TRIM: 72919
Using a risk management approach to meet the
Minimum Requirements for 2013
Health service organisations will need to meet all core actions in the National Safety
and Quality Health Service Standards (NSQHS) Standards to achieve accreditation.
As part of the flexible arrangements for implementing the NSQHS Standards, the
Commission has prescribed minimum requirements for 7 of the core actions. This
initiative was developed to provide health services with additional time to put all the
necessary strategies in place to meet these actions. These minimum requirements
are only applicable during 2013 and will need to be in place to achieve a ‘met’ rating
for these actions.
Some of these prescribed actions will require health services to assess the risks
associated with the action and to develop a plan of action that is prioritised in
accordance with the findings of the risk assessment. Health services may also need
to complete a sample audit to establish baseline data for the identified risks.
The 7 core actions that have prescribed minimum requirements can be found on the
Commission’s website at http://www.safetyandquality.gov.au/ourwork/accreditation/flexible-arrangements-for-2013/.
To determine if a standardised risk management approach has been set for your
health service organisation, it is recommend you contact your state or territory health
department or health service ownership group, for information on the recommended
risk framework.
Who is at risk?
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Patients – some patients more than others, for example elderly, surgical patients,
neonates or patients with indwelling devices
Health care workforce – the workforce are also health consumers and may have
extensive exposure to the risk
The organisation – this could be corporate or clinical risk.
Who has to address the risk management issues?
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The health system – the risk may be outside the control of an organisation
The organisation – the risk may be corporate or clinical in nature
The team who are delivering the care - the risk may come from the pattern of
work or team dynamics
The individual – the risk may be skills, knowledge or situationally based.
What are the principles of risk management?
The 5 basic principles of risk management are to:
Avoid risk
- If a risk cannot be eliminated then it must be managed
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Identify risk
Analyse risks
Evaluate risk
Treat risks
- Assess the risks and identify who is involved
- By examining how a risk can occur, what the likelihood and
consequences of this risk occurring
- Determine how the risk can be reduced or eliminated
- Manage the risk by determining who is responsible for taking actions,
when and how this will be monitored.
What are the steps to minimise risks?
To minimise risks, you will need to identify:
 Who is at risk?
 What is involved?
 Why can it happen?
 How likely is it?
 What are the consequences?
 What can be done?
 Is the solution applied to the situation?
You can use a risk management approach such as that set out in the Australian /
New Zealand Standard Risk Management – Principles and guidelines, or your
organisation may use a general risk analysis matrix, such as the matrix below:
Source:
Specialised risk matrixes exist for specific purposes, such as the Aseptic Technique
Risk Matrix in Appendix 1.
How will we know how often the risk is likely to happen?
The risk assessment requires you to assess whether the risk is likely to be common
or rare, or, severe or mild. The sources of data that may help you understand how
likely the risk will occur in the clinical environment include:
 Monitoring and audit results
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Surveillance data
Complaints
Observations
What are successful risk management strategies?
A range of strategies are available to address the risk identified. These strategies
will be influenced by a base-line review or gap analysis of the current governance
arrangements, systems, processes, practices and their effectiveness.
Health services will need to develop an action plan to prioritise strategies and
resources to address the risks.
How can collaboration help reduce risk?
Collaborating with others may help you to:
 Identify risks that are not always obvious to those in, or providing, the services
 Recognise how risks impact upon other areas (eg Workplace Health and Safety,
education and consumers)
 Develop and utilise a standardised tool for identification and analysis of risk
 Implement, monitor and evaluate the effectiveness of risk management strategies
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Appendix 1: Aseptic Technique Risk Matrix
Risk Factors
1. Clinical context
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Controlled environment eg theatres, interventional radiology, oncology units
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Semi controlled environment eg medical wards
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Uncontrolled environment eg emergency department, intensive care units, paediatric wards
2. Treatment type
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Simple, non invasive procedure e.g. simple dressing
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Complex procedure e.g. debridement of a wound
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Invasive procedure e.g. insertion of a peripheral or central venous access device
3. Recency of assessment of skills of clinical workforce
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Recent assessment, within 12 months
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Recently assessed, but now working in different clinical context
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Assessment between 1 and 3 years
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Last assessment unknown or greater than 3 years
4. Frequency of use
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Infrequent – less than monthly
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Occasional – several times/month
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Frequently – daily or several times/day
Calculating the level of risk (assess and score each factor separately)
1. Clinical Context
Frequency
Infrequent
Occasional
Frequent
Controlled
Semi-controlled
Uncontrolled
1 = Low
4 = Low
6 = Medium
4 = Low
6 = Medium
8 = High
6 = Medium
8 = High
10 = Very High
2. Treatment type
Frequency
Infrequent
Occasional
Frequent
Simple procedure
Complex procedure
Invasive procedure
1 = Low
4 = Low
6 = Medium
4 = Low
6 = Medium
8 = High
6 = Medium
8 = High
10 = Very High
3. Recency of assessment
Recent
Recent but changed
clinical context
Assessed 1-3 years
Assessment
unknown of >3 years
1 = Low
4 = Medium
4 = Medium
8 = High
Risk Score
Risk Factors
Overall Risk Rating
Score
Risk Factors
Score
Clinical Context
Low risk
3-9
Treatment Type
Medium
10 -16
Recency of Assessment
High
17 – 24
Risk Rating (total score)
Very High
25 – 28
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