# Policy - Program Review and Continuous Improvement > Fire Service Safety Management System, version 0.3.3 (2026-10-25). The Human Factor. Document FSSMS-POL-22. > > Canonical: https://thehumanfactor.ca/library/fire-service-safety/policy-program-review-and-continuous-improvement > > Licence: CC BY-NC-SA 4.0 with the Adopting Agency Grant (https://creativecommons.org/licenses/by-nc-sa/4.0/) > > General information only, not legal, medical or other professional advice. Verify every requirement against the current official text of the law, standards and manufacturer instructions that apply to you. Obtain your own legal review and consult your joint health and safety committee before adopting anything. You adopt, adapt, implement and rely on this material entirely at your own risk and on your own responsibility. Full terms: Terms of Use, thehumanfactor.ca. > **Warning: Adoption without implementation increases legal exposure** > > Adopting this policy without the training, equipment, supervision, verification and resources to carry it out as written increases municipal and command liability in a regulatory investigation or a fatality inquiry. See [00a Copyright, Licence and Legal Notices](https://thehumanfactor.ca/library/fire-service-safety/copyright-licence-and-legal-notices). > **Warning: Review before adoption** > > This model policy needs review by the department’s counsel and against every applicable collective agreement and volunteer association agreement before adoption. It is general information, not legal advice. Where it conflicts with a statute, regulation or agreement, the statute, regulation or agreement governs. Section numbers are cited as of 2026-10-22; confirm each one before signing. ## How to use this model **Format.** Adopt as a department policy. It is the “Check” and “Act” of the management system in one document, and the audit scores it as its own category. **Drafting conventions.** **Shall** means mandatory. **Should** means expected unless a documented reason exists. **May** means permitted. Placeholders in double curly braces, such as `{{Department}}`, are completed by the department. Drafting notes sit in callouts and are removed before adoption. **Keep intact.** The annual cycle (5.1), the quarterly update and annual appraisal (5.2), the audit independence rule (5.4), the management review inputs and outputs (5.5), the triennial external review (5.6), the Corrective Action Register rules (5.8), and the four house principles. **Adapt.** The calendar months to the department’s fiscal year; the external review product chosen; the role titles. | Field | Entry | |:---|:---| | Policy title | Program Review and Continuous Improvement Policy | | Policy number | FSSMS-POL-22 ({{Department}} number: {{Policy number}}) | | Approved by | {{Fire Chief}} | | Effective date | {{Effective date}} | | Next review date | {{Review date}} (12 months after adoption, then every three years) | | Policy owner | {{Division Chief, Safety}} | | Consulted | {{JOHSC}}; {{Union}}; {{Volunteer Association}}; program managers; municipal internal audit; counsel | ## 1. Purpose 1.1 To require that {{Department}} checks whether its safety management system is implemented and whether it works, on a fixed cycle, with evidence, by people independent of the work, and acts on what it finds. 1.2 To meet any duty in the applicable OHS statute to monitor the implementation and effectiveness of the written OHS program ([J03 OHS Policy and Program](https://thehumanfactor.ca/library/fire-service-safety/j03-ohs-policy-and-program)), the performance evaluation and improvement clauses of the management-system standard (ISO 45001:2018, cl. 9 and 10), the program effectiveness evaluation the fire service standard requires at least every three years [(NFPA 1550, 2024, ch. 6)](https://thehumanfactor.ca/library/fire-service-safety/policy-program-review-and-continuous-improvement#ref-nfpa-1550), and the annual appraisal the accreditation model expects [(CPSE, 2019, criterion 11B.6)](https://thehumanfactor.ca/library/fire-service-safety/policy-program-review-and-continuous-improvement#ref-cpse-2019). 1.3 To avoid the failure of a checklist standard that is self-declared, never audited from outside, and carries no measurement: thirty years of that model left most departments without the basic programs (NFPA, 2021; Fire Engineering, 1991; see [05 Design Principles and Lessons Learned](https://thehumanfactor.ca/library/fire-service-safety/design-principles-and-lessons-learned)). ## 2. Scope and application 2.1 Applies to every policy, program, procedure, team, committee process, register and indicator in the safety management system, and to the system as a whole. 2.2 Applies to the fire chief as chair of the management review, to every program manager as owner of an appraisal, to the safety division as administrator of the audit program, to the JOHSC as an audit actor within its statutory functions, and to the external reviewer. ## 3. Definitions **Annual program appraisal.