment records as required, and that these records would be reviewed for trends.

46. We found that first aid treatment records were not maintained in accordance with Departmental Policy 016. We found that 11 of the 82 first aid kits did not contain first aid registers as required, while others contained multiple registers. In total, we examined 79 first aid registers to verify the completeness of treatment records. In general, we found that treatment records did not contain all of the information required by Departmental Policy 016 and that no clear distinction was made as to whether the incident occurred during the course of employment. Because of these weaknesses in treatment records, their use for identifying trends is limited.

47. Not keeping accurate records and reviewing them for trends poses a risk that similar incidents will not be prevented or further action taken after the incident because there is no accurate information to identify trends; or that historical information is not available.

Significant shortage of Workplace Health and Safety Committees/Representatives particularly in the National Capital Area.

48. The Canada Labour Code Part II sets out the requirements for Workplace Health and Safety Committees and Representatives. Although the Canada Labour Code Part II and Treasury Board Occupational Health and Safety Directive contain a broad definition for workplace which is defined as "any place where an employee is engaged in work for the employee's employer," at PWGSC for the purpose of designating whether a workplace requires a committee or a representative, a workplace is defined as one address where an employee is engaged in work for the Department and which the Department has control over. If there are more than 20 employees at a workplace, a workplace health and safety committee is required; if there are 19 or less employees, a workplace health and safety representative is required. Committees are forums consisting of labour and management representatives who meet on a regular basis to deal with health and safety issues. The representatives' role is to participate in the control of health and safety hazards and address worker concerns about health and safety in the workplace. The representative acts as a liaison between the employer and coworkers, and brings worker concerns to the attention of the employer.

49. We expected to find that the required number of committees had been established or representatives had been appointed in each workplace in accordance with the Canada Labour Code Part II.

50. We found a significant shortage of Committees/ Representatives, particularly in the National Capital Area. Of all the regions, the National Capital Area has the greatest number of workplaces and employees. Fifty-nine workplaces have been identified as requiring a committee and 49 require a representative. Eleven of the required committees have not been established and 25 of the representatives required have not been appointed. This shortage may result in a lack of oversight for not only first aid, but also the overall departmental health and safety program.

51. In the context of first aid, Committees/Representatives play a monitoring role. This on-going activity helps the Department in taking appropriate corrective action in areas where deficiencies are encountered or improvements are needed. In PWGSC, Committees/ Representatives are responsible for monitoring first aid stations to ensure that they are properly identified, equipped and maintained. The Committees/ Representatives are also responsible for inspecting treatment records at three-month intervals to verify their proper maintenance. In other words, they serve as the oversight mechanism to ensure that the attendants complete the treatment records as prescribed by the departmental policy.

52. We expected to find that Committees/ Representatives inspect first-aid treatment records at three-month intervals to verify their proper maintenance and monitor first aid stations to ensure that these service areas are properly identified, equipped and maintained as required by Departmental Policy 016.

53. When reviewing the treatment records, we found no evidence demonstrating that Committees/ Representatives inspected the records. This was further supported by the attendants interviewed, who stated they were unaware of any inspection of the first aid records. Additionally, the Regional Managers, who are required to oversee the records inspection by the Committees/Representatives, were unsure if records are inspected as required because they do not receive any inspection reports.

54. Departmental Policy 016 does not state how often Committees/ Representatives must monitor first aid stations nor does it state how they are supposed to report this information or to whom. While examining the first aid stations, we observed that there was nothing at the station or in the kit to indicate that the Committees/ Representatives have inspected the stations to ensure that they are maintained.

The Departmental First Aid Policy was recently revised.

55. A departmental policy assists in the provision of first aid by identifying specific requirements and defining the roles and responsibilities of all employees. Policies are important as they inform and guide daily practice and ensure that employees are aware of their roles and responsibilities. We expected to find a departmental policy on first aid that is aligned with the Canada Labour Code Part II, the Canada Occupational Health and Safety Regulations, and the Treasury Board Occupational Health and Safety Directive.

