# 06 Program Improvement Teams

> Fire Service Safety Management System, version 0.3.3 (2026-10-25). The Human Factor. Document FSSMS-GOV-06.
>
> Canonical: https://thehumanfactor.ca/library/fire-service-safety/program-improvement-teams
>
> 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.

## Why this note matters more than any other

Safety programs in the fire service usually fail in the same place. The written program is fine. Nobody in the line owns it, nobody who does the work helped design it, nobody checks whether it changed anything, and the person who understood it retires. Program Improvement Teams are the mechanism this package uses to close all four gaps at once.

A Program Improvement Team is a standing team for one program or specialty, led by a line officer, staffed by the members who do the work, with a fixed cycle of assessment, improvement, reporting and budget input. The team owns the program’s content, its procedures, its equipment standards, its training needs and its annual appraisal. The health and safety officer verifies and the JOHSC consults; neither owns the program for the line.

The model answers the documented reasons fire service safety standards fail to take: prescriptive checklists whose cost lands all at once, safety held by a staff position rather than line command, no outside check, and no learning loop or measurement (NFPA 1500, 2021, program worksheet annex; see [05 Design Principles and Lessons Learned](https://thehumanfactor.ca/library/fire-service-safety/design-principles-and-lessons-learned)). It does four things that a policy manual cannot:

1.  **It designs from work-as-done.** Every change starts with a learning-team session with the people who do the task, so the procedure describes how the job is actually done safely, not how someone imagined it at a desk ([Hollnagel, 2014](https://thehumanfactor.ca/library/fire-service-safety/program-improvement-teams#ref-hollnagel-2014); [Conklin, 2012](https://thehumanfactor.ca/library/fire-service-safety/program-improvement-teams#ref-conklin-2012)).
2.  **It gives front-line leaders real authority.** Team leads and members do the risk assessment, the research, the field trials, the recommendation and the budget input. They learn quality improvement, planning and budgeting by doing them.
3.  **It closes the loop.** Quarterly updates, the annual appraisal and the Corrective Action Register give every program a feedback path and a closure record that the fire chief and the JOHSC can see.
4.  **It builds succession into the system.** Every member has a development plan against a named capability list, every lead has an understudy, and membership rotates on a rule, so the program survives the departure of any one person.

> **Information: Delivery note**
>
> This model was designed and run in a large Canadian composite department, where it has worked well for the specialty teams. It is the governance engine of the whole package. In delivery, stand up two or three teams first (Respiratory Protection, Protective Clothing and Decontamination, and one specialty the department already has energy around), prove the cycle for two quarters, then extend.

## 1. Purpose

To provide each program in the safety management system with a standing, line-led team that continuously assesses risk, designs and improves the program from work-as-done, verifies that it works, reports on a fixed cycle, informs the budget, and develops the next generation of program leaders.

## 2. Scope

Every program module in [01 Program Architecture](https://thehumanfactor.ca/library/fire-service-safety/program-architecture) has an owning team or, in a department too small for standing teams, a named officer who performs the same duties on the same cycle. The default team set for a large composite all-hazards department:

| Team | Programs it owns (05 Programs) | Typical size |
|:---|:---|:---|
| Respiratory Protection | Respiratory Protection; breathing air | 4 to 6 |
| Protective Clothing, Equipment and Decontamination | PPE selection, care and maintenance; Decontamination and Contamination Control | 5 to 8 |
| Health, Wellness and Rehab | Medical, Fitness and Wellness; Occupational Cancer Prevention and Screening; Firefighter Rehabilitation; Hearing Conservation | 5 to 8, with a clinician adviser |
| Psychological Health and Peer Support | Psychological Health and Safety and Peer Support | Peer team lead plus clinical adviser |
| Fire Suppression and Emergency Operations | Emergency Operations Safety (IMS, accountability, RIT, mayday, air management) | 6 to 10 |
| Training Safety | Training Safety and Live Fire; training grounds and props | 4 to 6 |
| Apparatus, Driving and Roadway | Apparatus, Driving and Roadway Operations | 4 to 6 |
| Equipment Standards, Apparatus and PPE | The department-wide standards gate (see section 7) | 6 to 8, with standing consultants |
| Facilities and Stations | Facilities and Station Safety; Workplace Inspections | 3 to 5, with facilities staff |
| Hazardous Materials | Hazmat, CBRN and Energy Hazards; WHMIS and Hazard Communication | 5 to 8 |
| Technical Rescue | Working at Heights; Confined Space; Trench and Collapse; Rope Rescue | Lead per discipline |
| Water and Ice Rescue | Water, Ice and Swiftwater; boat operations; diving if provided | 4 to 6 |
| Marine (conditional) | Marine Firefighting | 4 to 6 |
| Wildland and Interface | Wildland and Interface; Heat, Cold and Weather | 4 to 6 |
| RPAS (conditional) | RPAS | 3 to 4 |
| Medical First Response | Infection Control and Medical Response Safety; Workplace Violence (scene safety) | 4 to 6 |
| Volunteer Operations | Volunteer and composite station practice across all programs | Volunteer officers from each district |

