Audit
Management Review
Document FSSMS-AUD-05Stage 2Revision 2Version 0.3.3
Topic pages open on your jurisdiction, and requirements tables show its line. You can change this on any page.
The management review is the one meeting a year at which the fire chief, with the senior team and the JOHSC co-chairs in the room, looks at the whole safety management system on evidence and decides what changes, what is resourced and what the objectives for the next year are. It is the “Act” in Plan, Do, Check, Act. ISO 45001 requires top management to review the system at planned intervals for its continuing suitability, adequacy and effectiveness, with defined inputs and outputs, and to communicate the outputs to workers and their representatives (ISO 45001:2018, cl. 9.3). The CFAI model expects a formal, documented annual appraisal of each program (CPSE, 2019, criterion 11B.6 and the closing indicator of each Category V program criterion). The applicable OHS statute typically requires the written program to provide for monitoring its own implementation and effectiveness, and the OHS policy to be reviewed at a set interval with the committee or representative (J03 OHS Policy and Program); the management review is the annual point at which both are done and recorded, with the policy review taken under the legal and standards changes item. This note adapts all three to a fire department and ties the review to the budget and to the annual report to council.
A management review that produces no decisions, or decisions with no owner, is a presentation. The decision record is the product.
| Element | Default | Notes |
|---|---|---|
| When | April, within six weeks of the fiscal year end, after the annual internal audit report (issued by March 1) and the annual program appraisals (due March 15) | Shift with the fiscal year (04 Annual Program Cycle and Calendar) |
| Chair | Fire chief | Not delegated. If the chief cannot attend, the review is rescheduled |
| Required | Deputy chiefs; senior officer responsible for H&S; HSO; division chief, training; both JOHSC co-chairs; the program managers presenting appraisals (in rotation, or all in a small department); the municipality’s corporate safety lead or human resources representative; finance representative for the budget linkage | Union and volunteer association representatives invited as observers for the open sessions |
| Length | Half a day for the core agenda; a full day where program appraisals are presented in the same session | Large departments split: appraisals over two sessions in March, decisions in April |
| Pre-reading | The management review pack (section 4) issued 10 working days before | No pack, no meeting |
| Record | Form - Management Review Decision Record, issued within 10 working days; member summary within 30 days | Decisions enter the Corrective Action Register with the review as source |
| ISO 45001 input (ISO 45001:2018, cl. 9.3) | What it means in a fire department | Source in the package |
|---|---|---|
| Status of actions from previous reviews | Every decision from last year’s record: done, in progress, overdue, dropped with reason | Last year’s decision record; Corrective Action Register |
| Changes in external and internal issues | New services, stations, apparatus, staffing model; new or amended statutes, regulations and standard editions; community risk changes; a merger; a major event | Legal register update; 02 Standards and Law Master Map; 01 Program Profile Worksheet re-run |
| Needs and expectations of interested parties | Council and CAO direction; union and volunteer association positions; regulator and WCB contacts; mutual aid partners; members’ concerns raised through the JOHSC and the learning program | JOHSC minutes; hazard and concern reports; labour-management minutes |
| Legal and other requirements | Compliance evaluation results; orders, directions and their closure; standards the department has adopted or should | Compliance evaluation (category 18); register |
| Risks and opportunities | Hazard profile changes; new or emerging hazards (energy storage, lithium, wildland-urban interface, heat); opportunities from grants, partnerships, research | 03 Hazard Profile and Risk Register Method; program appraisals |
| Extent to which policy and objectives were met | Each of last year’s objectives with its measure, target and result | Objectives table from last year’s record; indicator report |
| Incidents, nonconformities and corrective actions | Injuries, exposures, vehicle collisions, near misses and good catches; the register’s open-item age, closure rate, reopen rate, escalations | Learning program annual summary; register summary |
| Monitoring and measurement results | The full indicator set for the year with baselines and trends | 04 Baseline Metrics and Indicator Set; monthly indicator reports |
| Results of compliance evaluation | Category 18 result | Audit |
| Audit results | Program score, category profile, effectiveness index, maturity band, findings by priority (P1 (Imminent) to P4 (Improvement)), trend | Annual audit report (01 Audit Program) |
| Consultation and participation of workers | JOHSC recommendations made and responses given, with response times; learning-team sessions held and participation; program team membership and turnover; the psychological-safety measure | 02 JOHSC Integration; 06 Program Improvement Teams; audit interviews |
| Risks and opportunities (again, for the system) | Where the system itself is fragile: one person holding a program, a records system at capacity, auditor pool too small | Audit program review; appraisals’ SWOT |
| Adequacy of resources | Program team budget worksheets; staffing for safety roles; training backfill; equipment life cycle | Form - Annual Program Appraisal budget worksheets |