56. PWGSC's archived Departmental Policy 016 - First Aid was approved in 1996. Since this time, changes have been made to the Canada Occupational Health and Safety Regulations (in 2000) and to the Treasury Board Occupational Health and Safety Directive (in 2008). To address the changes made to the legislation and directive, the Corporate Environment, Health and Safety Directorate was tasked with revising Departmental Policy 016 - First Aid. The revised policy, Departmental Policy 016 - Policy on First Aid, was promulgated in July 2009.

57. We conducted a comparison of requirements between the revised Departmental Policy 016 - Policy on First Aid (2009), the Canada Labour Code Part II, the Canada Occupational Health and Safety Regulations Part XVI (2000) and the Treasury Board Occupational Health and Safety Directive (2008) to ensure that the revised Departmental Policy was aligned with the aforementioned Act, Regulations and Directive.

58. We found that, the revised Departmental Policy 016 - Policy on First Aid (2009) was aligned with the requirements of the Canada Labour Code Part II and the Canada Occupational Health and Safety Regulations. However, some minor requirements of the Treasury Board Occupational Health and Safety Directive were not specifically reflected. In addition, the definition of workplace was redefined from "any place where an employee is engaged in work for the Department" to "any place controlled by the Department where an employee is engaged in work for the Department." The new definition is inconsistent with the requirements of the Canada Labour Code Part II and the Treasury Board Occupational Health and Safety Directive.

59. These gaps were communicated prior to the promulgation of the revised policy; however, two of the discrepancies we noted, including the definition of workplace, were not resolved prior to the new policy being promulgated.

60. If the identified gaps are not addressed, there may be issues of non-compliance with the Treasury Board Occupational Health and Safety Directive in the future.

CONCLUSION

61. The level of compliance of PWGSC first aid practices with relevant acts, regulations, policies, and directives related to health and safety needs improvement.

62. Records of attendants' names, locations and certification status are incomplete and/or outdated. As such, the Department is unable to demonstrate that the appropriate number of attendants have been designated. In general, training provided to attendants meets the requirements of acts, regulations, policies and directives related to health and safety with the exception of one region, which uses a provider that is not on an approved list. Monitoring over designated attendants could be strengthened to ensure that the required number of people are designated and trained.

63. The audit found that first aid stations, kits, and supplies were not properly provided and treatment records were not properly maintained nor inspected in accordance with acts, regulations, policies, and directives related to health and safety.

64. There are shortages of Workplace Health and Safety Committees/Representatives, which serve as an oversight mechanism, particularly in the National Capital Area.

65. In addition, although the departmental policy on first aid was recently revised to address requirements of acts, legislation and directives related to health and safety, some inconsistencies with the Treasury Board Occupational Health and Safety Directive were still noted.

MANAGEMENT RESPONSE

Management accepts the findings of the audit report on the PWGSC first aid program.

Corporate Services, Policy and Communications Branch will act on the three recommendations identified in the audit report by implementing the attached management action plan.

RECOMMENDATIONS AND MANAGEMENT ACTION PLAN

Recommendation 1: The Assistant Deputy Minister, Corporate Services, Policy and Communications Branch should ensure that the appropriate number of first aid attendants are designated and trained by maintaining up-to-date records and monitoring certification status.

Management Action Plan 1.1: Revise Departmental Policy 016 – First Aid. This action has been completed.

Management Action Plan 1.2: Maintain a directory of workplaces and a list of first aid attendants for each workplace, which includes the name of all attendants, the type of certification held, certification status, and location. In the National Capital Area, information on first aid training delivered is found in the Integrated Training System maintained by Human Resources Branch. This list of first aid attendants will be updated by December 31, 2009; the location, type of certification held, and certification status will by identified by January 30, 2010; and the list of PWGSC workplaces with the list of first aid attendants will be updated by April 2010. The directory will be maintained on a monthly basis, starting April 2010.

Recommendation 2: The Assistant Deputy Minister, Corporate Services, Policy and Communications Branch should periodically communicate to stakeholders, and particularly first aid attendants, Workplace Health and Safety Committees/ Representatives, and Regional Managers, their detailed roles and responsibilities with respect to first aid including responsibilities for maintaining first aid stations, kits, supplies and treatment records.