> **Note: Customize**
>
> Merge teams where volume is low (Health, Wellness and Rehab with Psychological Health in a mid-size department; Water and Marine together). Never merge a team into the safety division: the point is line ownership.

## 3. Roles

### 3.1 Program Manager (line officer, accountable)

A district chief, battalion chief or equivalent line officer. In a volunteer department, a deputy chief or district chief.

- Agree an annual work plan for the program with the senior team.
- Monitor program performance by district or planning zone and overall; brief the operations team monthly and the senior leadership team quarterly.
- Set and review team composition; apply the rotation rule (section 9).
- Schedule meetings, assign work, oversee progress, keep the program records.
- Complete the annual program appraisal on schedule and present it.
- Support the team lead’s quarterly updates.
- Approve and document attendance, scheduling, payroll or honoraria, training and certification records for team work.
- Act as the senior team’s subject matter expert for the program in strategic planning, budget and community risk.
- Hold the relationships: members, union and volunteer association representatives, the JOHSC, other divisions, the municipality’s corporate services, external experts and agencies.
- Own the program’s open corrective actions in the [Corrective Action Register](https://thehumanfactor.ca/library/fire-service-safety/corrective-action-register) until verified closed.
- Mentor the team lead and members in the discipline and in the capabilities that sustain the program (section 9).

### 3.2 Team Lead (front-line officer or senior member, responsible)

An operational member in good standing who holds the minimum qualification for the discipline.

- Carry the team’s objectives with the program manager.
- Lead, mentor and act as subject matter expert among the team and peers; invite and accept peer input and feedback on how the program works in practice.
- Facilitate the learning-team sessions for the program, or arrange a trained facilitator.
- Prepare the quarterly progress update; assist with the annual appraisal.
- Coordinate meetings, projects, research, reviews, analysis, member engagement and reports.
- Maintain the program’s action log and feed corrective actions to the register.

### 3.3 Team Members (front-line, responsible for assigned work)

- Do the work of the team: assessments, research, field trials, drafting procedures, training support, data review.
- Act as mentors and subject matter experts among peers and bring peer feedback back to the team.
- Onboard and mentor new team members.
- Attend meetings and complete assigned work and development activities.

### 3.4 Standing consultants (consulted, every team)

| Consultant | Provided by | Role on the team |
|:---|:---|:---|
| JOHSC member | The JOHSC designates one member per team, worker or employer side | Safety input during research and design; reports back to the JOHSC after each meeting attended; brings the team’s safety-sensitive recommendations to formal JOHSC consultation |
| Health and safety officer or safety division officer | Safety division | Verifies controls meet law and standards; advises on hazard assessment; keeps the program’s link to the audit |
| Training officer | Training division assigns one per team | Needs assessment, curriculum design and review, delivery coordination, evaluation, training records and cost reporting |
| Union and volunteer association representative | {{Union}}, {{Volunteer Association}} | Front-line voice; collective agreement and volunteer practice implications. Required on the Equipment Standards team; invited to others as needed |
| Workplace culture and equity adviser | Department or municipality | Equity and inclusion review of the program; fit, sizing and access for all members; GBA Plus analysis where grant or research funding is involved |
| Clinician or medical adviser | Department physician or contracted clinician | Required on Health, Wellness and Rehab, Respiratory Protection (medical clearance), Psychological Health, Medical First Response |

## 4. The improvement cycle

Every team uses the same six steps for any new program, change, procedure or piece of equipment. The cycle is also the standard method for any working group in the department.