| Communications with interested parties | What the department told council, the regulator, the WCB, the public and the members about safety, and what came back | Annual report; correspondence log |
| Opportunities for continual improvement | Good practices found by audit, learning reviews and peers; program team proposals | Audit report; appraisals; learning program |
| Added by this package: culture baseline and psychological safety | Culture survey results and trend; proportion of members who report they can raise a concern and get an answer; stop-work calls and their review; near-miss and good-catch reporting rate | 05 Safety Culture Baseline; audit psychological-safety measure; indicator report |
| Added by this package: program appraisals | Each program’s annual appraisal with its CQI recommendations, risks, SWOT, outcomes, next steps and budget lines | Form - Annual Program Appraisal |
| ISO 45001 output (ISO 45001:2018, cl. 9.3) | What it means here | Where it goes |
|---|---|---|
| Conclusions on the continuing suitability, adequacy and effectiveness of the system | A written statement by the chief: the system is suitable for the department’s services, adequate in resources, and effective on evidence, with the exceptions named | Decision record section A |
| Continual improvement opportunities | Which of the audit’s and appraisals’ opportunities the department will pursue | Decision record section B; register |
| Any need for changes to the system | Policies to revise, programs to add or merge, a module to switch on, governance changes (a RACI “A” moved, a team re-chartered) | Decision record section C; document control |
| Resources needed | Budget lines approved for submission, staffing, training backfill, equipment, external verification | Decision record section D; budget submission |
| Actions, if needed | Each with owner and due date | Decision record section E; register |
| Opportunities to improve integration with other business processes | Fleet, facilities, human resources, procurement, finance service levels | Decision record section C |
| Implications for the strategic direction | What the department tells council it will do and needs | Annual report to council; strategic plan |
| Communication of outputs to workers and their representatives | Member summary; JOHSC minutes; station briefings | Within 30 days |
| Retained documented information | The pack, the decision record, attendance | {{Records system}}, 10 years (05 Document Control and Records) |
Issued 10 working days before the meeting by the senior officer responsible for H&S. Fixed order so the chief can read it the same way every year. Target length: 40 pages plus appendices; every section has a one-paragraph summary at the top.
| # | Section | Content | Prepared by |
|---|---|---|---|
| 1 | Last year’s decisions | Status table of every decision and action from the last review | HSO |
| 2 | Indicator report, annual | The full indicator set: leading (inspection completion and closure time, training currency, fit-test currency, medical and fitness participation, near-miss and good-catch reports per working fire, learning-team sessions, stop-work calls reviewed without reprisal, effective response force attainment, decon compliance observed) and lagging (injury frequency and severity, lost time, exposures by type, vehicle collisions, WCB claims and cost); 12-month and three-year trend; by district and career or volunteer | HSO |
| 3 | Audit results | Executive summary of the annual audit; category profile; effectiveness index and maturity band; findings by priority; spot-audit summaries; external verification report in a year-three cycle; audit program review answers | Lead internal auditor; senior officer H&S |
| 4 | Corrective action status | Register summary: open by priority, open-item age profile, on-time closure rate, reopen rate, escalations and the resource gaps behind them, items over 180 days | HSO |
| 5 | JOHSC recommendations and responses | Every recommendation in the year, the response, response time against the statutory clock (J05 Joint Committee and Health and Safety Representative), and the status of accepted items; the committee’s own self-evaluation; inspection completion rate | JOHSC co-chairs |
| 6 | Program appraisals | One annual appraisal per program on Form - Annual Program Appraisal; a one-page summary table across programs (status, top risk, top ask) | Program managers |
| 7 | Incident and learning summary | Injuries, exposures, collisions, near misses; tier 1, 2 and 3 reviews held; the five most important learnings and what changed; the learning firewall’s record (no learning information used for discipline; any challenge to it) | Learning program lead |
| 8 | Culture and psychological safety | Culture baseline survey results and trend; the audit’s psychological-safety measure by group; what members said they would fix first | Senior officer H&S |
| 9 | Legal and standards changes | Statutes, regulations, orders, standard editions changed or expected; compliance evaluation result; what the department must do | Senior officer H&S; policy coordinator |
| 10 | Resource needs | Consolidated budget worksheet across programs for the next fiscal year and four years; staffing for safety roles; external verification cost | Finance liaison with program managers |
| 11 | Proposed objectives for next year | Draft objectives with measure, baseline, target, owner, due; linked to the stage gate in 01 Implementation Roadmap 0-36 Months | Senior officer H&S |
| 12 | Appendices | Audit report; register extract; appraisals in full; survey report |
| Time | Item | Lead | Output |
|---|---|---|---|