Management Action Plan 2.1: Include the revised roles and responsibilities in Departmental Policy 016. This action has been completed.

Management Action Plan 2.2: Recognize all designated first aid attendants for their contribution and remind them of their roles and responsibilities in regards to Departmental Policy 016 through an e-mail or communiqué. This will be done yearly, starting June 2010.

Management Action Plan 2.3: Include information on the roles and responsibilities of first aid attendants in the training program for first aid attendants by December 31, 2009.

Management Action Plan 2.4: Update the roles and responsibilities of the Workplace Health and Safety Committee Members/ Representatives in the Workplace Health and Safety Committee Members/ Representatives Training Program to reflect the revised Departmental Policy 016 – First Aid by November 30, 2009.

Management Action Plan 2.5: Recognize the members of the health and safety committees and representatives of their contribution and remind them of their roles and responsibilities in regards to Departmental Policy 016 through e-mail or communiqué. This will be done yearly, starting June 2010.

Recommendation 3: The Assistant Deputy Minister, Corporate Services, Policy and Communications Branch should ensure that the required number of Workplace Health and Safety Committees or Representatives have been designated.

Management Action Plan 3.1: Maintain a directory of the workplaces and the required / established Workplace Health and Safety Committee members/ required / appointed representatives for each one of these workplaces in each region. This will be done every six months, starting April 2010.

ABOUT THE AUDIT

Authority

This audit was approved by the Audit and Evaluation Committee of Public Works and Government Services Canada as part of the 2008-2011 Risk-Based Multi-Year Audit and Evaluation Plan.

Objective

The objective of the audit was to determine whether selected PWGSC Health and Safety programs are compliant with Acts, Regulations, Policies, and Directives related to Health and Safety.

Scope and Approach

This audit was conducted from February 2009 to May 2009. The scope of the audit covered all aspects related to the first aid practice within PWGSC.

During the preliminary survey phase of the audit, a risk assessment was conducted to identify which areas of the overall health and safety program should be considered during the examination phase. As a result of this assessment, it was determined that the focus of the audit would be on key aspects related to first aid practices within PWGSC and to determine whether these key aspects of first aid practices are compliant with relevant acts, regulations, policies, and directives related to health and safety.

A sample of workplaces was chosen for on-site inspection based on an analysis of workplace profile checklists that had been completed prior to the preliminary survey phase of the audit by the Regional Managers responsible for health and safety. The National Capital Area and the Atlantic Region had been assessed as being highest risk based on these results and because they have the highest population of PWGSC employees and greatest number of workplaces.

This audit was conducted in accordance with the Institute of Internal Auditors' International Standards for the Practice of Internal Auditing.

Audit criteria were derived from the Canada Labour Code Part II, the Canada Occupational Health and Safety Regulations, the Treasury Board Occupational Health and Safety Directive, and the Departmental Policy 016 – First Aid (1996). The fact that the policy is under review was taken into consideration when deriving the audit criteria.

Criteria

The criteria were as follows:

1. PWGSC has a Departmental Policy on First Aid that is aligned with the requirements of the Canada Labour Code Part II, the Canada Occupational Health and Safety Regulations, and the Treasury Board of Canada Occupational Health and Safety Directive.
2. First aid attendants are designated in accordance with Acts, Regulations, Directives and Policies related to Health and Safety.
3. First aid training is provided in accordance with Acts, Regulations, Directives and Policies related to Health and Safety.
4. First aid supplies are provided and inspected in accordance with Acts, Regulations, Directives and Policies related to Health and Safety.
5. First aid stations are provided in accordance with Acts, Regulations, Directives and Policies related to Health and Safety.
6. First aid records/reporting are maintained in accordance with Acts, Regulations, Directives and Policies related to Health and Safety.

Audit Work Completed

Audit fieldwork for this audit was substantially completed on May 8, 2009.

Audit Team

The audit was conducted by members of the Office of Audit and Evaluation overseen by the Director of Internal Audit and under the overall direction of the Chief Audit Executive, Office of Audit and Evaluation.

The audit was reviewed by the Quality Assessment function of the Office of Audit and Evaluation.