** The program manager’s formal, documented assessment of a program each year: description, personnel, equipment, training, hazards, indicators against baseline and target, strengths and weaknesses, accomplishments, corrective action status, lessons, next year’s milestones, five-year plan and budget worksheet ([06 Program Improvement Teams](https://thehumanfactor.ca/library/fire-service-safety/program-improvement-teams) section 10). **Audit.** A systematic, independent, documented process for obtaining evidence and evaluating it objectively against criteria (ISO 19011:2026, cl. 3). **Corrective action.** Action to eliminate the cause of a deficiency and prevent recurrence, tracked in the [Corrective Action Register](https://thehumanfactor.ca/library/fire-service-safety/corrective-action-register). **Effectiveness.** Whether a program produced the outcome it exists for, shown by evidence, as distinct from whether it is documented or practised. **External review.** A review of the system by a person or body independent of the department: a peer team, a compensation board approved auditor, a certification body or an accreditation assessor. **Indicator.** A measure of performance; leading (a measure of what the department does that should prevent harm) or lagging (a measure of harm that occurred) ([04 Baseline Metrics and Indicator Set](https://thehumanfactor.ca/library/fire-service-safety/baseline-metrics-and-indicator-set)). **Internal audit.** An audit by department or municipal staff trained as auditors and independent of the program audited. **Management review.** The fire chief’s annual review of the system against defined inputs, producing defined outputs ([Management Review](https://thehumanfactor.ca/library/fire-service-safety/management-review)). **Maturity.** The department’s position on a ladder from reactive through calculative and proactive to generative, assessed from audit scores and the culture survey ([02 Gap Assessment Tool](https://thehumanfactor.ca/library/fire-service-safety/gap-assessment-tool)). **Quarterly progress update.** The team lead’s report each quarter on indicators, milestones, corrective actions, learning sessions, training, trials and asks ([06 Program Improvement Teams](https://thehumanfactor.ca/library/fire-service-safety/program-improvement-teams) section 10). ## 4. Principles 1. **People are the solution we build around, not the problem to fix.** Reviews ask the people who do the work what works and what does not; an audit that never leaves the office is not an audit. 2. **Procedures describe work as done, written with the people who do it.** The audit scores implementation and effectiveness, not only documentation, because a documented procedure nobody follows is a hazard. 3. **Learning comes before blame, and learning information is never used for discipline.** Audit findings are about the system; an auditor who finds a member working around a procedure reports the procedure. 4. **Psychological safety is a condition of safety, so speaking up is expected and protected.** Audit interviews are confidential and one-on-one, and the culture survey is anonymous; the department measures whether members feel safe to speak and treats the score as a finding. 5. **Independence.** The person who runs a program does not audit it, and the consultant who built the system does not audit it. 6. **Evidence.** Every score has a document, an observation or an interview behind it, and the effectiveness questions cannot be answered from documents. 7. **Closed loop.** Every finding gets an owner, a due date, verification and a report back; the age of open items is a measure of the department’s seriousness. 8. **Externally checked.** Self-declaration overstates practice; every three years someone from outside looks. ## 5. Policy statements ### 5.1 The annual cycle 5.1.1 The department shall run the cycle in [04 Annual Program Cycle and Calendar](https://thehumanfactor.ca/library/fire-service-safety/annual-program-cycle-and-calendar) every year: monthly indicator review at the operations meeting and the JOHSC; quarterly program progress updates; annual program appraisals two months before the budget submission; the annual internal audit; the annual management review; the annual policy review of the signed statement; the annual report to council. Accountable: {{Fire Chief}}; {{Division Chief, Safety}} for the calendar. 5.1.2 Each program’s cycle is run by its Program Improvement Team or named officer using the six-step improvement cycle in [06 Program Improvement Teams](https://thehumanfactor.ca/library/fire-service-safety/program-improvement-teams) section 4 [(Langley et al., 2009)](https://thehumanfactor.ca/library/fire-service-safety/policy-program-review-and-continuous-improvement#ref-langley-2009). Accountable: program managers. ### 5.2 Quarterly updates and annual appraisals 5.2.1 Each team lead shall submit a quarterly progress update within 15 days of quarter end, in the standard form, to the program manager, the senior leadership team and the JOHSC for information. Accountable: team leads. 