Checklist - Management Review | Fire Service Safety Management System

1. Scope

This category audits the top of the loop: the annual management review chaired by the fire chief, the inputs it must receive, the decisions it must make, how those decisions are resourced and communicated, and whether the department’s safety objectives exist, have owners and are met. It also audits the annual program appraisals that feed the review and the reporting to the chief administrative officer and council.

It does not re-score the audit program (category 19), the indicator set (category 18) or the Program Improvement Teams’ quarterly cycle (scored in each program’s own checklist); it checks that their outputs arrived at the review and that something came of them.

The management-system requirement is that top management review the system at planned intervals, considering a defined list of inputs, and produce decisions on suitability, adequacy and effectiveness, improvement, changes and resources, with the outputs communicated to workers and their representatives and the records retained (ISO 45001:2018, cl. 9.3). Continual improvement is a separate requirement (ISO 45001:2018, cl. 10.3) and measurable objectives with plans are another (ISO 45001:2018, cl. 6.2). CFAI requires a formal, documented appraisal at least annually of the wellness and fitness program (CPSE, 2019, criterion 11B.6) and of the training program including a SWOT analysis (CPSE, 2019, criterion 8C.8); this package extends the annual appraisal to every program (06 Program Improvement Teams section 10). Ontario’s COR program carries management review as a distinct element (IHSA, 2017). The applicable OHS statute requires the written program to provide for monitoring its implementation and effectiveness, and it may also set how often the OHS policy is reviewed (J03 OHS Policy and Program); this department reviews the policy at every annual management review.

2. Criteria

Source	What it sets	Items
ISO 45001 cl. 9.3 management review (ISO 45001:2018)	Planned intervals; inputs: previous actions, changes in context and legal requirements, policy and objective attainment, performance trends (incidents, nonconformities, corrective actions, monitoring, compliance evaluation, audit results, worker consultation, risks and opportunities), resources, communications with interested parties, improvement opportunities; outputs: suitability, adequacy, effectiveness, improvement, changes, resources, integration, strategic implications; communicated and recorded	1 to 19
ISO 45001 cl. 6.2 objectives and cl. 10.3 continual improvement (ISO 45001:2018)	Measurable objectives with plans, owners, resources, timelines and evaluation; continual improvement of suitability, adequacy and effectiveness	20 to 25
CSA Z45001:19 (R2023)	Same clauses; Canadian deviations on worker and worker-representative participation in decision-making	9, 27
CFAI criteria 1A, 1B, 2D, 8B and 11B (CPSE, 2019, criteria 1A.3, 1A.7, 1B.1, 2D.2, 2D.7, 2D.9, 2D.10, 8B.6, 11B.6)	Governing body periodically reviews services and programs; communication between governing body and administration; resources reflect mission and size; quarterly internal reporting on delivery; continuous improvement plan; annual notice to the authority having jurisdiction of gaps; stakeholder expectations determined every three years; annual training program appraisal; annual wellness and fitness appraisal. The crosswalk is to the 10th edition; the 11th edition applies to agencies appearing from 2027 (CPSE, 2024)	CFAI column
IHSA COR management review element (IHSA, 2017)	Management review as an audited element of an OHS program	All
Westrum (2004)DOI; Hudson (2007)DOI; Edmondson (1999)DOI	Culture ladder and psychological safety as management review inputs	12, 13, 29
Provincial or territorial OHS statute (J03 OHS Policy and Program; J06 Written Procedures and Committee Consultation)	Monitoring implementation and effectiveness; policy review in consultation with the committee; committee consultation on changes to written policies and procedures	1, 4, 9, 17, 18, 20
This package: Management Review, Form - Management Review Decision Record, Form - Annual Program Appraisal, 03 Accountability and Reporting, 04 Annual Program Cycle and Calendar	The April review, agenda, pack contents, decision record, budget and council links, 30-day communication	All

3. How to score

Full rules in 01 Audit Program section 5. In short: the CFAI column gives the 10th edition indicator the item evidences, or a dash. Score D, I and E each 0 to 3; derive the item score (0 not in place; 1 documented not implemented; 2 implemented not verified effective; 3 implemented and effective with evidence); both-required evidence codes need both types to score above 1 on implementation; weights C3, K2, S1 and the L flag (must score at least 2); category score is the weighted roll-up; effectiveness index from E alone.

