13.1 Health and Safety at Work

13.1 Health and Safety at Work Act 2015

Practices compliant with the Health and Safety at Work Act 2015 (the Act), provide an accessible, comfortable and safe environment for patients.

Standard - what we'll be assessing on Evidence to provide for assessment

The practice complies with the Health and Safety at Work Act 2015.

  • A documented health and safety policy and hazard and risks register.
  • A record of any health and safety incidents (including ‘near misses’) and resultant actions taken.
  • Completed team training records including certification of any required training, for example; health and safety representative, if applicable. 
  • A documented induction plan and process for all team members, including GPEP registrars and volunteers.

The Health and Safety at Work Act 2015

Practices compliant with the Health and Safety at Work Act 2015 (the Act), provide an accessible, comfortable and safe environment for patients.

The Act recognises that to improve health and safety we need to work together and establish better leadership, participation in, and accountability for people’s health and safety.

The Act is essentially about reducing harm in New Zealand workplaces and introduces new responsibilities for managing work-related risks that could cause serious injury, illness or even death.

To summarise, the Act:

  • ensures everyone has a role to play
  • makes sure everyone’s responsibilities are clear
  • focuses on managing work risk
  • requires those who create the risk to manage the risk
  • requires businesses to engage with workers and enables the workers to actively participate in health and safety
  • allows flexibility in managing health and safety risks.

Health and safety committee

A health and safety committee:

  • needs to be in place if five or more workers request it
  • the committee cooperates with workers and business owners
  • works together to develop policies and procedures'
  • makes recommendations.

PCBU (Person Conducting a Business or Undertaking)

A PCBU has the ‘primary duty of care’ (primary responsibility for people’s health and safety at work). The PCBU must ensure the health and safety of:

  • their primary workforce
  • any other workers (for example, contractors or volunteers)
  • people who could be put at risk for example, patients, visitors, or the general public.

The primary duty of care is a broad, overarching duty and includes providing and maintaining:

  • a work environment that is without risk to health and safety
  • safe structures
  • safe systems of work.
  • adequate facilities for the welfare of workers at work

The Health and Safety Officer

A PCBU is required to have a health and safety officer. The Health and Safety Officer has a vested interest in the practice and is usually the owner/business partner, however, this may vary depending on the organisational structure, especially with corporate style practices. The Health and Safety Officer needs to be able to make financial decisions and supply resources to ensure health and safety is maintained in the workplace.

If the PCBU and/or Health and Safety Officer do not fulfil their duty of care, this breach could result in a work-related event.

  • A breach of due diligence is a criminal offence attracting a maximum penalty of $600,000 and up to five years’ imprisonment for serious offences
  • These penalties are imposed on Health and Safety Officers personally and are over and above any penalty that is imposed on the PCBU arising from any incident .

Worker engagement and participation 

Workplaces have better health and safety outcomes when workers have a say about health and safety. Workers are the eyes and ears of the business and know where the health and safety pressure points are.

Some general practices use a team approach to health and safety responsibilities.  For example:

  • A monitor: checks for hazards and updates the hazards and risks register
  • A coordinator: organises meetings, reports to the Health and Safety Officer and communicates with the team
  • An officer: understands health and safety requirements, sits on the clinical governance team and reports to the PCBU

A health and safety representative (optional): inputs into all health and safety processes and has the power to close the workplace if they consider it to be unsafe

Notifying Worksafe

WorkSafe is the regulator of the workplace health and safety system. They work collaboratively with business and provide training and resources.

WorkSafe must be notified when work-related events cause:

  • a death
  • a notifiable injury or illness
  • a notifiable incident.

Health and Safety Policy

The Health and Safety Policy must include:

  • a policy statement
  • practice team members’ roles and responsibilities
  • health and Safety Officer identified and process for reporting
  • how workers are engaged in health and safety and participate in risk management
  • systems to manage and control risk
  • how health and safety in the workplace is monitored and actioned as required
  • how team members are trained to safely use hazardous substances in the workplace
  • reference to the hazards and risk register.

Risks and hazards register

The first step in managing health and safety is to identify the risks in the practice and using a matrix, assess the likelihood of serious injury or illness.

The five steps to managing risk:

  1. Identify hazards in all work areas in the practice
  2. Assess the risk level of risk each hazard identified
  3. Control the risk to reduce the harm and its severity
  4. Reassess the level of risk for each hazard

Review and monitor that the controls are working and risk levels are acceptable
Regularly review the accident and incident register to identify the hazards that cause harm. It is important to involve team members in identifying hazards and risks when compiling the risks and hazards register.

The risks and hazards register is to be reviewed and updated 6 -12 monthly or earlier if needed, for example, when the practice introduces a new piece of equipment or work process.

The register must list all potential hazards to team members, visitors, patients and contractors along with a rating for the risk of each hazard and how the practice plans to control and manage them.

Incidents/accidents and near misses

In healthcare, incidents, accidents and near misses will occur. When they do, the response should include open disclosure and be one of learning and reducing risk for future patients, team members and other visitors to general practices.

Under the Health and Safety at Work Act 2015, employers must have records for all work-related accidents and take reasonable steps to resolve the cause for the future.

By having this information in an easy to understand format, the Health and Safety Officer along with the clinical governance group, can identify the problem and take actions to reduce the risk of injury, fatality and illness. These actions can be incorporated into the practice’s quality plan.


In the event of an epidemic or pandemic the practice will update the risk register on a continuous basis as the pandemic evolves and practice processes are reviewed.

Examples of pandemic risks could include patient safety, team members health and safety, wellbeing of team members, quality of patient care and business continuity.

Training and induction

Practice team members are familiar with the practices Health and Safety policy and the Health and Safety at Work Act.

If the practice has over 20 employees and a team member requests it, a trained Health and Safety Representative is to be appointed.


Health and safety must be included in the induction of all new team members (including College registrars) and include information on:

  • the Health and Safety Policy
  • the Health and Safety at Work Act
  • roles and responsibilities of team members
  • the hazards and risks register
  • hazardous substances training (either in-house or external, as applicable).