5.2.2 Each program manager shall complete the annual program appraisal in the standard form, present it to the senior leadership team, and submit it to the management review and the budget process two months before the department’s budget submission ([CPSE, 2019, criterion 11B.6](https://thehumanfactor.ca/library/fire-service-safety/policy-program-review-and-continuous-improvement#ref-cpse-2019); the appraisal structure follows the accreditation practice of description, appraisal and plan). Accountable: program managers. 5.2.3 The appraisal shall report each indicator against its baseline and target, and shall say whether the program is at Stage 1, 2 or 3 and what it would take to advance. Accountable: program managers. ### 5.3 Indicators and measurement commitments 5.3.1 The department shall maintain the indicator set in [04 Baseline Metrics and Indicator Set](https://thehumanfactor.ca/library/fire-service-safety/baseline-metrics-and-indicator-set): for every program at least one leading and one lagging indicator paired so the link can be seen, at least one psychological-safety measure, and the baseline fixed before the program starts. Accountable: {{Health and Safety Officer}}. 5.3.2 Indicators shall be reported by station and by career and volunteer status, never only as one number for the department, and published to members quarterly in a form they can read in five minutes. Accountable: {{Health and Safety Officer}}. 5.3.3 The department commits to measure at least: near-miss and good-catch reports per 100 calls; days from report to feedback; corrective actions open, overdue and median days to closure; medical and fit-test currency; SCBA, bunker gear and apparatus test completion; mandatory training currency; inspections completed on schedule; rehabilitation provided at qualifying incidents; personnel accountability reports at benchmarks; exposure reports filed per fire; lost-time and medical-aid injuries; vehicle incidents; psychological injury claims and assistance program use in aggregate; the culture survey results at baseline, 12 and 24 months. Accountable: {{Division Chief, Safety}}. 5.3.4 Every indicator shall have a written definition, data source, owner and target. Accountable: {{Health and Safety Officer}}. ### 5.4 Internal audit 5.4.1 The department shall run the audit program in [01 Audit Program](https://thehumanfactor.ca/library/fire-service-safety/audit-program): quarterly element spot-audits so that every category is audited within the year; an annual full internal audit of every category; post-event audits after any death, critical injury, mayday or high-potential near miss (ISO 45001:2018, cl. 9.2; ISO 19011:2026, cl. 5). Accountable: {{Division Chief, Safety}}. 5.4.2 Every checklist item shall be scored 0 to 3 on documentation, implementation and effectiveness, with the evidence type recorded (document, observation, interview) and with items flagged as needing two evidence types scoring no higher than 1 without both; interviews one-on-one, confidential, sampled by headcount across rank and career and volunteer status, and scored on the majority of responses [(CFCSA, 2021)](https://thehumanfactor.ca/library/fire-service-safety/policy-program-review-and-continuous-improvement#ref-cfcsa-2021). Accountable: the audit lead. 5.4.3 Internal auditors shall be trained to an internal auditor standard, drawn from a division other than the one audited, and never audit a program they run; the health and safety officer is auditee, not auditor, for the OHS program; a consultant who built the system does not audit it (ISO 19011:2026, cl. 4 and 7; [CFCSA, 2021](https://thehumanfactor.ca/library/fire-service-safety/policy-program-review-and-continuous-improvement#ref-cfcsa-2021)). Accountable: {{Fire Chief}}. 5.4.4 The JOHSC is an audit actor: it audits compliance with health and safety requirements in the workplace through its inspections and its review of the audit report, within the functions the applicable statute gives the committee ([J05 Joint Committee and Health and Safety Representative](https://thehumanfactor.ca/library/fire-service-safety/j05-joint-committee-and-health-and-safety-representative)), and a committee member joins the audit team as an observer. Accountable: JOHSC co-chairs; the audit lead. 5.4.5 Findings shall be graded and rated on the department’s one priority scale, the same scale every inspection, investigation and register entry uses ([Corrective Action Register](https://thehumanfactor.ca/library/fire-service-safety/corrective-action-register)): a major nonconformity (a critical control absent or broken, a legal breach, an imminent danger) is P1 (Imminent) or P2 (Serious) according to the risk; a minor nonconformity is P3 (Moderate); an opportunity for improvement is P4 (Improvement). Each priority carries its deadlines: P1, interim control the same shift (stop, isolate, tag out or remove from service, with the fire chief and the JOHSC co-chairs told within 24 hours), plan within 2 working days, closure within 7 days; P2, interim control within 24 hours where practicable, plan within 7 days, closure within 30 days; P3, plan within 30 days, closure within 90 days; P4, plan by the next quarterly program update, closure within 365 days or by the next budget cycle, dated. Every finding records the evidence, the criterion, the cause and the owner (ISO 19011:2026, cl. 6.4). Accountable: the audit lead; program managers for the actions. 