1.  **Define the scope and purpose.** What area, method, process, skill or equipment, and what the change is for (safety, effectiveness, efficiency, quality, cost, member experience). Write the outcome statement first.
2.  **Assess risk, gaps and needs, starting from work-as-done.** Run a learning-team session (section 5) with the members who do the task. Then add the evidence: incident, injury, exposure and near-miss data; response data; literature and research; standards and law; industry practice and innovations; benchmarks; input from members, leadership, partners and the community.
3.  **Develop the program work plan.** Goals, actions, owners, timelines, milestones, performance measures and evaluation methods; training needs with the training officer; equipment needs with the Equipment Standards team; alignment with the accreditation criteria the department uses; costed in the budget worksheet (section 10). Recorded in the annual program appraisal.
4.  **Implement.** Procedures, guidelines, equipment standards, training. Safety-sensitive changes go through formal JOHSC consultation before adoption (section 6). Monitor and record progress in the quarterly update.
5.  **Evaluate quarterly.** Compare results with the outcome statement and measures; review the program’s indicators and the response data; hold a short learning-team check-in with members on whether the change works as done; record strengths, weaknesses, lessons and areas for improvement.
6.  **Revise and communicate.** Update the program, the appraisal and the procedures; close or re-plan corrective actions; tell the members what changed and why, and tell the person who raised the issue what happened to it.

> **Tip: Volunteer and composite departments**
>
> Hold the learning-team sessions where volunteers can attend (evenings, weekend training nights) and pay or credit the time on the same basis as training. A program designed without volunteer stations in the room will be work-as-imagined for half the department.

## 5. The learning-team method

A learning team is a short, facilitated conversation with the people who do the work, held to understand how the work actually gets done, where it is hard, where people adapt to make it work, and where the margins are thin [(Conklin, 2012, 2017)](https://thehumanfactor.ca/library/fire-service-safety/program-improvement-teams#ref-conklin-2012). It is not an investigation and it does not look for fault. The output is understanding the team uses to design the program, the procedure or the equipment. It rests on two ideas from safety science: that the gap between work-as-imagined and work-as-done is where both risk and good practice live [(Hollnagel, 2014)](https://thehumanfactor.ca/library/fire-service-safety/program-improvement-teams#ref-hollnagel-2014), and that people speak candidly only where it is safe to do so [(Edmondson, 1999)](https://thehumanfactor.ca/library/fire-service-safety/program-improvement-teams#ref-edmondson-1999).

**When to use it.** Step 2 of every cycle; step 5 check-ins; after a near miss or a good catch; when a procedure is routinely worked around; before buying equipment that changes how a task is done; when the hazard profile flags a task as high risk and low frequency.

**How to run one.**

| Session | Time | What happens |
|:---|:---|:---|
| Learning session | 60 to 90 minutes | Six to ten members who do the task, plus the team lead and a facilitator. Walk through the task as it is really done: what makes it go well, what makes it hard, what workarounds exist and why, what equipment, staffing, time, weather, radio or command conditions change it, what the near misses look like. No supervisors who rate the participants in the room, unless the crew asks for them. |
| Soak time | One to seven days | Facilitator and lead write up what was heard, without names; participants review the write-up. |
| Design session | 60 to 90 minutes | Same group, or a subset: which conditions to change, which controls to add, which procedure steps reflect reality, what to try in a field trial, what to measure. |

**Rules.** The learning firewall applies: what is said in a learning team is used for learning and is never the basis for discipline; conduct concerns go to a separate process run by different people (Dekker, 2016; Reason, 1997; see [Incident Investigation and Learning Program](https://thehumanfactor.ca/library/fire-service-safety/incident-investigation-and-learning-program)). The JOHSC consultant may attend. Write-ups name no individuals.

**What it changes.** The procedure the team drafts reflects the task as done safely; the controls address the conditions people actually face; members recognize their own work in the result. Procedures that people helped write and recognize as their own are the ones that get followed; procedures imposed from outside drift toward routine workarounds, the pattern [Vaughan (1996)](https://thehumanfactor.ca/library/fire-service-safety/program-improvement-teams#ref-vaughan-1996) described as the normalization of deviance.

