Guide for Performance Audits and Special Examinations on Psychological Health and Safety in the Workplace (November 2018)

Contents

Introduction
Purpose of this guide
Applicability and audience of this guide
Auditor’s responsibilities
Background and context
Key terms and concepts
Key terms
Legislative and related requirements
Audit guidance
Why psychological health and safety is important
Identifying and assessing risks for audit selection and/or audit scoping
Recommended audit approach

Introduction

Purpose of this guide

The purpose of this guide is to assist audit teams who have identified a risk that the entity under audit does not have a psychologically healthy and safe workplace, and therefore employees’ physical and psychological health may be negatively affected and make them unable to carry out their functions in an engaged and productive manner. As a result, the audit team is considering and/or planning to carry out audit work in this area.

This guide provides audit teams with

  • an understanding of psychological health and safety, including legislative and related requirements;

  • guidance on determining whether psychological health and safety is an area of risk that should be examined; and

  • a recommended approach to auditing psychological health and safety in the workplace. While this approach is comprehensive, audit teams may wish to tailor it to their audit context in consultation with the Human Resource Management Internal Specialist.

Applicability and audience of this guide

This guide applies to performance audits and special examinations. It is intended for engagement leaders and their respective audit teams.

Auditor’s responsibilities

Per the Direct Engagement Manual section 3081, audit teams are to consult with internal specialists when dealing with matters requiring specialized knowledge and experience.

Background and context

Key terms and concepts

Key terms

Mental health is “a state of well-being in which the individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully and is able to make a contribution to her or his own community.”1

Mental illnesses can take several forms, such as depression, anxiety, addiction, phobias and panic disorders, and post-traumatic stress disorder (PTSD).

A psychologically healthy and safe workplace is “one that promotes employees’ psychological well-being and actively works to prevent harm to employee psychological health due to negligent, reckless, or intentional acts.”2

Psychological health and safety good practices

The National Standard of Canada for Psychological Health and Safety in the Workplace provides a framework to create and continually improve psychological health and safety in the workplace. The framework includes the following:3

  • identifying and eliminating hazards in the workplace that pose a risk of psychological harm to a worker;

  • assessing and controlling the risks in the workplace associated with hazards that cannot be eliminated (e.g., stressors due to organizational change or reasonable job demands);

  • implementing structures and practices that support and promote psychological health and safety in the workplace; and

  • fostering a culture that promotes psychological health and safety in the workplace.

Legislative and related requirements

While there is no legislation that governs psychological health and safety in the federal public service, in 2016, the Government of Canada adopted the Federal Public Service Workplace Mental Health Strategy, which establishes responsibilities for deputy heads to improve psychological health and safety in the workplace. The Strategy focuses on three strategic goals:

  • changing culture to be respectful to the mental health of all colleagues,
  • building capacity with tools and resources for employees at all levels, and
  • measuring and reporting on actions.

To achieve these goals, the Strategy sets out a number of organization-specific activities that deputy heads must undertake in order to promote positive mental health and prevent psychological harm due to workplace factors. These activities are organized by strategic goal, and include the following:4

Organization-specific activities related to changing culture to be respectful to the mental health of all colleagues:

  • Appoint a champion and demonstrate sustained and visible leadership consistent with the roles and responsibilities expected of the position.

  • Raise awareness of the mental health continuum in the workplace and of available workplace health support services.

  • Engage employees and occupational health and safety committees, and promote employee participation in psychological health and safety actions and measures in each workplace and work location.

Organization-specific activities related to building capacity with tools and resources for employees at all levels:

  • Identify organizational needs and provide employees with the proper training and tools to identify their own strengths and areas where mental health can be improved to help face day-to-day stressors and challenges, including resiliency, support for each other, and support for the public.

  • Educate and equip managers and occupational health and safety committees with tools to ensure timely and appropriate identification of risks to reduce harm and appropriate responses to employee needs and workplace incidents.

  • Ensure early intervention and active case management, including stay-at-work and return-to-work practices.

Organization-specific activities related to measuring and reporting on actions:

  • Review available data and current workplace programs, policies, and practices to identify risks and areas for improvement.

  • Implement corrective action to address risks and improve psychological health and safety in the workplace.

  • Establish regular transparent reporting around key data points and indicators.