5.4.6 The audit report shall go to the fire chief, the JOHSC, the chief administrative officer, and the union and volunteer association representatives, with an executive summary, category scores, a maturity map, the trend since the last audit, the critical findings and the action plan (ISO 45001:2018, cl. 9.2). Accountable: {{Division Chief, Safety}}. ### 5.5 Management review 5.5.1 The fire chief shall chair a management review at least annually, attended by the deputy chiefs, the senior officer responsible for health and safety, the health and safety officer, the program managers, both JOHSC co-chairs, and the union and volunteer association representatives for the open portion (ISO 45001:2018, cl. 9.3). Accountable: {{Fire Chief}}. 5.5.2 Inputs shall include at least: the status of actions from the previous review; changes in law, standards, context and the Profile Worksheet; the extent to which the policy and the annual objectives were met; performance trends from the indicators, incidents, exposures, near misses, corrective actions, compliance evaluation, audit results and worker consultation; the annual program appraisals; the Corrective Action Register’s open-item age; the risk register’s top risks; the culture survey; the learning system’s annual learning report; JOHSC recommendations and responses; the adequacy of resources; communications with interested parties; opportunities for improvement (ISO 45001:2018, cl. 9.3; [Management Review](https://thehumanfactor.ca/library/fire-service-safety/management-review)). Accountable: {{Division Chief, Safety}} for the package. 5.5.3 Outputs shall be minuted: decisions on the continuing suitability, adequacy and effectiveness of the system; next year’s safety objectives with owners; the corrective action priorities; resource decisions and escalations to the CAO and council; changes to policies, programs or structure; and the communication of the outputs to all members within 30 days (ISO 45001:2018, cl. 9.3). Accountable: {{Fire Chief}}. ### 5.6 Triennial external review 5.6.1 Every three years, the department shall have its safety management system reviewed by a party independent of the department: a peer assessment team, a compensation board approved auditor, a certification body, or an accreditation peer team, chosen at Stage 3 under [01 Implementation Roadmap 0-36 Months](https://thehumanfactor.ca/library/fire-service-safety/implementation-roadmap-0-36-months) ([NFPA 1550, 2024, ch. 6](https://thehumanfactor.ca/library/fire-service-safety/policy-program-review-and-continuous-improvement#ref-nfpa-1550); [CFCSA, 2021](https://thehumanfactor.ca/library/fire-service-safety/policy-program-review-and-continuous-improvement#ref-cfcsa-2021)). Which certificate of recognition and compensation board programs are open to a municipal fire department, and any premium incentive, depends on the province or territory ([J36 External Verification and Funding](https://thehumanfactor.ca/library/fire-service-safety/j36-external-verification-and-funding)). Accountable: {{Fire Chief}}. 5.6.2 The external review uses the same categories and scoring as the internal audit, so results are comparable, and its report goes to the same recipients plus council. Accountable: {{Division Chief, Safety}}. 5.6.3 Where the department pursues accreditation, the annual appraisals and audit reports are the exhibits for the health and safety category and the related criteria, and the department does not prepare a second set of documents [(CPSE, 2019, Category 11)](https://thehumanfactor.ca/library/fire-service-safety/policy-program-review-and-continuous-improvement#ref-cpse-2019). Accountable: the accreditation manager. ### 5.7 Review of the policy set and the documents 5.7.1 The signed OHS policy statement shall be reviewed annually in consultation with the JOHSC; some jurisdictions require exactly that review of the written policy, and the department does it wherever it operates ([J03 OHS Policy and Program](https://thehumanfactor.ca/library/fire-service-safety/j03-ohs-policy-and-program)). Accountable: {{Division Chief, Safety}}. 5.7.2 Every policy in the set shall be reviewed 12 months after adoption and then at least every three years; every program module, procedure and form at least every three years; and any of them after a Tier 3 learning review, a legislative or standards change, a major audit finding, or a JOHSC request [(CPSE, 2019, criterion 9C.3)](https://thehumanfactor.ca/library/fire-service-safety/policy-program-review-and-continuous-improvement#ref-cpse-2019). Where the applicable regulation requires written procedures to be reviewed with the people affected and updated when conditions change, that duty applies as well ([J06 Written Procedures and Committee Consultation](https://thehumanfactor.ca/library/fire-service-safety/j06-written-procedures-and-committee-consultation)). Accountable: policy and program owners. 