Standards for designated entities
These standards apply to organizations designated under section 22.5 of the Occupational Health and Safety Act as safe workplace associations, medical clinics or training centres specializing in occupational health and safety matters.
Published: December 1, 2024
Preamble
The Ontario Minister of Labour, Immigration, Training and Skills Development (Minister) is authorized under section 22.5 of the Occupational Health and Safety Act (OHSA) to designate an entity as a safe workplace association (SWA), medical clinic or training centre specializing in occupational health and safety matters if the entity meets the Standards for Designated Entities (standards) established by the Minister. A designated entity shall operate in accordance with the established standards that apply to it, and in accordance with any other direction issued under section 22.6 of the OHSA.
Standards for Designated Entities, as established under section 22.5 of the OHSA, may be revised or amended by the Minister. The standards set out herein apply to all designated entities operating as a SWA, medical clinic or training centre, are effective December 1, 2024, and supersede all prior versions. These standards continue to be in effect until amended, at which time compliance with the amended standards will be required.
Pursuant to section 22.7 of the OHSA, the Chief Prevention Officer (CPO) has an on-going responsibility to monitor the operation of all designated entities, including those operating as a SWA, medical clinic and training centre and, in this regard:
- may require a designated entity to provide such information, records or accounts as the CPO specifies
- may make such inquiries and examinations as the CPO considers necessary
- shall report to the Minister on compliance of all designated entities with the standards established under section 22.5 of the OHSA and with directions given by the Minister or CPO under section 22.6
All designated entities shall be on notice that any of the remedies outlined in sub-section 22.6 (3) of the OHSA, including the reduction or termination of the entity’s funding, may be invoked at the discretion of the Minister for failure to meet any standard or written direction under section 22.6 of the OHSA or for any other reason specified in the Act.
1. Governance
- Every designated entity shall incorporate and continue under the Not-for-Profit Corporations Act, 2010 as a not-for-profit corporation without share capital and shall comply with all applicable laws.
- Every designated entity shall enact or amend articles of incorporation and corporate by-laws in accordance with the Not-for-Profit Corporations Act, 2010 that:
- set out all governing functions, duties, and responsibilities
- require members of the entity’s Board of Directors to serve without remuneration or compensation from any source in relation to the designated entity, except as permitted by section 1.6
- specify that upon dissolution of the entity, all remaining assets, after payment of the entity’s liabilities, shall revert to the Ministry of Labour, Immigration, Training and Skills Development (Ministry) for subsequent distribution to the Workplace Safety and Insurance Board (WSIB)
- ensure governance continuity, while at the same time, allowing for the renewal of the entity’s Board, based on recognized governance practices
- Every designated entity shall take steps to have a Board of Directors that:
- is knowledgeable on current occupational health and safety issues within Ontario workplaces, with consideration of worker, sectoral, geographic and equity group (as defined in the glossary of terms) perspectives
- includes competencies in the areas of law, financial/resource management controllership, accounting, risk management and strategic and operational planning
- is of optimum size for ensuring the effective and efficient functioning of a Board based on recognized governance practices (approximately 12–18 members)
- In addition to the governance set out in 1.3 above, a designated medical clinic shall take steps to have a Board of Directors that reflects its status as an organization providing clinical consultation, technical assistance and diagnostic services to its clients throughout Ontario, including workers, joint health and safety committees, unions, employers, medical professionals, community groups, legal clinics, students, and members of the public.
- In addition to the governance set out in 1.3 above, a designated training centre shall take steps to have a Board of Directors that reflects its status as a worker-focused organization responsive to the health and safety needs of its worker clients throughout the province.
- Every designated entity shall have a policy in place governing the reimbursement of business-related expenses of its Board of Directors consistent with the mandatory requirements of the Broader Public Sector Expenses Directive issued on January 1, 2020, and as may be amended from time to time.
- Every designated entity shall operate in accordance with its by-laws.
- Every designated entity shall have sub-committees of its Board of Directors that report directly to the Board and are dedicated to the functions of finance and/or audit and/or human resources (as defined in the glossary of terms).
