1. Licensing
    • Licensee issues:
      • insolvency, other legal matters, financial difficulties
    • Commissioning of a new facility/alterations & additions/ new services or classes:
      • lack of processes and resources e.g. insufficient staff numbers/experience
      • director of nursing not appointed
      • lack of policy/procedure i.e. specialised services
      • insufficient equipment for services/classes
      • relevant certification not provided
      • building works do not meet plan approval conditions
      • Medical Advisory Committee membership non compliant
    • Licence conditions:
      • patients accommodated in unlicensed areas
      • overcrowding – more recovery spaces than scheduled
      • paediatric patients accommodated in unapproved areas
      • closure/relocation of ward/service/beds without notice
      • commencement of a new service
    • Patient data:
      • trends identified – excessive number of transfers for higher level of care
      • evidence that facility is operating outside of licence conditions/admission criteria.
  2. Governance/management
    • Medical Advisory Committee:
      • inadequate membership
      • inadequate governance processes (by-laws/terms of reference)
      • inadequate health professional credentialing
    • Management:
      • director of nursing not appointed
      • director of nursing not approved by the Ministry of Health
      • high turnover of management staff
      • insufficient management systems
  3. Environment
    • Non-compliance with Australasian Health Facility Guidelines.
    • Non-compliance with Building code of Australia.
    • Inadequate risk assessment and safety inspection program.
    • Inadequate maintenance of building facilities and equipment.
    • Inadequate maintenance program.
    • Inadequate provision of equipment and stores for services for which the facility is licensed.
    • Inadequate communication system provided.
    • Inadequate policies and procedures for the management of environmental issues (e.g. waste & hazardous substances, fire safety, disaster management).
    • No or insufficient back-up power supply.
  4. Clinical care
    • Insufficient number of appropriately qualified staff to carry out the services provided at the facility.
    • Inadequate clinical record documentation.
    • Lack of policies and procedures for the management of patient's clinical care (e.g. identification, admission & separation, transfer, privacy).
    • Infection control:
      • inadequate policies and procedures for the management of infection control
      • decontamination systems and processes do not comply with AS/NZS 4187
      • inadequate staff infection control education.
  5. Quality improvement
    • Incidents/root cause analysis (RCA):
      • inadequate policies and procedures for the management of incidents/RCA
      • inadequate reporting of incidents/RCA to Ministry of Health
      • reportable incident reported
      • any other adverse event reported to Ministry of Health that has been identified as an ongoing potential risk to patient safety
    • Complaints:
      • inadequate policies and procedures for the management of complaints
      • complaint received by Ministry of Health for investigation and report
    • Quality management system:
      • inadequate policies and procedures for the management of quality processes
      • lack of regular compliance/outcome audits
      • notification of "not met" with the National Safety and Quality Health Service Standards.
  6. Compliance response from licensee:
    Refers to the level of compliance demonstrated by a licensee in response to recommendations made by the Regulation and Compliance Unit i.e. no response, incomplete/inappropriate response, written response but actions not implemented. The response is assessed over a 12 month period.

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Current as at: Friday 17 June 2022
Contact page owner: Private Health Care