5.7.3 Reviews are scheduled in [04 Annual Program Cycle and Calendar](https://thehumanfactor.ca/library/fire-service-safety/annual-program-cycle-and-calendar) on a rolling basis so that one-third of the documents are reviewed each year, and recorded in [05 Document Control and Records](https://thehumanfactor.ca/library/fire-service-safety/document-control-and-records) with what changed and who was consulted. Accountable: {{Division Chief, Safety}}. 5.7.4 The review of any document starts with the people who use it: a learning-team session or a station round asking what works, what is worked around and why. Accountable: program managers. ### 5.8 The Corrective Action Register 5.8.1 The [Corrective Action Register](https://thehumanfactor.ca/library/fire-service-safety/corrective-action-register) is the single register for every deficiency from inspections, audits, investigations, learning reviews, JOHSC recommendations, near-miss reports, regulator orders and management review decisions. Accountable: {{Health and Safety Officer}}. 5.8.2 Every entry records: identifier; source and date; the finding and its evidence; the cause; the action; the owner; the due date; status; verification evidence and verifier; closure date; and an effectiveness check at six months for P1 and P2 items (ISO 45001:2018, cl. 10.2). Accountable: {{Health and Safety Officer}}. 5.8.3 Entries are made within five working days of identification, and a P1 item on the day it is found; each entry carries its priority and the plan and closure dates in 5.4.5. Overdue items escalate on the priority scale: a P1 to the fire chief at once; a P2 to the deputy chief at the due date and to the fire chief at 30 days overdue; a P3 to the deputy chief at 30 days overdue and to the fire chief at 60 days. One extension is allowed: by the fire chief for a P1, to 30 days and only with the interim control kept in place; by the deputy chief for a P2, to 90 days, and for a P3, to 180 days. A P4 item is cancelled only with a written reason. Where the permanent fix needs capital work that cannot be finished inside the closure clock, the interim control does not close the item: the permanent fix keeps its priority, flagged Capital, with a dated plan approved by the fire chief and reviewed quarterly by the JOHSC, and the interim control is re-verified monthly until the fix is in ([Corrective Action Register](https://thehumanfactor.ca/library/fire-service-safety/corrective-action-register) section 4). Closure requires evidence and a verifier’s sign-off by someone other than the doer; the register summary goes to the JOHSC monthly and to the operations meeting monthly, and the open-item age is a standing management review input ([Policy - Internal Responsibility and Accountability](https://thehumanfactor.ca/library/fire-service-safety/policy-internal-responsibility-and-accountability) 5.3). Accountable: program managers; {{Deputy Chief}}. 5.8.4 The person who raised an item hears back when it closes or when a decision is made not to act, with reasons. Accountable: the receiving officer. ### 5.9 Culture and maturity 5.9.1 The department shall measure its safety culture at baseline, at 12 months and at 24 months, then every two years, with the instrument and protocol in [05 Safety Culture Baseline](https://thehumanfactor.ca/library/fire-service-safety/safety-culture-baseline), segmented by career and volunteer status, and publish the results to every station within 30 days ([NZFS, 2016a](https://thehumanfactor.ca/library/fire-service-safety/policy-program-review-and-continuous-improvement#ref-nzfs-2016a); [Geczik et al., 2024](https://thehumanfactor.ca/library/fire-service-safety/policy-program-review-and-continuous-improvement#ref-geczik-2024)). Accountable: {{Division Chief, Safety}}. 5.9.2 The audit scores and the culture results place the department on the maturity ladder in [02 Gap Assessment Tool](https://thehumanfactor.ca/library/fire-service-safety/gap-assessment-tool), and the management review records the position and the next step. Accountable: {{Fire Chief}}. ### 5.10 Improvement 5.10.1 The department shall set annual safety objectives at the management review, each measurable, with an owner and a date, integrated with the strategic plan and the budget (ISO 45001:2018, cl. 6.2 and 10.3). Accountable: {{Fire Chief}}. 5.10.2 Improvement proposals from teams, members, the JOHSC and the learning system are decided within 30 days with reasons recorded; delayed items get an interim control and a revisit date. Accountable: {{Deputy Chief}}. ## 6. Roles and responsibilities Only the differences from [01 Roles and Responsibilities](https://thehumanfactor.ca/library/fire-service-safety/roles-and-responsibilities) are stated here. 6.1 **Fire chief.** Chairs the management review; sets the objectives; chooses the external review product; receives escalations. 6.2 **Senior officer responsible for health and safety.** Administers the audit program and the calendar; assembles the management review package; is auditee for the OHS program. 6.3 **Audit lead.** A trained internal auditor independent of the programs audited; may be a municipal internal auditor or an officer from another division. 