- Every designated entity shall provide to the CPO on an on-going basis:
- a copy of its articles of incorporation, corporate by-laws, and any Board-approved amendments to said articles and by-laws
- an up-to-date list and background profile of all members of its Board of Directors, including contact information
- immediate notification of vacancies on its Board of Directors
- advance copies of the agenda of all Board of Director meetings, one week prior to the Board meeting
- Every designated entity shall implement effective governance performance as demonstrated in accordance with a measurement framework and timelines specified by the CPO from time to time.
- Every designated entity shall implement effective internal financial, administrative and operational controls as demonstrated in accordance with a measurement framework and timelines specified by the CPO from time to time. The CPO may request an independent audit and/or any other mechanism to confirm that effective internal financial, administrative and operational controls are in place.
- Every designated entity shall adhere to a CPO-approved policy respecting recruitment and compensation of its Chief Executive Officer (CEO) or equivalent position. To enhance the designated entity’s reputation of being an equal opportunity employer and an employer of choice, the policy shall require the following:
- competitive recruitment and selection guidelines and procedures that ensure a process that is equitable, free from conflict of interest, transparent and designed to provide evidence of the required competencies
- that candidates, whether internal or external to the organization, be assessed by a selection panel comprised of individuals who are informed about effective and equitable recruitment processes
- that the CPO or such delegate as the CPO may identify, is to be represented on the assembled selection panel as a fully participating member of the panel
- that the CEO or CEO-equivalent be selected on the basis of evidence that demonstrates relevant knowledge, skills, competencies, experience and qualifications required for successful job performance and the achievement of corporate goals and objectives
- that the minimum and maximum range of total compensation for the CEO, or CEO-equivalent positions of the designated entity, including maximum levels for base salary, earnable incentives/bonuses and benefits, shall be those established and set by the CPO
- that decisions relating to annual adjustments to CEO or CEO-equivalent base salaries, as well as earnable incentives/bonuses and benefits, shall be the responsibility of the designated entity’s Board of Directors, based on a formalized and well-documented performance management process and subject to the following:
- annual adjustments shall not result in total compensation exceeding the maximum ranges set by the CPO under clause (e)
- performance-related increases shall be reasonable, defensible and applied in accordance with a system-wide performance pay policy developed by the CPO consistent with the spirit and intent of the Broader Public Sector Executive Compensation Act, 2014 and the regulation under that Act regarding compensation frameworks (406/18)
- annual adjustments shall also conform to any direction issued by the Ministry under section 22.6 of the OHSA on compensation restraint, including those in respect to base salary increases and/or earnable incentives and bonuses, which, at the discretion of the Ministry, may be eliminated or limited in their amount in any given year for fiscal/affordability reasons or consistency with other system partners
- Every designated entity shall provide the CPO with a copy of the entity’s current employment contract for its CEO or CEO-equivalent.
- Every designated entity shall have implemented recruitment and conflict of interest policies for its organization that are consistent with the principles of transparency, openness, accountability and integrity which guide public sector recruitment and conflict of interest management, and shall provide a copy of its Board of Director-approved policies to the CPO.
Without limiting the generality of the foregoing, in respect to its Board of Directors, the conflict of interest policy of the designated entity shall specify that:- every Director is required to disclose any outside interest that conflicts with or may appear to conflict with the interests of the designated entity
- no Director may act on behalf of the designated entity in any matter where he or she is or appears to be in a conflict of interest
- no Director may use his or her position to pursue or advance their personal interest or those of a person with whom the Director is not at arms-length, (including but not limited to, a friend, family member, business associate, corporation or business)
- In the event of a dissolution of a designated entity, a Ministry representative, as chosen by the CPO, shall participate in all aspects of the dissolution process, including, but not limited to, the statutory requirements for dissolution and the distribution of the entity’s assets in accordance with section 1.2 (c) of these standards.