4. Checklist

#	Item	Stage	Wt	Evid	CFAI	Scoring anchors (1 / 2 / 3)
20.1 Annual review held with the required inputs
1	A management review of the safety management system is held at least annually, in April for an April to March fiscal year, chaired by the fire chief, with the deputy chiefs, the senior officer responsible for H&S, the HSO, program managers and both JOHSC co-chairs attending; the record shows who attended (ISO 45001:2018, cl. 9.3)	S1	C3 L	D+I	1A.3, 11B.6	1: an informal meeting without a record / 2: held in the window, attendance recorded, agenda followed / 3: held every year for three years with the co-chairs present each time and attendees describe it as a decision meeting
2	The review pack is issued to attendees at least 10 working days before the meeting and contains every input in Management Review section 3	S2	K2	D	-	1: material tabled on the day / 2: pack issued on time, all inputs / 3: attendees confirm they read it and the record shows questions raised from it
3	The status of actions from the previous review is the first input, drawn from the Corrective Action Register, with each action closed, open or overdue	S1	K2	D	2D.7	1: previous actions not listed / 2: listed with status / 3: all previous actions closed or re-dated with a reason in the record
4	Changes in external and internal issues are reviewed: new or amended law and standards editions, department services and stations, staffing model, the community risk assessment, the needs of interested parties (members, volunteers, union, association, regulator, workers’ compensation board, municipality)	S1	K2 L	D	2D.10	1: not on the agenda / 2: reviewed from the legal register and the standards map / 3: each change traced to a decision or a recorded “no change needed”
5	The extent to which the OHS policy and the year’s objectives were met is reviewed with data, objective by objective	S1	K2	D	2D.7	1: objectives not revisited / 2: each objective rated met, partly met or not met / 3: reasons recorded for every objective not met and carried into next year’s plan
6	Performance trends are reviewed from the monthly indicator reports: injuries, exposures, near misses and good catches, stop-work calls, inspection closure time, training currency, fit test and medical currency, effective response force attainment, vehicle collisions, with at least 12 months of trend	S1	C3	D	2D.2	1: annual totals only / 2: trends with 12 months of data / 3: trends compared with targets and prior years, outliers explained by the program manager
7	Audit results are an input: the program score, category profile, effectiveness index, maturity band, major findings and the register’s open-item age profile and closure rate (ISO 45001:2018, cl. 9.3)	S2	C3	D	2D.6	1: audit not tabled / 2: full audit summary in the pack / 3: decisions in the record cite audit findings by reference
8	Compliance evaluation results are an input: the legal register review, regulator contacts, orders and their closure (ISO 45001:2018, cl. 9.1.2 and 9.3)	S1	K2 L	D	-	1: not tabled / 2: tabled / 3: every order in the year closed and the category spot-audited
9	Worker consultation and participation results are an input: JOHSC recommendations and the employer responses, the committee’s self-evaluation, learning-team sessions held, and the standing consultants’ reports (CSA Z45001:19, deviations on participation)	S1	C3 L	D	-	1: JOHSC not represented in the pack / 2: recommendations and responses tabled with status / 3: co-chairs confirm the pack reflects the committee’s year and any disagreement is recorded
10	Incident and learning summary is an input: serious events, learning reviews by tier, lessons adopted, near-miss themes, external learning intake	S1	K2	D	-	1: a count of incidents / 2: summary with lessons and status / 3: at least one procedure or control changed on a lesson, cited in the record
11	Risks and opportunities are an input: the hazard profile’s top risks, changes in the risk register, new hazards (energy systems, climate, service changes) and the opportunities the program teams identified	S2	K2	D	-	1: not tabled / 2: top risks tabled with controls status / 3: a new or escalated risk in the year led to a resourced decision
12	The safety culture baseline results (05 Safety Culture Baseline) and the maturity band from the effectiveness index are in the pack and discussed, with any gap between the two explained	S2	K2	D	-	1: culture survey never run or not tabled / 2: tabled with the band / 3: gap discussed, a decision taken on it, re-measure scheduled