6.4 **Program managers.** Own the appraisal, the quarterly updates, and the corrective actions for their program. 6.5 **Team leads.** Submit the quarterly updates; keep the action log. 6.6 **JOHSC.** Audit actor within its statutory functions; observer on the audit team; receives the register summary and the audit report; consulted on this policy. 6.7 **Accreditation manager (where applicable).** Maps appraisals and audit reports to the criteria. ## 7. Program and procedures this policy requires [01 Audit Program](https://thehumanfactor.ca/library/fire-service-safety/audit-program); [02 Audit Checklist Master Index](https://thehumanfactor.ca/library/fire-service-safety/audit-checklist-master-index); [Annual Inspection and Review Schedule](https://thehumanfactor.ca/library/fire-service-safety/annual-inspection-and-review-schedule); [Corrective Action Register](https://thehumanfactor.ca/library/fire-service-safety/corrective-action-register); [Management Review](https://thehumanfactor.ca/library/fire-service-safety/management-review); [04 Annual Program Cycle and Calendar](https://thehumanfactor.ca/library/fire-service-safety/annual-program-cycle-and-calendar); [04 Baseline Metrics and Indicator Set](https://thehumanfactor.ca/library/fire-service-safety/baseline-metrics-and-indicator-set); [05 Safety Culture Baseline](https://thehumanfactor.ca/library/fire-service-safety/safety-culture-baseline); [02 Gap Assessment Tool](https://thehumanfactor.ca/library/fire-service-safety/gap-assessment-tool); [06 Program Improvement Teams](https://thehumanfactor.ca/library/fire-service-safety/program-improvement-teams); [Form - Program Team Charter](https://thehumanfactor.ca/library/fire-service-safety/form-program-team-charter); [Form - Program Team Budget Worksheet](https://thehumanfactor.ca/library/fire-service-safety/form-program-team-budget-worksheet). ## 8. Records, confidentiality and disclosure 8.1 Records: quarterly updates; annual appraisals; audit plans, working papers, interview sampling records and reports; management review packages and minutes; the Corrective Action Register; indicator definitions and data; culture survey raw data and reports; external review reports. 8.2 Audit interview notes are confidential and destroyed after the report is issued; the report records findings, not who said what. Culture survey raw data stays with the administrator; reports are aggregate with no cell below the minimum size. Governed by [Policy - Records, Privacy and Health Information](https://thehumanfactor.ca/library/fire-service-safety/policy-records-privacy-and-health-information). 8.3 All records are written for disclosure under municipal freedom-of-information law. ## 9. Reporting | Report | From | To | When | |:---|:---|:---|:---| | Indicators; Corrective Action Register summary | {{Health and Safety Officer}} | Operations meeting; JOHSC | Monthly | | Quarterly progress updates | Team leads | Program managers; senior team; JOHSC | Within 15 days of quarter end | | Indicator dashboard to members | {{Health and Safety Officer}} | All stations | Quarterly | | Annual program appraisals | Program managers | Senior team; management review; budget | Two months before budget submission | | Internal audit report | Audit lead | Fire chief; JOHSC; CAO; union and association representatives | Annually | | Management review outputs | {{Fire Chief}} | All members; JOHSC; CAO | Within 30 days of the review | | Annual health and safety report | {{Fire Chief}} | Council | Annually | | External review report | External reviewer | Fire chief; JOHSC; CAO; council | Every three years | ## 10. Training requirements | Role | Minimum training | Refresh | |:---|:---|:---| | Program managers and team leads | Program manager and team lead course: the cycle, the appraisal, the budget worksheet, indicators (two days) | Every three years | | Internal auditors | Internal auditor course to an internal auditor standard, with this system’s scoring method (three days) | Every three years; one audit per year to stay current | | Fire chief and deputy chiefs | Management review and the chief’s role in the system (half day) | Every three years | | JOHSC members | The audit program and the committee’s audit role (half day) | On appointment | | Health and safety officer | Indicator design and data; audit administration (two days) | Every three years | | Every member | What the department measures and why; how to read the dashboard (in orientation) | Annually | ## 11. Legal and standards basis - The applicable OHS statute and regulations, which differ by province and territory: any duty to monitor the implementation and effectiveness of the written OHS program and to review the written policy, with the workforce size that triggers each ([J03 OHS Policy and Program](https://thehumanfactor.ca/library/fire-service-safety/j03-ohs-policy-and-program)); the committee’s functions, including any function of auditing compliance, and its meeting and minute rules ([J05 Joint Committee and Health and Safety