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Sample list of risk indicators
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Sample list of risk indicators
Content 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.
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
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.
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.
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.
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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Content 2
Current as at: Friday 17 June 2022
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