13	The psychological-safety measure is in the pack: the audit’s two standing questions by group, near-miss and good-catch reports per working fire, stop-work calls made and reviewed without reprisal (Edmondson, 1999)DOI	S2	K2	D	-	1: not reported / 2: reported / 3: trend discussed and a leadership action recorded
14	Resource adequacy is reviewed: safety division staffing, program team time, auditor pool, training capacity, equipment and PPE life cycle, with the asks from the annual program appraisals	S1	K2	D	1B.1	1: not reviewed / 2: reviewed with the appraisal asks / 3: each ask accepted, deferred with a date, or declined with a reason in the record
15	Communications with interested parties are reviewed: regulator, workers’ compensation board, union, association, municipality, mutual aid partners, the public where relevant	S2	S1	D	1A.7, 2D.10	1: not reviewed / 2: reviewed / 3: an outstanding external issue is assigned an owner
16	Opportunities for continual improvement are tabled from the audit’s OFIs, the program appraisals, the learning program and the JOHSC (ISO 45001:2018, cl. 10.3)	S2	K2	D	2D.7	1: not tabled / 2: tabled / 3: at least three adopted with owners in the year
17	The review decides, and records, whether the system remains suitable, adequate and effective, in those words, with the reasons (ISO 45001:2018, cl. 9.3)	S1	K2	D	2D.6	1: no conclusion / 2: conclusion recorded / 3: conclusion supported by the audit result and the indicators, and a “not effective” conclusion in any year led to a plan
18	The review decides on changes to the system (policies, programs, procedures, structure) and on the resources needed, each with an owner and a date, on Form - Management Review Decision Record	S1	C3	D	2D.7	1: discussion without decisions / 2: decisions on the record with owners and dates / 3: every decision in the register or the work plan, none orphaned at the next review
19	The review considers the implications for the strategic plan and the integration of safety into the department’s business processes (budget, procurement, staffing, standards of cover) (ISO 45001:2018, cl. 9.3)	S2	S1	D	1B.1	1: not considered / 2: considered and recorded / 3: strategic plan or standards of cover amended on a safety decision in the year
20.2 Objectives and targets with owners
20	The department sets written annual OHS objectives that are measurable, consistent with the policy, informed by the hazard profile, the audit and the indicators, and consulted with the JOHSC (ISO 45001:2018, cl. 6.2)	S1	C3	D	2D.7	1: objectives vague or absent / 2: measurable objectives set at the review / 3: objectives traced to data and the JOHSC’s consultation minuted
21	Each objective has one accountable owner, a plan of actions, the resources required, a timeline and the measure by which it will be evaluated	S1	K2	D	2D.7	1: owners missing / 2: all fields complete / 3: owners can describe their objective and its status without notes
22	Objectives include at least one leading indicator target, at least one effectiveness target from the audit and at least one psychological-safety or participation target	S2	K2	D	-	1: lagging targets only / 2: the three kinds present / 3: targets met or trending as planned at year end
23	Objectives are communicated to every station and program team within 30 days of the review, and members at sampled stations can name one	S2	K2	D+I	-	1: not communicated / 2: communicated on time / 3: members name an objective and what their station is doing on it
24	Progress on objectives is reported quarterly to the senior team and the JOHSC, not only at the next review	S2	K2	D	2D.2	1: annual only / 2: quarterly reports on file / 3: a quarterly report triggered a change of plan during the year
25	Objectives not met are carried forward with a reason and a changed plan, or closed with a decision, never silently dropped	S2	S1	D	2D.7	1: unmet objectives disappear / 2: each unmet objective dispositioned / 3: three-year view of objectives shows the pattern and the department’s response
20.3 Culture baseline and maturity band considered
26	The safety culture baseline is measured at least every two years with a recognized instrument, anonymous, with volunteer members included proportionately, and the results are reported by group (Westrum, 2004 DOI; Hudson, 2007 DOI)	S2	K2	D	-	1: never measured / 2: measured within two years, reported / 3: re-measured on schedule and the change explained
27	Members and worker representatives took part in interpreting the culture results and in choosing the response, consistent with the participation requirement (CSA Z45001:19)	S2	K2	D+I	-	1: results held by management / 2: results shared with the JOHSC and stations / 3: JOHSC worker members describe helping choose the response