### 5.1 Psychological safety inside the team

A team that is not safe to speak in will design work-as-imagined however good its intentions. The program manager and team lead are responsible for the team’s psychological safety [(Edmondson, 1999)](https://thehumanfactor.ca/library/fire-service-safety/program-improvement-teams#ref-edmondson-1999):

- Open every meeting by asking what has changed on the floor and what people are worried about; take the answers seriously before the agenda.
- The most junior member speaks first on any design question; officers speak last.
- Disagreement is recorded in the minutes as a design input, not smoothed over.
- Anyone on the team can ask for an item to go to the JOHSC consultant, and that request is never refused.
- At each quarterly update the team answers one question in writing: “Is there anything members are not telling us, and why?”

## 5a. Safety Differently in the teams’ work

| Part | What the team does |
|:---|:---|
| Work-as-done | No procedure, equipment standard or training change is drafted until a learning-team session has described how the task is really done, including the adaptations crews make |
| Capacity and margins | The annual appraisal names the conditions that make the work go right (staffing, time, equipment, familiarity) and the ones eroding it, and the budget worksheet asks for what protects capacity, not only what fixes failures |
| Just culture | Workarounds surfaced in a learning team are treated as information about the system; nobody is disciplined for disclosing one |
| Psychological safety | Section 5.1 rules; members see their concerns answered in the quarterly change notice |
| Learning link | Each team receives the Tier 1 After-Action Review themes and Tier 2 Post-Incident Analysis recommendations for its discipline within 30 days and reports what it did with them in the next quarterly update ([Incident Investigation and Learning Program](https://thehumanfactor.ca/library/fire-service-safety/incident-investigation-and-learning-program); full method in Manual 02 - The Three Tiers and Event Triage) |

## 6. Interfaces

### 6.1 JOHSC

- The JOHSC designates a standing consultant to each team and records the designations in its minutes.
- The consultant attends when safety input is needed and reports to the next JOHSC meeting after each attendance.
- **Formal JOHSC consultation is mandatory** before adoption of any team recommendation that is safety-sensitive: new or changed safety-sensitive equipment; new or changed PPE; new or changed policy, SOG or safe work procedure with safety content; new or changed safety-sensitive training. The team sends the recommendation with its evidence (learning-team summary, research, field trial report) through the policy coordinator or training division as applicable. The JOHSC response, and the department’s decision on it, are filed with the program records.
- Team recommendations never bypass the JOHSC’s statutory role, and the JOHSC’s own recommendations to the employer follow the statutory route in [02 JOHSC Integration](https://thehumanfactor.ca/library/fire-service-safety/johsc-integration).
- Where the statute requires written procedures to be reviewed with the people who use them, or requires the employer to consult the committee when it establishes or reviews a procedure ([J06 Written Procedures and Committee Consultation](https://thehumanfactor.ca/library/fire-service-safety/j06-written-procedures-and-committee-consultation)), the team cycle (learning team, formal consultation, change notice) meets those duties as a by-product.

### 6.2 Safety division

The safety division verifies that each program meets law and standards, maintains the hazard profile and the audit program, runs the Corrective Action Register, and supports teams with data. It does not own a team’s program and does not sign off on the team’s behalf.

### 6.3 Training division

Assigns a training officer to each team; reviews new curriculum for consistency with department training standards; schedules delivery; keeps training and certification records; reports training costs into the budget worksheet.

### 6.4 Other teams

Teams whose programs touch each other (Respiratory Protection with Protective Clothing and Decontamination; Health and Wellness with Rehab and Psychological Health; Technical Rescue with Working at Heights) hold a joint session at least annually and share their quarterly updates.

## 7. The Equipment Standards, Apparatus and PPE team

This team has a special role. It is the single gate through which supplies, tools, equipment, PPE and apparatus are standardized, reviewed, field tested, recommended and accepted, so that what goes on the apparatus is current, compatible, standard and safe. Because its decisions touch every member, it carries the heaviest duty of engagement and documentation.

- Standing consultants: safety division, JOHSC, union representative, volunteer association representative, training division, and the program team whose discipline the item serves.
- Every request for a new or changed item enters through a request form, is logged, and gets a written disposition.
- Field trials follow section 8. Recommendations go to formal JOHSC consultation when safety-sensitive.
- The team keeps the department equipment standards list and the apparatus manifest standards, with the date and basis of each decision.