As part of the government’s focus on mental health, a new measure on workplace health was added to the people management component of the Management Accountability Framework in the 2016–17 fiscal year. The Framework states that a healthy workplace is essential to the physical and psychological health of federal public service employees, and is the underpinning of an effective, productive, and engaged federal public service. The Framework measures this through two indicators, which will be reported on annually by the Treasury Board of Canada Secretariat:5

  • Average number of paid sick days per full-time equivalent (FTE)
    • average number of certified paid sick days6 per FTE
    • average number of uncertified paid sick days per FTE
    • average number of certified and uncertified (total) paid sick days per FTE
  • What does the organization do to support open and stigma-free dialogues in the workplace on mental health?

    • Develop an action plan on mental health?

    • Appoint a champion for mental health?

    • Educate and equip managers, supervisors, and occupational health and safety committee members, including through information sessions?

    • Offer mental health awareness sessions to employees including available workplace health support services?

Mental health was also referenced in the Clerk of the Privy Council’s 23rd and 24th Annual Reports to the Prime Minister on the Public Service of Canada. In both reports, the Clerk confirmed his commitment to making mental health and workplace well-being a priority in order to build a healthier, more respectful, and supportive work environment that strengthens the public service. He referenced a number of initiatives underway in this respect, including:

  • a Federal Public Service Workplace Mental Health Strategy,

  • a new Treasury Board of Canada Secretariat Public Service Employee Annual Survey,

  • a new Centre of Expertise on Mental Health in the Workplace, and

  • the requirement of all deputy ministers and executives to take action on mental health and workplace well-being as part of their performance agreements.7

Audit guidance

Why psychological health and safety is important

As indicated in the Federal Public Service Workplace Mental Health Strategy, in order for Canada’s public service to be engaged and productive, it needs to have a workplace that is healthy. A healthy workplace is essential to the physical and psychological health of all public service employees, as it enables them to bring the best of their diverse talents, skills, and energy as they deliver services to Canadians.8A psychologically healthy and safe workplace leads to enhanced employee engagement, morale, recruitment, retention, and productivity, while it reduces absenteeism, grievances, health costs, sick leave usage, and workplace injuries.9

If an organization does not have a psychologically healthy and safe workplace, this could

  • reduce employee productivity, which could lead organizations to place an over-reliance on other staff and/or temporary, more costly resources (e.g., overtime and contractors) to carry out the work; and

  • affect employees’ mental health and morale, which could lead to increased sick leave usage, disability claims, and employee turnover. Currently, psychological health challenges account for approximately half of all approved disability claims in Canada’s public service.10

Taken together, these consequences result in higher costs to complete the work and create an unproductive, unstable, and unhealthy workplace, all of which may contribute to inefficient delivery of services to Canadians.

Identifying and assessing risks for audit selection and/or audit scoping

To help determine whether psychological health and safety is a risk that should be considered for audit, audit teams should ask the following questions:

  • Does the organization have a mental health policy and/or strategy in place?

  • Has the organization fulfilled the requirements of the Federal Public Service Workplace Mental Health Strategy? Specifically, has the organization:

    • Appointed a champion for mental health?

    • Raised awareness of mental health and available workplace health support services?

    • Promoted employee participation in psychological health and safety actions and measures?

    • Provided training and tools to managers and employees on mental health?

    • Ensured early intervention and active case management for employees dealing with mental health issues?

    • Identified areas for improvement and developed and implemented an action plan(s) to address risks and improve psychological health and safety in the workplace?

    • Established indicators and regular reporting on mental health?

  • Has the organization committed the resources necessary to meet the Federal Public Service Workplace Mental Health Strategy?

  • Do Deputy Minister and executive performance agreements include an objective on establishing and maintaining a psychologically healthy and safe workplace?

  • Does the organization participate in the new Treasury Board of Canada Secretariat employee annual survey focused on respect, diversity, and well-being?

  • Does the organization periodically evaluate its mental health strategy and/or action plan(s) to determine whether they are achieving intended results, and make adjustments as required?

  • Do employee survey results and exit interviews indicate problems with psychological health and safety?

  • Is sick leave usage and absenteeism high and/or increasing?

  • Are harassment complaints high and/or increasing?

  • Do Employee Assistance Program results show a high or increasing use of these services for mental health reasons?

