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Appendix E – Audit Elements of Effective Management of Change Procedure

  • Issued: April 15, 2015
  • Content last reviewed: April 2015
  • See also: Final Report

These audit elements were compiled by the Review to serve as a guideline for industry use.

1. Organizational commitment and mandate to a Management of Change (MOC) process.

It is the employer’s responsibility to implement and ensure compliance with effective processes and management systems for prevention of unauthorized change. Assurance activities that check the management systems effectiveness attest to management’s commitment to the mandate.

  • 1.1 Policy endorsed and supported by the site management.
  • 1.2 Procedure defines all roles within the MOC process including the Joint Health and Safety Committee and workers affected by change.
  • 1.3 Established MOC training provided to all levels within the workforce (including workers, supervisors and process and subject matter experts)

2. Management of Change Process Developed.

The process provides a means for workers to understand how the policy is to be applied, company expectations and their role. The process operationalises the company mandate and policy. Without process there is no means for workers to adhere to mandate and expectations.

  • 2.1 Process developed with input from key company stakeholders.
  • 2.2 Method and criteria established that define “change” and when the process is to be applied.
    • flow chart to describe the process
    • organizational change is included in definition of change
    • differentiate between short term (emergency changes) and permanent changes
    • change request aligned to the business unit objectives
  • 2.3 Objective and risk identified supporting the need for change.
  • 2.4 Criteria to define level of review rigor depending on the degree of impact.
  • 2.5 Procedure gives examples of the different levels of change.
  • 2.6 Procedure requires that the technical basis of the proposed change be described.
  • 2.7 Change details and assessment and approval for each MOC is captured and retained in a document format.
  • 2.8 Process owner is identified.
  • 2.9 Skilled facilitator is identified for the MOC process (to ensure that the MOC process is being properly followed).

3. Hazard and Risk Assessment requirements of MOC.

Knowledgeable persons or subject matter experts need to determine whether the change will in fact lower risk and not introduce other new risks. This assessment information enables effective decision making. Consideration for Risk Assessments:

  • 3.1 Process assesses the risk level of the current situation against the hazards and risks associated with the proposed change.
  • 3.2 Procedure specifies the method of hazard identification and risk assessment appropriate for the change proposed.
  • 3.3 The hazard and risk assessment method utilizes established internal severity and likelihood criteria.
  • 3.4 Means to trigger additional or more rigorous risk assessments.

4. Review team composition defined in MOC.

A diverse team of knowledgeable persons and stakeholders involved in the change review will have high likelihood of identifying potential risks and developing solutions to mitigate the risk. Consideration for team composition:

  • 4.1 Composition of the review team changes with the potential severity or magnitude of the change.
  • 4.2 Engage the appropriate knowledgeable persons in the change review
    • front line workers and supervisors impacted by the proposed change
    • representatives of the health and safety team
    • specialists, engineers, subject matter experts, individuals trained to lead the MOC etc.
  • 4.3 Guidance to define what constitutes an effective team.

5. Defined Change approval process.

In order to prevent uncontrolled change, it must be clearly understood by all that no change is to be implemented without management approval. Management representatives must recognize the importance of conducting thorough assessments prior to initiating change and the significance of providing approval for change.

  • 5.1 Sign-off authority for the change varies with the magnitude of the change (process defines who has the authority to approve change).

6. Implementation plan for the intended change.

Most change is implemented to improve performance. This step is intended to ensure no additional risks materialize as a result of incomplete implementation. Change can produce adverse results if the appropriate change measures are not put in place. Risk events of this nature often materialize as a result of the workforce not being made aware of the change. Consideration for implementation plan:

  • 6.1 Timeline established for the change process.
  • 6.2 Identification of tasks to be done before, during and after implementation. (examples: update as-built diagrams, procedures, workforce communication, etc.)
  • 6.3 Communication plan.

7. Follow up to the change.

The Change Owner (as company representative) must apply due diligence in this respect to provide assurance of complete and effective change implementation. Consideration for follow-up step:

  • 7.1 Verify completeness such as the updating of standard operating procedures, training material, drawings etc.
  • 7.2 Evaluate effectiveness of change.
  • 7.3 Capture any suggestions for improvements to the MOC process prior to closing off the initiative.

8. Monitoring the effectiveness of the MOC process.

The employer has implemented a Management of Change system. In addition to mandating policy, they must also monitor compliance to the policy and be assured of the management system’s effectiveness. The employer must act on/correct any process defects identified. Assurance activities need to be identified and implemented along with a means to review assurance activities and develop process improvement plans as required. Consideration for monitoring process:

  • 8.1 Requirement to assess the effectiveness of the MOC process.
  • 8.2 Method or process to identify and investigate incidents where change occurred and the MOC process was not followed, to enable management to correct MOC process findings.
  • 8.3 Performance indicators developed to review compliance and effectiveness of the MOC process.

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