2. Objectives
- Consistent with its role as an occupational health and safety system partner, every designated entity shall align its organizational objectives in support of the vision, goals and priorities of the provincial occupational health and safety strategy described in subsection 22.3 (3) of the Occupational Health and Safety Act. In this regard, each designated entity shall:
- provide support to the CPO in implementing the provincial occupational health and safety strategy, pursuant to section 22.3 of the OHSA
- participate, as required, in system-wide integrated planning and service delivery, benchmarking, measurement and evaluation of products, programs and services
- engage with stakeholders and participate, as required, in the design, development, implementation and dissemination of products, services, information, research and best practices in occupational health and safety training and education
- Every designated entity shall have a current strategic plan posted on its website that:
- reflects consistency with and support for the provincial occupational health and safety strategy developed in accordance with section 22.3 of the OHSA
- addresses the workplace priorities and needs of its clients
- focuses resources, products, programs and services on Ontario workplaces
- incorporates explicit outcomes and key performance indicators for measuring the achievement of applicable occupational health and safety system goals
- Consistent with its role as an occupational health and safety system partner, every designated entity shall align its organizational objectives in support of the vision, goals and priorities of the provincial occupational health and safety strategy described in subsection 22.3 (3) of the Occupational Health and Safety Act. In this regard, each designated entity shall:
3. Functions
- Every designated entity shall:
- promote occupational health and safety and the prevention of workplace injuries and occupational disease
- align its operational plans and policies with the provincial occupational health and safety strategy described in subsection 22.3 (3) of the Occupational Health and Safety Act
- support innovation in occupational health and safety and be responsive to the changing needs of employers and workers
- promote public awareness of occupational health and safety
- educate Ontario employers, workers and other persons about occupational health and safety and provide its workplace partners with information on workplace hazards and means of eliminating them
- foster a commitment to occupational health and safety among employers, workers and others, and promote effective internal responsibility systems within Ontario workplaces
- In addition to the functions set out in 3.1 above, a designated entity operating as a SWA shall deliver innovative education and training programs and provide consulting services and technical assistance to help foster effective workplace health and safety programs and systems among its clients and customers.
- In addition to the functions set out in 3.1 above, a designated entity operating as a training centre shall develop and deliver education and training programs to help foster effective health and safety programs and systems among its stakeholders, customers, constituency and clients.
- In addition to the functions set out in 3.1 above a designated entity operating as a medical clinic shall develop and deliver services and programs that support the specific occupational health services and information needs of its clients.
- Every designated entity shall:
4. Operations
- Every designated entity shall submit to the CPO an annual business plan and associated funding request outlining its operational and financial plans for the forthcoming business year and as many subsequent years as requested by the Ministry. Such business plan shall be presented in a format prescribed by the CPO and within timelines set by the CPO and describe all programs and activities for which funding is being requested, along with measurable program outcomes to be achieved with the funding.
- Every designated entity shall execute the programs and activities contained in its business plan using prudent management of its resources and in strict accordance with terms and conditions set out in a Transfer Payment Agreement with the Ministry.
- Every designated entity shall immediately report to the Ministry any changes or potential developments that may adversely impact the reputation of the Ministry, government or the designated entity, or otherwise significantly impact customer/client relations, the achievement of planned goals or objectives, corporate governance, operations, finances, or value of assets.
- Every designated entity carrying out a business activity that is not compulsorily subject to the Workplace Safety and Insurance Act, 1997 shall apply, under s.74 of that Act to be deemed by the WSIB as a Schedule 1 employer in respect of that activity.
- Every designated entity shall, in a format prescribed by the Ministry, disclose annually to the CPO, information on compensation in respect to its management personnel, (as defined in the glossary of terms), or as otherwise specified by the CPO.
- Every designated entity shall contribute to constraint measures and/or the identification and establishment of efficiencies required or deemed necessary by the Ministry to sustain or improve the delivery of products, programs and services to Ontario workplaces.
- Every designated entity shall obtain written Ministry approval prior to entering into, extending or modifying any lease, tenancy agreement, license or other understanding concerning real property or occupancy.