## 8. Evidence methods

### 8.1 Research and literature review

1.  Define the question (an equipment item, a technique, a standard, a safety issue).
2.  Search systematically: standards, regulations, peer-reviewed research, NIOSH and other investigation reports, industry research (for example UL FSRI), other departments’ practice.
3.  Appraise quality (a structured tool such as the CASP checklists; the PRISMA 2020 statement for reporting where a full systematic review is warranted) (Critical Appraisal Skills Programme, n.d.; [PRISMA, 2020](https://thehumanfactor.ca/library/fire-service-safety/program-improvement-teams#ref-prisma-2020-statement)).
4.  Synthesize the findings and the gaps.
5.  Report: question, method, findings, implications, recommendation, references.

What a review produces: a short evidence report comparing the department with the standard and with peer practice, and, where a purchase or change follows, the proposal and its business case.

### 8.2 Field trials

Two kinds, never mixed:

| Type | Purpose | Ends with |
|:---|:---|:---|
| Evaluation trial | Test whether a new idea, technique, tool, equipment or PPE item works for the department; build understanding to inform a later procurement | A trial report and recommendation; no product selection |
| Procurement trial | Select a product the department has decided to buy or replace | Requirements and standards, a structured competitive scoring of submissions, and a selection recommendation through the municipality’s procurement rules |

Steps: objective and scope (item, outcomes, criteria, users); trial plan (location, duration, sample, data collection and analysis, consent and safety); preparation (calibration, training, safety check); conduct (data, observation, member feedback); analysis (against criteria); report and recommendation, with the business case where a purchase follows.

## 9. Succession and development

Every team member has a short development plan, reviewed annually by the program manager, against the ten capabilities a program needs from the people who carry it:

| Capability | How it is developed on the team |
|:---|:---|
| Depth in the discipline | Certification path for the discipline; teaching peers |
| Finding and weighing evidence | Completing a literature review or a field trial report |
| Assessing risk | Contributing to the discipline’s hazard profile and risk assessment |
| Planning for the year and the next five | Contributing to the annual work plan and the five-year plan |
| Carrying work through to closure | Owning a work-plan action from start to closure |
| Building the budget case | Preparing a line of the budget worksheet |
| Writing for decision-makers | Drafting a section of the quarterly update or annual appraisal |
| Presenting and explaining change | Presenting at the quarterly or annual review; writing the member-facing change notice |
| Working relationships with other teams, agencies and suppliers | Liaison with an external agency, supplier or another team |
| Leading a team or a session | Leading a project or a learning-team session; acting as lead in the lead’s absence |

**Rules.**

- Every team lead has a named understudy who has acted in the role during the year.
- Membership terms are three years, renewable once; one-third of the team turns over in any year where possible, so knowledge is retained while new members come in.
- Each team includes at least one member from a volunteer or composite station where the department has them.
- A member’s team service and completed development activities are recorded and recognized in promotional and assignment processes as the collective agreement permits.

## 10. Reporting, deliverables and the closed loop

| Deliverable | Accountable | Due | Goes to |
|:---|:---|:---|:---|
| Annual work plan | Program manager | Start of fiscal year | Senior leadership team |
| Monthly briefing | Program manager | Monthly operations meeting | Operations team |
| Quarterly progress update ([Form - Quarterly Program Progress Update](https://thehumanfactor.ca/library/fire-service-safety/form-quarterly-program-progress-update)) | Team lead | Within 15 days of quarter end; Q4 folded into the annual appraisal | Program manager, senior leadership team, JOHSC (for information) |
| Annual program appraisal | Program manager | Two months before the department’s budget submission | Senior leadership team presentation; management review; budget process |
| Discipline hazard profile and risk assessment update | Program manager with team | With the annual appraisal | Hazard register; community risk assessment |
| Standards of cover input (specialty programs) | Program manager with team | With the annual appraisal | Planning and accreditation |
| Research reviews, field trial reports, business cases | Program manager | As proposed or requested | Senior team; Equipment Standards team; JOHSC when safety-sensitive |
| Corrective actions | Program manager | Logged within five working days of identification | [Corrective Action Register](https://thehumanfactor.ca/library/fire-service-safety/corrective-action-register) |
| Records (minutes, attendance, work plans, research, trials, correspondence, training and certification, regulator logs) | Program manager | Contemporaneous | {{Records system}} |

**Quarterly progress update content.** Indicators for the quarter by district and overall; trends, outliers and events needing detailed review; milestones achieved and planned; corrective actions opened, closed and overdue; learning-team sessions held and what they found; training delivered; research and trials; equipment reviewed; JOHSC consultations and outcomes; risks and asks of the senior team.