Audit teams should request and review relevant documents, such as:

  • Mental health policy and/or strategy (if available)

  • Name and position of the champion for mental health, and the description of the champion’s roles and responsibilities

  • Documentation that provides evidence of the organization’s efforts to increase and promote awareness of psychological health and safety and available workplace health support services

  • Training materials and tools related to mental health awareness training and learning, along with attendance records and evaluations

  • Documentation that explains how the organization ensures early intervention and active case management for employees dealing with mental health issues

  • Performance indicators that are being used to measure and report on the status of psychological health and safety in the workplace

  • Evaluations and analyses that assess the effectiveness of the organization’s mental health strategy and/or action plans to improve psychological health and safety in the workplace

  • Action plan(s) to address risks identified and improve psychological health and safety in the workplace and related documentation

  • Reports to senior management on the status of the organization’s mental health strategy and/or action plan(s) and related activities

  • Documentation that shows the commitment of resources (financial and human) to implement the Federal Public Service Workplace Mental Health Strategy and the organization’s own mental health strategy (if applicable)

  • Deputy Minister and executive performance agreements for the last fiscal year

  • Most recent employee survey results (Treasury Board of Canada Secretariat public service triennial and new annual survey, Guarding Minds at Work survey (if applicable))

  • Summary of exit interviews

  • Data on sick leave usage and the number and nature of harassment complaints for the last two fiscal years

  • Employee Assistance Program summary results for the last two fiscal years

  • Corporate risk profile and risk register

Recommended audit approach

The tables below outline the audit criterion and sources, as well as the audit questions, key interview questions and documentation, and audit steps and techniques recommended to carry out the examination work on psychological health and safety.

Audit Criterion and Sources

Audit criterion: The organization provides a psychologically healthy and safe workplace for all employees.

Sources

NOTE: Also refer to the organization’s own mental health policy and/or strategy (if available) for criterion sources.

Federal Public Service Workplace Mental Health Strategy, 2016 (https://www.canada.ca/en/treasury-board-secretariat/services/healthy-workplace/workplace-wellness/mental-health-workplace/federal-public-service-workplace-mental-health-strategy.html)

“Deputy Heads will be expected to promote positive mental health and prevent psychological harm due to workplace factors (…)”

“As a first step, Deputy Heads will be expected to demonstrate visible and sustained leadership commitment, engage senior management, managers and employees, and promote healthy workplace activities.”

“We must consider psychological health and safety in every aspect of work within the federal public service. Employees must feel free and able to raise concerns and seek help when they need to, in an environment free from stigma.”

“We must provide the right training, tools and other resources for staff and managers to promote mental health, enhance resiliency, prevent harm, and address incidents and concerns.”

“We must agree on a modest number of indicators that we can use to measure progress, frequently take the pulse of our organizations and our workforce, and be transparent about progress.”

Mental Health Commission of Canada (https://www.mentalhealthcommission.ca/English/national-standard)

“Ensuring good psychological health and safety in the workplace is vitally important for all Canadians.”

National Standard of Canada for Psychological Health and Safety in the Workplace, 201311

“The vision for a psychologically healthy and safe workplace is one that actively works to prevent harm to worker psychological health, including negligent, reckless, or intentional ways, and promote psychological well-being.”
Audit Question Key Interview Questions and Documentation Audit Steps and Techniques

Q1—Does the organization have a mental health policy and/or strategy in place?

NOTE: Organizations are not legally required to have a mental health policy or strategy but some do. If the audit entity does have one, respond to Q1; if not, move to Q2.

Key interview questions

  • Is the strategy reasonable? That is, does it include objectives or priorities, the programs and activities to achieve those objectives, timelines, and a plan for how progress and success will be measured and monitored?

  • Does the policy and/or strategy clearly define the roles and responsibilities for psychological health and safety in the workplace?

  • Are roles and responsibilities for psychological health and safety communicated to those responsible, and if so, how?

  • Is the strategy designed based on information about the organization’s psychological health and safety (i.e., was baseline data collected and analyzed to understand the current state and to determine the desired state)? Baseline data may include the number of harassment complaints, the number of disability claims related to mental health, sick leave usage, employee survey results, Employee Assistance Program usage for mental health reasons, and other risk factors as identified by the National Standard of Canada for Psychological Health and Safety in the Workplace.12

Key documentation

  • Mental health policy and/or strategy

  • Baseline data that was used to assess the organization’s psychological health and safety and to develop the organization’s mental health strategy

  • Communications to staff regarding their roles and responsibilities for psychological health and safety

Request and review documentation.

Interview

  • Officials responsible for psychological health and safety; e.g., VP HR, HR Director / Manager / Advisor

  • Senior / line managers

Assess whether the organization has a mental health policy and/or strategy in place, and if so, whether it is reasonable; i.e., it includes objectives or priorities, the programs and activities to achieve those objectives, timelines, and a plan for how progress and success will be measured and monitored. Also assess whether and what baseline data was used to assess the organization’s health and safety and to develop the organization’s mental health strategy.