28	The maturity band is used to set the next stage’s work plan in 01 Implementation Roadmap 0-36 Months, not as a score to publish	S2	S1	D+I	-	1: band not used / 2: band cited in the work plan / 3: senior team describe what moving one band requires
29	Leaders’ own behaviours are reviewed as part of the culture input: visible PPE use, attendance at learning teams, response times to concerns and recommendations, and the handling of stop-work calls (Edmondson, 1999)DOI	S3	K2	D+I	-	1: not reviewed / 2: reviewed and recorded / 3: a leadership behaviour commitment recorded with a measure
20.4 Decisions resourced in the budget
30	Every program’s annual appraisal (Form - Annual Program Appraisal) is complete by March 15 and received by the review, with the five-year budget worksheet (06 Program Improvement Teams section 11) (CPSE, 2019, criteria 11B.6, 8C.8)	S2	C3	D	11B.6, 8B.6	1: fewer than half received / 2: all received by the review / 3: appraisals presented by the program managers and questioned
31	Review decisions requiring money are carried into the department’s budget submission in the year’s budget cycle, and the submission cross-references the decision record	S2	C3	D	1B.1	1: no link / 2: decisions in the submission / 3: approved budget traced back to the decisions and the gap reported to the next review
32	Safety-critical gaps that cannot be resourced are escalated to the chief administrative officer and council in writing by the fire chief, with the risk stated plainly (01 Roles and Responsibilities section 3.3)	S1	C3	D	2D.9	1: gaps absorbed silently / 2: escalation letter on file where applicable / 3: council’s decision recorded and the risk register updated
33	The decision record is filed in {{Records system}} and retained per 05 Document Control and Records	S1	K2 L	D	-	1: notes in an inbox / 2: filed and retrievable / 3: three consecutive years retrievable in one request
20.5 Outputs communicated
34	The review’s decisions and the new objectives are communicated to all members and to the JOHSC within 30 days, in a form members read (station briefing, bulletin, short video), not only as minutes (ISO 45001:2018, cl. 9.3)	S1	C3 L	D+I	-	1: minutes posted only / 2: member communication on time / 3: members at sampled stations can describe one decision
35	Anyone who raised an issue that reached the review (through a JOHSC recommendation, a program appraisal, a near-miss report or the audit) is told what the review decided on it	S2	K2	D+I	-	1: no reply loop / 2: replies recorded / 3: a member confirms receiving the answer to their issue
20.6 Council and CAO reporting
36	The annual health and safety report to council is produced in June from the review’s outputs, on the outline in 03 Accountability and Reporting, covering performance, audit result, objectives, resources and the gaps escalated	S2	K2	D	1A.3, 2D.9	1: no report or a statistics page / 2: report delivered on the outline / 3: council’s questions and decisions recorded and brought back to the next review
37	The chief administrative officer receives the decision record and any escalation within 30 days of the review	S2	K2	D	1A.7	1: not sent / 2: sent on time / 3: CAO response recorded
20.7 Program appraisals received
38	Each appraisal follows the form: description, continuous quality improvement with recommendations and plans, strategic goals, risks and mitigations with status tags, inputs (personnel, financial, equipment, professional development), SWOT, outcomes, next steps and the budget worksheet	S2	K2	D	11B.6, 8B.6	1: free-form reports / 2: on the form / 3: appraisals compared year to year on the same fields
39	Appraisals report the program’s indicators against baseline and target, the corrective action status, the JOHSC consultation record and the succession status of the team	S2	K2	D	8B.6	1: narrative only / 2: all four present / 3: the review’s decisions on a program cite its appraisal
40	Accountability loop. The management review has a completed accountability and closed-feedback-loop table (fire chief as owner; senior officer H&S as doer for the pack; internal audit and the JOHSC as verifiers; the 30-day communication and the June council report as feedback; the register as closure) and the owner can answer the loop test with a real example from the year	S1	K2	D+I	-	1: table blank or generic / 2: filled, owner describes each row / 3: loop test answered with a decision from the year, resourced and reported back

