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Published in July 2006 by the Health and Safety Authority. © All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the Health and Safety Authority. i Health and Safety Authority Guidance Document for the Healthcare Sector How to develop and implement a Safety and Health Management System Table of Contents ACKNOWLE
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  Published in July 2006 by the Health and Safety Authority.© All rights reserved.No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by anymeans, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the Health and Safety Authority. i Health and Safety Authority Guidance Document for the Healthcare SectorHow to develop and implementa Safety and Health ManagementSystem  Table of Contents ACKNOWLEDGEMENTS.......................................................................................ivFOREWORD.......................................................................................................11.0EXECUTIVE SUMMARY..................................................................................22.0INTRODUCTION TO A SAFETY AND HEALTH MANAGEMENT SYSTEM AND AUDIT TOOL............................................................................32.1Background to the healthcare sector.......................................................32.2Key elements of a safety and health management system.........................42.3Policy and commitment.........................................................................42.4Planning.............................................................................................42.5Implementation and operation...............................................................42.6Measuring performance.........................................................................52.7Reviewing performance.........................................................................52.8Auditing..............................................................................................62.9Linkage between this guidance document and the audit tool......................82.10Steps to assist in the implementation, development and evaluation of asafety and health management system...................................................83.0CORPORATE GOVERNANCE...........................................................................93.1Introduction........................................................................................93.2Evidence.............................................................................................93.3Leading a safety culture......................................................................103.4Summary..........................................................................................104.0INITIAL SAFETY AND HEALTH MANAGEMENT SYSTEM REVIEW........................114.1 Purpose of initial review......................................................................115.0POLICY....................................................................................................125.1 Introduction to policy..........................................................................125.2 Content of policy................................................................................125.3 Policy objectives.................................................................................125.4 Linkages with other accreditation bodies...............................................135.5 Commitment to policy.........................................................................136.0PLANNING................................................................................................146.1 Introduction to planning......................................................................146.2 Planning process................................................................................14 GUIDANCE DOCUMENT FOR THE HEALTHCARE SECTOR ii  HOW TO DEVELOP AND IMPLEMENT A SAFETY AND HEALTH MANAGEMENT SYSTEM  iii 7.0IMPLEMENTATION AND OPERATION.............................................................167.1 Management responsibilities................................................................167.2 Individual responsibilities....................................................................177.3 Managing the implementation process...................................................177.4 Changing attitudes and behaviour........................................................177.5 Hazard identification and risk assessment process..................................177.6 Definitions.........................................................................................177.7 Hazard identification...........................................................................187.8.1. Injuries due to manual handling.........................................................197.8.2. Injuries due to slips, trips and falls.....................................................197.8.3. Injuries due to violence (Injured by person; malicious).........................207.9Risk assessment.................................................................................217.10Risk control.......................................................................................227.11Review effectiveness of control measures..............................................228.0MEASURING PERFORMANCE........................................................................238.1Introduction to measuring performance.................................................238.2Process of measuring performance.......................................................238.3What to measure...............................................................................239.0REVIEWING PERFORMANCE........................................................................259.1Introduction to reviewing performance..................................................259.2Process of reviewing performance........................................................259.3Outcome of reviewing performance.......................................................2610.0AUDITING................................................................................................2710.1Safety and health management system audits.......................................2710.2Audit protocols...................................................................................2710.3Audit records.....................................................................................27Appendix 1:Audit Tool Criteria.........................................................................28Appendix 2:Terminology...................................................................................38Appendix 3:References....................................................................................40  GUIDANCE DOCUMENT FOR THE HEALTHCARE SECTOR iv Acknowledgements Special thanks to the Forum Group for their assistance and dedication in compiling theAudit Tool and Guidance Document;Ms Laura Breen, Ms Anne Daly and the site steering group of the Adelaide and MeathHospital Inc. the National Children’s Hospital;Mr Kieran Sludds, Mr Frank Power and Ms. Louise Dalton of the Health and SafetyAuthority.Mr. John Taylor, Health Care, Health and Safety Consultant;Mr Paddy O’Brien and the site steering groups of Cheshire Ireland;Ms Cora McCaughan, Mr Kevin O’Malley and the site steering group of the HSE MidlandArea;Ms Margo Leddy, Ms Karen McKiernan and the site steering group of the HSE NorthEastern Area;Ms Siobhan Fitzpatrick, Mr Des Pearson and the site steering group of the HSE SouthWestern Area.
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