Assess whether roles and responsibilities are clearly defined and communicated to those responsible for psychological health and safety.

Document observations and respond to audit question.

Q2—Has the organization carried out the specific activities required by the Federal Public Service Workplace Mental Health Strategy related to

  • changing the culture to be respectful to the mental health of all colleagues,

  • building capacity with tools and resources for employees at all levels, and

  • measuring and reporting on actions?

Key interview questions

  • As required by the Federal Public Service Workplace Mental Health Strategy, has the organization:

    • Appointed a champion for mental health?

    • Raised awareness of psychological health and safety and available workplace health support services?

    • Promoted employee participation in psychological health and safety actions and measures?

    • Provided training and tools to managers and employees on mental health?

    • Ensured early intervention and active case management for employees dealing with mental health issues?

    • Identified areas for improvement and developed and implemented an action plan(s) to address risks and improve psychological health and safety in the workplace?

    • Established indicators and regular reporting on mental health? Indicators may include the number of harassment complaints, the number of disability claims related to mental health, sick leave usage, employee survey results, Employee Assistance Program usage for mental health reasons, and other risk factors as identified by the National Standard of Canada for Psychological Health and Safety in the Workplace.13

  • Has the organization committed the resources (financial and human) needed to meet the Federal Public Service Workplace Mental Health Strategy?

  • Did the organization use the National Standard of Canada for Psychological Health and Safety in the Workplacein developing its mental health strategy and/or action plan(s) to improve psychological health and safety in the workplace?

Key documentation

  • Name and position of the champion for mental health.

  • Documentation that provides evidence of the organization’s efforts to increase and promote awareness of psychological health and safety and available workplace health support services (e.g., mental health awareness sessions, communiqués, Intranet, other correspondence).

  • Training materials and tools related to mental health awareness training and learning, along with attendance records and evaluations.

  • Documentation that explains how the organization ensures early intervention and active case management for employees dealing with mental health issues.

  • Documentation that explains areas for improvement and action plans to address risks identified and improve psychological health and safety in the workplace.

  • Performance indicators that are being used to measure and monitor psychological health and safety.

  • Reports to senior management on psychological health and safety.

  • National Standard of Canada for Psychological Health and Safety in the Workplace.

  • Other relevant documentation, e.g.

    • senior management committee documentation (agendas, minutes, presentations and reports discussed, records of decisions);

    • HR committee meeting documentation;

    • relevant internal audits or evaluations of psychological health and safety in the workplace.

Request and review documentation.

Interview

  • Officials responsible for psychological health and safety; e.g., VP HR, HR Director / Manager / Advisor

  • Senior / line managers

Assess whether the organization has fulfilled the requirements of the Federal Public Service Workplace Mental Health Strategy. Specifically, assess whether the organization carried out the specific activities related to:

  • changing culture to be respectful to the mental health of all colleagues,

  • building capacity with tools and resources for employees at all levels, and

  • measuring and reporting on actions.

Assess whether the organization has committed the resources (financial and human) it needs to meet the Strategy’s requirements.

Document observations and respond to audit question.

Q3—Are the organization’s Deputy Minister and executives assessed on whether they have established and maintained a psychologically healthy and safe workplace in their performance agreements?

Key interview questions

  • Do the Deputy Minister and executives’ performance agreements include an objective on establishing and maintaining a psychologically healthy and safe workplace?

  • Are the organization’s Deputy Minister and executives being assessed against this objective at year end?

  • Is performance pay tied to the achievement of this objective?

Key documentation

  • Deputy Minister and executive performance agreements for the last fiscal year (both the objectives and the final assessment).

Request and review documentation.

Interview

  • Officials responsible for psychological health and safety and/or executive performance management; e.g., VP HR, HR Director / Manager / Advisor

  • Senior managers

Assess whether the organization’s Deputy Minister and executives are evaluated on whether they have established and maintained a psychologically healthy and safe workplace in their performance agreements.

Document observations and respond to audit question.

Q4—Does the organization monitor the implementation of its mental health strategy and/or action plans and related activities to determine whether they are achieving intended results, and make adjustments as required?

Key interview questions

  • How does the organization monitor its mental health strategy and/or action plans and related activities to determine whether they are achieving intended results? How often is this done?

  • What performance indicators and/or other measures are being used to monitor progress? (Cross-reference with Q2.)