**Annual program appraisal content.** Program description and outcome statement; staffing and team composition; training and certification status; equipment and PPE status and life cycle; hazard profile and risk changes; indicator results against targets and baseline; SWOT; accomplishments; corrective action status; JOHSC consultation record; lessons learned from events; next year’s milestones by quarter; five-year plan; budget worksheet; development and succession status.

### 10.1 Accountability and closed feedback loop for the teams themselves

| Element | Who | How |
|:---|:---|:---|
| Owner | Fire chief, through the deputy chief of operations | Approves team charters, receives quarterly updates, decides on annual appraisals |
| Doer | Program manager, team lead, members | The cycle in section 4 |
| Verifier | Safety division (program content against law and standards); JOHSC (consultation record, inspection findings); internal audit (annually) | Audit category for each program scores the team’s cycle and records |
| Feedback | Quarterly update to senior team and JOHSC; member change notices; reply to whoever raised an issue | Within 15 days of quarter end; change notices with every adopted change |
| Closure | Corrective Action Register | Every action has an owner, a priority from P1 (Imminent) to P4 (Improvement) and a due date; overdue items escalate on the clock for their priority (a P3 (Moderate) item goes from the program manager to the deputy chief at 30 days overdue and to the fire chief at 60); closure needs evidence and the verifier’s sign-off |
| Member’s concern route | Any member to the team lead, the JOHSC consultant or their officer | Acknowledged within one shift; logged within five working days; the member hears back what was decided and why, by name, before the change notice goes out |

**Loop test.** A firefighter at a volunteer station tells the team lead on Monday that a new SCBA cylinder bracket on a tanker will not release in cold weather. By Friday, the item is in the program’s action log and the Corrective Action Register with an owner and a due date, and the Equipment Standards team and the JOHSC consultant have it. The firefighter has heard back. Within the quarter, the fix has been trialled with the people who use the bracket. A change notice has gone to every station, and the item is closed with evidence and reported in the quarterly update.

**Indicators for the teams.** Quarterly updates on time (target 100 percent); learning-team sessions held per team per year (target at least two); member participation in learning teams by station type (career, volunteer); concerns raised to teams and median days to answer; corrective actions closed with evidence; understudies who acted in the lead role during the year. The psychological-safety measure is the share of team members who agree, in an anonymous annual check, that “I can disagree with the team lead or program manager without it costing me” ([05 Safety Culture Baseline](https://thehumanfactor.ca/library/fire-service-safety/safety-culture-baseline)).

## 11. Budget worksheet

Each team prepares the worksheet annually with the appraisal. Columns: current fiscal year, next fiscal year, years 2, 3 and 4.

| Group | Line | What it covers |
|:---|:---|:---|
| Capital | Equipment replacement due | Standard-issue items reaching their service-life limit, expiry or failed test this period |
| Capital | Equipment additions | Items the team recommends adding to the department standard, with the trial or review that supports each |
| Capital | Program vehicles | Vehicles the program needs, with replacement cost spread over their service life |
| Operating | Service, testing and certification | Inspection, third-party testing, certification and repair the program’s equipment requires each year |
| Operating | Consumables | What response and training use up each year |
| Operating | Protective equipment | Program-specific PPE for new team members and replacement of worn or expired items |
| People | Initial training | Courses that bring new members or a new capability to the required level |
| People | Recurring training and recertification | What keeps current members qualified |
| People | Training time | Wages or honoraria for the hours members spend training |
| People | Shift coverage | Backfill or overtime so operations stay staffed while members train |
| Capacity | Protecting the margin | Staffing, time or equipment that the appraisal identified as keeping the work going right, funded before it erodes |
| Improvement | Trials, studies and outside expertise | Field trials, evidence reviews and specialist advice |
| Other | Anything else | With a note explaining it |
| Annual totals |  |  |

## 12. Terms of reference shell (one per team)

Copy this block into a team charter and complete it. The fielded version is [Form - Program Team Charter](https://thehumanfactor.ca/library/fire-service-safety/form-program-team-charter); the budget worksheet is [Form - Program Team Budget Worksheet](https://thehumanfactor.ca/library/fire-service-safety/form-program-team-budget-worksheet); the annual appraisal is [Form - Annual Program Appraisal](https://thehumanfactor.ca/library/fire-service-safety/form-annual-program-appraisal).