Representative](https://thehumanfactor.ca/library/fire-service-safety/j05-joint-committee-and-health-and-safety-representative)); the review and updating of written procedures in consultation with the committee ([J06 Written Procedures and Committee Consultation](https://thehumanfactor.ca/library/fire-service-safety/j06-written-procedures-and-committee-consultation)); and the certification and incentive programs available for external verification ([J36 External Verification and Funding](https://thehumanfactor.ca/library/fire-service-safety/j36-external-verification-and-funding)). The Jurisdiction requirements table at the end of this policy lists what to confirm for your province or territory. - Objectives, monitoring and measurement, compliance evaluation, internal audit, management review inputs and outputs, incident and corrective action, continual improvement (ISO 45001:2018, cl. 6.2, 9.1, 9.2, 9.3, 10.2, 10.3; CSA Z45001:19). - Audit principles, audit programme management, conducting audits, auditor competence (ISO 19011:2026, cl. 4 to 7). - Program effectiveness evaluation at least every three years; internal annual and external triennial audit expectation [(NFPA 1550, 2024, ch. 6 and annex H)](https://thehumanfactor.ca/library/fire-service-safety/policy-program-review-and-continuous-improvement#ref-nfpa-1550). - The certificate of recognition audit model: documentation, observation and interview evidence; majority-of-interviews rule; 80 percent overall and 50 percent per element thresholds; internal annual and external triennial cycle; auditor independence [(CFCSA, 2021)](https://thehumanfactor.ca/library/fire-service-safety/policy-program-review-and-continuous-improvement#ref-cfcsa-2021). Which certificate of recognition and compensation board certification programs a municipal fire department can use, and on what terms, is set out in [J36 External Verification and Funding](https://thehumanfactor.ca/library/fire-service-safety/j36-external-verification-and-funding). - The model for improvement [(Langley et al., 2009)](https://thehumanfactor.ca/library/fire-service-safety/policy-program-review-and-continuous-improvement#ref-langley-2009). - Culture measurement and its link to injury [(Geczik et al., 2024)](https://thehumanfactor.ca/library/fire-service-safety/policy-program-review-and-continuous-improvement#ref-geczik-2024); what makes volunteer and career members report [(NZFS, 2016a)](https://thehumanfactor.ca/library/fire-service-safety/policy-program-review-and-continuous-improvement#ref-nzfs-2016a). - The CPSE/CFAI accreditation path: a formal, documented appraisal at least annually of the wellness and fitness program [(CPSE, 2019, criterion 11B.6)](https://thehumanfactor.ca/library/fire-service-safety/policy-program-review-and-continuous-improvement#ref-cpse-2019); documented steps taken to address hazards (11A.3); near-miss reporting used to share lessons (11A.6); a process to investigate and determine root cause with an information system that supports it (11A.7); documents reviewed at least every three years (9C.3); annual performance appraisal of each operational program and continuous improvement planning (Category 2); a corrective actions system (7C.3). The 11th edition from 2027 keeps the categories [(CPSE, 2025)](https://thehumanfactor.ca/library/fire-service-safety/policy-program-review-and-continuous-improvement#ref-cpse-2025). ## 12. Review and approval 12.1 Reviewed 12 months after adoption, then every three years; after each external review; after any change to the statute, the management-system standard or the audit standard; and on JOHSC request. ## 13. Adoption checklist | Step | Lead | Done | |:---|:---|:---| | Fix the calendar months to the fiscal year in [04 Annual Program Cycle and Calendar](https://thehumanfactor.ca/library/fire-service-safety/annual-program-cycle-and-calendar) | {{Division Chief, Safety}} | | | Name the audit lead and train the first internal auditors | {{Fire Chief}} | | | Confirm the Corrective Action Register is live with the five-day entry rule and the priority scale’s deadlines and escalation rules | {{Health and Safety Officer}} | | | Fix the indicator baseline from the Profile Worksheet Part D | {{Health and Safety Officer}} | | | Issue the quarterly update and annual appraisal forms to every program manager | {{Division Chief, Safety}} | | | Schedule the first management review and the culture baseline | {{Fire Chief}} | | | Decide the external review product for year three (peer team, board-approved auditor, certification, accreditation) | {{Fire Chief}} | | | Consult the JOHSC, {{Union}} and {{Volunteer Association}} | JOHSC employer co-chair | | | Counsel review | Municipal counsel | | | Enter in document control with review date | Policy owner | | ## 14. Consulting the JOHSC and bargaining agents | They will ask | Honest answer | |:---|:---| | Who audits the chief? | The external reviewer every three years, and the management review’s outputs go to council. The committee sees every audit report and every register summary. | | Will audit interviews be used against members? | No. Interviews are confidential, one-on-one, and