  • Does the organization participate in the annual employee survey focused on respect, diversity, and well-being? (Note: this annual survey was introduced in 2017.)

  • What information systems (electronic or paper-based) exist to document mental health activities and results?

  • Does the organization have data quality systems and practices in place to ensure the integrity of HR data, including mental health-related data?

  • Are results from the evaluations of the organization’s mental health strategy and/or action plans and activities used to make adjustments as required?

  • Are results reported to senior management? How and how often?

Key documentation

  • Documentation that explains how the organization’s mental health strategy and/or action plans and activities are monitored and assessed.

  • Performance indicators used to monitor progress in improving psychological health and safety in the workplace.

  • Reviews of the organization’s mental health strategy and/or action plans and activities for the last fiscal year.

  • Reports to senior management on the organization’s mental health strategy and/or action plans and activities, including any improvements and adjustments proposed.

  • Other relevant documentation, e.g.

    • senior management committee documentation (agendas, minutes, presentations and reports discussed, records of decisions);

    • HR committee meeting documentation;

    • relevant internal audits or evaluations of the organization’s mental health strategy and/or action plans and related activities.

Request and review documentation.

Interview

  • Officials responsible for psychological health and safety; e.g., VP HR, HR Director / Manager / Advisor

  • Senior / line managers

Perform a walkthrough of key HR information systems (electronic or paper-based) that collect and maintain mental health-related data (including workforce data) to determine what information exists, its quality, and how it is used and reported on, if this was not already done in the planning phase.

Document observations and respond to audit question.

1 National Standard of Canada for Psychological Health and Safety in the Workplace, 2013

2 Guarding Minds at Work: https://www.guardingmindsatwork.ca/about/about-safety

3 National Standard of Canada for Psychological Health and Safety in the Workplace, 2013

4 Federal Public Service Workplace Mental Health Strategy, 2016: https://www.canada.ca/en/treasury-board-secretariat/services/healthy-workplace/workplace-wellness/mental-health-workplace/federal-public-service-workplace-mental-health-strategy.html

5 Management Accountability Framework: https://www.canada.ca/en/treasury-board-secretariat/services/management-accountability-framework.html

6 A certified sick day is one where a medical certificate is required in order to grant the sick leave.

7 Twenty-Third Annual Report to the Prime Minister on the Public Service of Canada: https://www.canada.ca/en/privy-council/corporate/clerk/publications/2016-annual-report-landing-page.html; Twenty-Fourth Annual Report to the Prime Minister on the Public Service of Canada: https://www.canada.ca/en/privy-council/corporate/clerk/publications/2017-annual-report-landing-page.html

8 Federal Public Service Workplace Mental Health Strategy, 2016: https://www.canada.ca/en/treasury-board-secretariat/services/healthy-workplace/workplace-wellness/mental-health-workplace/federal-public-service-workplace-mental-health-strategy.html

9 “Mental health in the workplace,” Employment and Social Development Canada: https://www.canada.ca/en/employment-social-development/services/health-safety/mental-health.html

10 Federal Public Service Workplace Mental Health Strategy, 2016: https://www.canada.ca/en/treasury-board-secretariat/services/healthy-workplace/workplace-wellness/mental-health-workplace/federal-public-service-workplace-mental-health-strategy.html

11 https://www.mentalhealthcommission.ca/English/national-standard

12 National Standard of Canada for Psychological Health and Safety in the Workplace, 2013 (section 4.3.4.1). Factors to assess should include, but are not limited to, the following:

  1. psychological support;
  2. organizational culture;
  3. clear leadership and expectations;
  4. civility and respect;
  5. psychological job demands;
  6. growth and development;
  7. recognition and reward;
  8. involvement and influence;
  9. workload management;
  10. engagement;
  11. work / life balance;
  12. psychological protection from violence, bullying, and harassment;
  13. protection of physical safety; and
  14. other chronic stressors as identified by workers.

13 National Standard of Canada for Psychological Health and Safety in the Workplace, 2013 (section 4.3.4.1). Factors to assess should include, but are not limited to, the following:

  1. psychological support;
  2. organizational culture;
  3. clear leadership and expectations;
  4. civility and respect;
  5. psychological job demands;
  6. growth and development;
  7. recognition and reward;
  8. involvement and influence;
  9. workload management;
  10. engagement;
  11. work / life balance;
  12. psychological protection from violence, bullying, and harassment;
  13. protection of physical safety; and
  14. other chronic stressors as identified by workers.