Loop test. A program appraisal in March asks for a second set of structural gear for a volunteer district. By when has the April review decided, where is the decision recorded, how does it reach the budget submission, and when does the volunteer officer who asked hear the answer?

5. Effectiveness questions

Answer each from observation or interview only, record the evidence, and use it for the E score of the items it touches.

Did the review decide anything that cost money or changed a program? Ask the fire chief and two program managers, without the record, to name one decision from the last review, what it cost, and where it stands. Score 3 only if the answers are specific, agree with the decision record and the item is resourced or closed.
Can the people who did the appraisals see their work in the decisions? Ask three program managers whether the review responded to the asks in their appraisal, and how they learned the answer. A manager who does not know what happened to their budget worksheet is evidence of a broken loop whatever the record says.
Do members report they can raise a concern and get an answer, and did the review hear from them? Ask every interviewee the two standing questions from 01 Audit Program section 1a, and ask members at sampled stations whether they can name one decision from the last review. Record the proportion with a specific, positive answer, by group (Edmondson, 1999)DOI.

6. Interview and observation prompts

Fire chief: what did last year’s review conclude about whether the system is effective, and on what evidence?
Fire chief: which decision from the review did you escalate to the CAO or council, and what came back?
Deputy chief: name the three objectives for this year and who owns each.
Program manager: what did your appraisal ask for, and what did the review decide?
JOHSC co-chair (worker): was the committee’s year fairly represented in the pack? Did the review answer the committee’s recommendations?
Senior officer H&S: how far ahead did the pack go out, and what was missing from it?
Member: what did the department decide at its safety review this year? Where did you hear it?
Member: have you raised a concern in the last year, and did you get an answer?
Observe: the decision record against the register; count decisions with no owner or no date.
Observe: the budget submission for the cross-references to decisions.
Observe: the culture baseline report and the maturity band side by side in the pack.
Observe: the member communication issued after the review, and its date against the review date.

Jurisdiction requirements

This chapter relies on the following legal requirements, which differ by province and territory. Check your jurisdiction’s section on each topic page before adopting it.

Topic	What to check in your jurisdiction	Page
OHS Policy and Program	Whether the written OHS program must provide for monitoring its own implementation and effectiveness, and how often the OHS policy must be reviewed and with whom (items 1, 4, 9, 17)	J03 OHS Policy and Program
Written Procedures and Committee Consultation	Whether the committee or representative must be consulted when written policies, procedures and plans are established or changed, including changes the review decides (items 18, 20)	J06 Written Procedures and Committee Consultation

References

Center for Public Safety Excellence [CPSE]. (2019). Fire and emergency service self-assessment manual (10th ed.). Commission on Fire Accreditation International. https://cpse.org/wp-content/uploads/2019/08/10th-Edition-FESSAM-Strikethrough-Underline-v.4.pdf

Center for Public Safety Excellence [CPSE]. (2024). Fire and emergency service self-assessment manual (11th ed.). Commission on Fire Accreditation International. https://www.cpse.org/accreditation/cfai10/

CSA Group. (2019). CSA Z45001:19 (R2023), Occupational health and safety management systems: Requirements with guidance for use (adopts ISO 45001:2018 with Canadian deviations). https://www.csagroup.org/store/product/CSA%20Z45001:19/

Edmondson, A. C. (1999). Psychological safety and learning behavior in work teams. Administrative Science Quarterly, 44(2), 350–383. doi:10.2307/2666999

Hudson, P. (2007). Implementing a safety culture in a major multi-national. Safety Science, 45(6), 697–722. doi:10.1016/j.ssci.2007.04.005

Infrastructure Health and Safety Association [IHSA]. (2017). COR program guidelines. https://www.ihsa.ca/pdfs/cor/cor-program-guidelines.pdf

International Organization for Standardization. (2018). ISO 45001:2018, Occupational health and safety management systems: Requirements with guidance for use. https://www.iso.org/standard/63787.html

Westrum, R. (2004). A typology of organisational cultures. Quality and Safety in Health Care, 13(Suppl. 2), ii22–ii27. doi:10.1136/qshc.2003.009522