the notes are destroyed after the report. Findings are about the system. | | What if the audit score is bad? | Then the department has learned something, and the action plan says what it will do. A department can be honestly at Stage 1 and still be safe. The score is not published outside the department except in the council report’s summary. | | Does the committee get to see the management review? | Both co-chairs attend. The outputs go to every member within 30 days. | | Is this just more reports? | The quarterly update is two pages and the appraisal feeds the budget. If a report does not change a decision, the committee should say so and it will be cut. | Put the consultation in writing. Record disagreement, adopt what can be adopted, revisit at 12 months. ## 15. Customization and sector variants > **Note: Customize** > > Decide: the fiscal calendar; who the audit lead is (municipal internal audit is often the cleanest); the external review product; whether the department pursues accreditation. A department already accredited maps the annual appraisals directly to its annual compliance reports. > **Tip: Volunteer and composite departments** > > A small volunteer department runs the same cycle with one named officer per program and a two-page appraisal. Pool internal auditors with neighbouring departments so nobody audits their own work, and use a peer audit pool as the external check; a provincial peer pool is realistic and cheap. **Closing disclaimer.** This model policy is general information prepared by The Human Factor for licensed use by {{Department}}. It is not legal advice. Confirm every statutory reference with counsel before adoption. ## 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 statute requires a written OHS policy and program at your department’s size, whether the program must provide for monitoring its own implementation and effectiveness, and how often the written policy must be reviewed | [J03 OHS Policy and Program](https://thehumanfactor.ca/library/fire-service-safety/j03-ohs-policy-and-program) | | Joint Committee and Health and Safety Representative | The committee’s statutory functions (including any function of auditing compliance), how often it must meet, and how its minutes are kept and posted | [J05 Joint Committee and Health and Safety Representative](https://thehumanfactor.ca/library/fire-service-safety/j05-joint-committee-and-health-and-safety-representative) | | Written Procedures and Committee Consultation | Whether written procedures must be reviewed with the people affected and updated when conditions change, and the duty to consult the committee on them | [J06 Written Procedures and Committee Consultation](https://thehumanfactor.ca/library/fire-service-safety/j06-written-procedures-and-committee-consultation) | | External Verification and Funding | Which external verification programs (certificate of recognition or compensation board certification) a municipal fire department can use, how long a certificate lasts, and any premium incentive | [J36 External Verification and Funding](https://thehumanfactor.ca/library/fire-service-safety/j36-external-verification-and-funding) | ## References Canadian Federation of Construction Safety Associations \[CFCSA\]. (2021). *National COR accreditation standard* (final draft, 2021-06-11). Center for Public Safety Excellence \[CPSE\]. (2019). *Fire and emergency service self-assessment manual* (10th ed.). Commission on Fire Accreditation International. Center for Public Safety Excellence \[CPSE\]. (2025). *Board approval of Fire and Emergency Service Accreditation Model updates (11th edition)* \[Web page\]. 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). Fire Engineering. (1991). *Compliance with NFPA 1500: Room for improvement* (survey of 99 departments). Geczik, A. M., Lee, J., Allen, J. A., Raposa, M., Robinson, L., Quistberg, D. A., Davis, A. L., & Taylor, J. A. (2024). An updated analysis of safety climate and downstream outcomes in two convenience samples of U.S. fire departments (FOCUS 1.0 and 2.0 survey waves). *Injury Epidemiology, 11*. https://doi.org/10.1186/s40621-024-00502-8 International Organization for Standardization. (2018). *ISO 45001:2018, Occupational health and safety management systems: Requirements with guidance for use*. International Organization for Standardization. (2026). *ISO 19011:2026, Guidelines for auditing management systems* (4th ed.). Langley, G. J., Moen, R. D., Nolan, K. M., Nolan, T. W., Norman, C. L., & Provost, L. P. (2009). *The improvement guide: A practical approach to enhancing organizational performance* (2nd ed.). Jossey-Bass. National Fire Protection Association. (2024). *NFPA 1550, Standard for emergency responder health and safety* (consolidates NFPA 1500, 1521 and 1561). National Fire Protection Association \[NFPA\]. (2021). *Fifth needs assessment of the U.S. fire service*. New Zealand Fire Service \[NZFS\]. (2016a). *Report 153: International good practice in safety, health and wellbeing in fire and emergency services* (prepared by Litmus; case studies). Hosted by Fire and Emergency New Zealand.