5. Public sector accountability
- Every designated entity shall comply with all policies and directions specified by the Minister or CPO for accountability purposes or for the receipt and management of transfer payment funding, as well as applicable Government of Ontario directives and policies, including but not limited to:
- the Broader Public Sector Procurement Directive issued by Management Board of Cabinet on January 1, 2024, and as may be amended from time to time
- the Broader Public Sector Expenses Directive issued by Management Board of Cabinet on January 1, 2020, and as may be amended from time to time
- the Broader Public Sector Perquisites Directive issued by Management Board of Cabinet on August 2, 2011, and as may be amended from time to time
- any other requirements that it may be directed to comply with from time to time to reflect prudent management of resources or to address a need for financial constraint
- Every designated entity shall comply with all policies and directions specified by the Minister or CPO for accountability purposes or for the receipt and management of transfer payment funding, as well as applicable Government of Ontario directives and policies, including but not limited to:
Glossary of terms
These definitions are for the purposes of the Standards for Designated Entities only.
Audit sub-committee — a sub-committee of the Board of Directors composed of some or all members of the Board and responsible for overseeing financial reporting and related internal controls, risk, independent and internal auditors, and ethics and compliance. The role of the audit sub-committee may be subsumed under an existing committee of the Board, so long as there are regular meetings that capture the function of the audit sub-committee, and regular report-backs to the Board.
Benchmark — a point of reference for making measurements and evaluating performance.
Business plan — a management document that summarizes the operational and financial objectives of an organization and the detailed plans and budgets showing how the objectives are to be realized year-by-year. Once approved by the Ministry, the business plan constitutes a business agreement between the Ministry and the designated entity.
Designated entity — a corporation designated by the Ministry pursuant to section 22.5 of the OHSA as a safe workplace association, medical clinic or training centre specializing in occupational health and safety matters.
Equity groups —populations which have historically been underserved, underrepresented or may be more vulnerable due to increased risk of exposure to hazards and/or other systemic barriers and inequities. Groups include, but are not limited to: Indigenous people, racialized individuals, people with disabilities, women, new immigrants, and temporary and foreign workers.
Finance sub-committee — a sub-committee of the Board of Directors composed of some or all members of the Board and responsible for the development and oversight of financial policies; reviewing consolidated budgets and financial statements; reviewing, monitoring and advising the Board on the financial health of the entire organization; and making recommendations and providing advice for steps for improvement. The role of the finance sub-committee may be subsumed under an existing committee of the Board, so long as there are regular meetings that capture the function of the finance sub-committee, and regular report-backs to the Board.
Goal — a desired future state or condition.
Governance — the exercise of authority, direction and control, and the fulfillment of accountabilities to stakeholders.
Human resources (HR) sub-committee — a sub-committee of the Board of Directors composed of some or all members of the Board and responsible for the oversight of HR policies of the organization; reviewing the management of HR within the organization; providing recommendations and advice on the organization’s HR management strategies, risks, initiatives and policies; and reporting these recommendations and advice to the Board. The role of the HR sub-committee may be subsumed under an existing committee of the Board, so long as there are regular meetings that capture the function of the HR sub-committee and regular report-backs to the Board.
Management personnel — management-level employees including Officers (for example, Chief Executive Officer, Chief Administrative Officer, Chief Operating Officer), Presidents and Vice Presidents, Directors (including Executive Director, Managing Director), Managers (including Regional Manager, Finance Manager, Senior Manager) and any other executive position or office, regardless of actual position title or office.
Measurement — the evaluation of how well an organization is managed and the value it delivers to clients, customers and other stakeholders.
Objective — a specific target or milestone to promote achievement of a specific goal by a specific future date. Objectives answer both ‘what’ and ‘when’ quantitatively.
Occupational health and safety system — the system of organizations comprised of the Ministry of Labour, Immigration, Training and Skills Development, the WSIB, the designated entities and other agencies and institutions with public accountabilities for occupational health and safety.
Performance — the measurable results of the activities of an organization over a given period of time.
Stakeholders — those who believe they have a claim to an organization’s attention, resources and/or inputs, or are affected by an organization’s outputs and/or outcomes. This includes any groups who feel they can influence, or be affected by, the organization’s products, programs and services.
Strategic plan — a governance document that describes the organization’s fundamental purpose, values and client base, assesses the organization’s strengths and weaknesses as well as opportunities and threats in the environment, and communicates the organization’s direction in terms of goals and measurable objectives for the future. It provides a framework for accountability and meeting client needs.
System partners — the organizations that comprise the occupational health and safety system.