    Team name:                       {{Team}}
    Programs owned:                  (links to the program chapters in Part 5)
    Program manager:                 {{Role}}
    Team lead / understudy:          {{Role}} / {{Role}}
    Members (term ends):             
    Standing consultants:            JOHSC member; safety division; training officer; union rep; volunteer rep; equity adviser; clinician (as applicable)
    Outcome statement:               In one paragraph, what "working" looks like for this program
    Meeting cadence:                 Monthly (minimum), plus learning-team sessions as scheduled
    Decision authority:              What the team decides itself (procedure drafts, trial design, training content proposals);
                                     what goes to the program manager; what goes to the senior team; what needs JOHSC consultation
    Deliverables and due dates:      Section 10 table, with this year's dates
    Indicators:                      From the program module, with baseline and target
    Budget envelope:                 From the approved worksheet
    Records location:                {{Records system}} path
    Rotation and succession:         Terms, understudy, development plans
    Approved:                        Fire chief (role), date; JOHSC consulted, date

## 13. Stage and cost

- **Stage 1:** two or three teams chartered; one learning-team session each; first quarterly update. Cost: member time (about four hours a month per member plus sessions), facilitator training for two or three people.
- **Stage 2:** all applicable programs have a team or a named officer; quarterly updates and annual appraisals on cycle; budget worksheets inform the budget.
- **Stage 3:** team appraisals feed the management review and external review; succession measured (understudies acted, turnover rule met); teams publish lessons to peers.

## Definitions

- **Annual program appraisal.** The yearly written evaluation of a program’s status, results, risks, resources and plans, presented to the senior team and used in the budget cycle; the department’s evidence for accreditation program-appraisal criteria.
- **Evaluation trial.** A field trial that tests whether an idea, technique or item works for the department, ending in a recommendation, not a product selection.
- **Learning team.** A facilitated session with the people who do a task, held to understand how the work is really done before anything is changed.
- **Learning firewall.** The rule that information gathered for learning is never the basis for discipline; conduct concerns go to a separate process run by different people.
- **Procurement trial.** A field trial that selects a product against set requirements through structured competitive scoring.
- **Program Improvement Team.** A standing, line-led team that owns one program’s assessment, design, improvement, reporting and budget input.
- **Program manager.** The line officer accountable for a program and its team.
- **Quarterly progress update.** The team’s quarterly report of indicators, milestones, corrective actions, learning and asks.
- **Work-as-done / work-as-imagined.** The work as people actually perform it, compared with the work as written in procedures or pictured by those who plan it.

## 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 |
|:---|:---|:---|
| Joint Committee and Health and Safety Representative | The committee’s statutory functions, including any duty to take part in developing the OHS program and its policies and procedures | [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 | When written procedures are required, the rules for their adequacy, availability at the work area, review with the people who use them and updating, and whether the committee must be consulted when they are established or reviewed | [J06 Written Procedures and Committee Consultation](https://thehumanfactor.ca/library/fire-service-safety/j06-written-procedures-and-committee-consultation) |

## References

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Dekker, S. (2016). *Just culture: Restoring trust and accountability in your organization* (3rd ed.). CRC Press.

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

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National Fire Protection Association. (2021). *NFPA 1500, Standard on fire department occupational safety, health, and wellness program* (last standalone edition; now part of NFPA 1550). <https://www.nfpa.org/codes-and-standards/nfpa-1500-standard-development/1500>

PRISMA. (2020). *PRISMA 2020 statement*. <https://www.prisma-statement.org>

Reason, J. (1997). *Managing the risks of organizational accidents*. Ashgate.

Vaughan, D. (1996). *The Challenger launch decision: Risky technology, culture, and deviance at NASA*. University of Chicago Press.