| 0:00 | Opening: purpose, principles (people as the solution; work-as-done; learning before blame; psychological safety), ground rules (decisions, not presentations; every action has an owner) | Fire chief | |
| 0:10 | Last year’s decisions: status, what was not done and why | HSO | Carry-forward list |
| 0:30 | Indicators: the year on one page; the three trends that matter | HSO | Trends noted for objectives |
| 0:55 | Audit results and effectiveness index; maturity band; the three priorities | Lead internal auditor | Priorities accepted or amended |
| 1:25 | Corrective action status; escalations and the resource gaps behind them | HSO, deputy chiefs | Decisions on stuck items |
| 1:45 | Break | ||
| 2:00 | JOHSC: recommendations, responses, response times, self-evaluation; what the committee asks of the chief | JOHSC co-chairs | Responses recorded |
| 2:25 | Program appraisals: summary table, then the three programs with the highest risk or the largest ask present (10 minutes each) | Program managers | Appraisal decisions |
| 3:00 | Incident and learning summary; culture and psychological safety results | Learning lead; senior officer H&S | Learnings adopted; culture actions |
| 3:25 | Legal and standards changes; compliance evaluation | Senior officer H&S | Changes to policies and programs |
| 3:40 | Resources: the consolidated budget worksheet; what goes into the submission | Finance liaison; fire chief | Budget decisions |
| 4:05 | Objectives for next year: measure, target, owner, due | Fire chief | Objectives table |
| 4:30 | Suitability, adequacy, effectiveness statement; decisions read back; communication plan | Fire chief | Decision record complete in draft |
| 4:45 | Close |
Full template at Form - Management Review Decision Record. Sections: A statement on suitability, adequacy and effectiveness; B improvement opportunities adopted or declined, with reasons; C changes to the system; D resources approved for submission; E actions with owner and due date; F objectives for the year with measure, baseline, target, owner, due; G communication plan; H attendance and sign-off (fire chief; JOHSC co-chairs note that they were consulted). Each action and objective receives a register ID.
Objectives are few and measurable. Five to eight for the department; each program team then sets its own, nested under them. An objective without a measure is a hope.
Budget. Program appraisals carry the five-year budget worksheet (06 Program Improvement Teams section 11). The review consolidates them, decides what goes forward, and records the safety-critical items the department could not fund in the decision record, section D, so the gap is a written decision rather than a silent omission. The consolidated worksheet goes into the department’s budget submission to {{Municipality}} on {{Budget submission date}}. Where the municipality’s cycle requires the submission before the review, the review is split: resources in a session before the submission date, the remainder in April (04 Annual Program Cycle and Calendar).
Annual report to council. The review’s statement, objectives, audit results and the resource decisions become the core of the annual health and safety report to council (03 Accountability and Reporting section 6), delivered in June. Council sees the maturity band, the trend, the priorities and the unfunded safety-critical items in plain language.
| Element | Who | How |
|---|---|---|
| Owner | Fire chief | Chairs; signs the decision record; accountable for every decision having an owner and a date |
| Doer | Senior officer responsible for H&S (pack, agenda, record); HSO (indicators, register); program managers (appraisals); JOHSC co-chairs (section 5 of the pack); finance liaison (section 10) | Sections 4 to 6 |
| Verifier | Internal audit (category 20 checks: held on time, inputs complete, outputs recorded, actions in the register, outputs communicated); external verification; council (receives the annual report) | Checklist - Management Review |
| Feedback | Decision record within 10 working days to attendees, program managers and JOHSC; member summary to every station within 30 days; station officers brief crews; the JOHSC records the summary in its minutes | Section 3 outputs row “Communication” |
| Closure | Every action and objective in the Corrective Action Register; status reviewed at the next review as item 1; overdue actions escalate like any other register item | Register rules |
Loop test. The April review decides that every volunteer station will have a second set of structural gear for interior-qualified members within 18 months, funded over two budget years. By May the decision is in the register with the Protective Clothing program manager as owner and quarter-by-quarter milestones; the member summary has reached every station; the volunteer association has the decision in writing. The quarterly program updates report progress; the next April review reads the status as its first item. If the budget is cut in the municipal process, the decision record is amended, the reason recorded, and the members are told what changed and why.
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 program must provide for monitoring its own implementation and effectiveness, and how often the OHS policy must be reviewed and with whom (sections 1 and 5) | J03 OHS Policy and Program |
| Joint Committee and Health and Safety Representative | The deadline for the employer’s written response to a committee recommendation, against which pack section 5 reports response times, and the committee’s right to be consulted on the review’s outputs (sections 2 and 4) | J05 Joint Committee and Health and Safety Representative |
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
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