Risk management

Action 1.04
The healthcare service: Supports the workforce to identify, mitigate and manage safety and quality risks Documents and routinely monitors safety and quality risks Plans for, and manages, ongoing service provision during internal and external emergencies and disasters.

Action 1.04

The healthcare service:

Supports the workforce to identify, mitigate and manage safety and quality risks
Documents and routinely monitors safety and quality risks
Plans for, and manages, ongoing service provision during internal and external emergencies and disasters.

Risk management helps healthcare services make decisions to avoid or mitigate adverse events and outcomes. It involves implementing a continuous process to identify, mitigate and manage safety and quality risks.

Risks will differ between services and are dependent on the complexity associated with the services it delivers, as well as the size and scope of the healthcare service.

Examples of risks include:

Cold chain failures in the storage of temperature-sensitive medicines
Lack of privacy controls to protect patient healthcare records
Loss of key utilities such as electricity.

Access to technology such as electronic medical records

By using a risk management approach, healthcare services will identify, analyse, evaluate and treat risks to safety and quality in the service. By determining the best course of action to mitigate and manage safety and quality risks, healthcare services can use a general risk analysis matrix, such as the one in Table 1: Healthcare service risk analysis matrix.

Table 1: Healthcare service risk analysis matrix

Likelihood	Insignificant Consequences	Minor Consequences	Moderate Consequences	Major Consequences	Catastrophic Consequences
Almost certain	Medium	High	High	Extreme	Extreme
Likely	Medium	Medium	High	High	Extreme
Possible	Low	Medium	Medium	High	High
Unlikely	Low	Low	Medium	Medium	High
Rare	Low	Low	Low	Medium	Medium

Low risk	Manage by routine procedures.
Medium risk	Manage by specific monitoring or audit procedures.
High risk	This is serious and must be addressed immediately.
Extreme risk	The magnitude of the consequences of an event, should it occur, and the likelihood of that event occurring, are assessed in the context of the effectiveness of existing strategies and controls.

Planning for emergencies and disasters

A risk management approach should be applied when planning for emergencies and disasters, for example, floods, fires and pandemics. Consider possible scenarios where disruption to service provision may occur and determine how these will be managed to ensure continuity of care for patients.

Links to Action 1.17 Safety and quality roles and responsibilities

Reflective questions

Key tasks

Develop and implement a risk-management process to identify, manage and mitigate safety and quality risks.
Identify risks to the service and document them in a central location accessible to the workforce.
Support the workforce to understand, document and participate in managing risks using the service’s orientation system, education, or other existing strategies.
Maintain a risk register and regularly monitor risks and the strategies or activities that have been put in place to mitigate them.
Clearly articulate the roles and responsibilities for identifying and managing risks and ensure those with responsibilities for taking action on risks have the training, knowledge and resources required to fulfil their responsibilities.
Identify and plan for emergency or disasters scenarios and the risks that may be associated with these situations to ensure safety and high-quality care.

For certain healthcare services, it may be appropriate to integrate risk-management systems with other systems to meet safety and quality requirements, and legal and business obligations.

Examples of evidence

The type and comprehensiveness of evidence used is dependent on each healthcare service context. The content and complexity of policies and processes will likely depend on the size of the healthcare service, but could include:

Documented processes that describe how safety and quality risks are identified, managed, documented and monitored
Risk register implemented and utilised by the workforce
Training documents (for example, syllabus, attendance records, competency assessments) relating to risk management
Emergency and disaster plans
Business continuity plans.

Where to go for more information

Commission resource

Risk Management Approach – provides a framework to assess and address risks identified in the organisation.

Other resources

Australian Government Business: Assess and manage risk – learn how to develop a risk management plan to prepare and protect your business.
ISO Standards: 31000:2018 Risk management – Guidelines – for use by people who create and protect value in organisations by managing risks, making decisions, setting and achieving objectives and improving performance.
The New England Journal of Medicine Catalyst: What Is Risk Management in Healthcare? – looks at the systems and processes employed to uncover, mitigate and prevent risks in healthcare institutions.
Your local Primary Health Network – may have guidelines, tools and resources to support your healthcare service prepare for emergencies and disasters, specific to your local area.