Reports
Managing risks in the NSW public sector: risk culture and capability
The Ministry of Health, NSW Fair Trading, NSW Police Force, and NSW Treasury Corporation are taking steps to strengthen their risk culture, according to a report released today by the Auditor-General, Margaret Crawford. 'Senior management communicates the importance of managing risk to their staff, and there are many examples of risk management being integrated into daily activities', the Auditor-General said.
We did find that three of the agencies we examined could strengthen their culture so that all employees feel comfortable speaking openly about risks. To support innovation, senior management could also do better at communicating to their staff the levels of risk they are willing to accept.
Effective risk management is essential to good governance, and supports staff at all levels to make informed judgements and decisions. At a time when government is encouraging innovation and exploring new service delivery models, effective risk management is about seizing opportunities as well as managing threats.
Over the past decade, governments and regulators around the world have increasingly turned their attention to risk culture. It is now widely accepted that organisational culture is a key element of risk management because it influences how people recognise and engage with risk. Neglecting this ‘soft’ side of risk management can prevent institutions from managing risks that threaten their success and lead to missed opportunities for change, improvement or innovation.
This audit assessed how effectively NSW Government agencies are building risk management capabilities and embedding a sound risk culture throughout their organisations. To do this we examined whether:
- agencies can demonstrate that senior management is committed to risk management
- information about risk is communicated effectively throughout agencies
- agencies are building risk management capabilities.
The audit examined four agencies: the Ministry of Health, the NSW Fair Trading function within the Department of Finance, Services and Innovation, NSW Police Force and NSW Treasury Corporation (TCorp). NSW Treasury was also included as the agency responsible for the NSW Government's risk management framework.
In assessing an agency’s risk culture, we focused on four key areas:
Executive sponsorship (tone at the top)
In the four agencies we reviewed, senior management is communicating the importance of managing risk. They have endorsed risk management frameworks and funded central functions tasked with overseeing risk management within their agencies.
That said, we found that three case study agencies do not measure their existing risk culture. Without clear measures of how employees identify and engage with risk, it is difficult for agencies to tell whether employee's behaviours are aligned with the 'tone' set by the executive and management.
For example, in some agencies we examined we found a disconnect between risk tolerances espoused by senior management and how these concepts were understood by staff.
Employee perceptions of risk management
Our survey of staff indicated that while senior leaders have communicated the importance of managing risk, more could be done to strengthen a culture of open communication so that all employees feel comfortable speaking openly about risks. We found that senior management could better communicate to their staff the levels of risk they should be willing to accept.
Integration of risk management into daily activities and links to decision-making
We found examples of risk management being integrated into daily activities. On the other hand, we also identified areas where risk management deviated from good practice. For example, we found that corporate risk registers are not consistently used as a tool to support decision-making.
Support and guidance to help staff manage risks
Most case study agencies are monitoring risk-related skills and knowledge of their workforce, but only one agency has addressed the gaps it identified. While agencies are providing risk management training, surveyed staff in three case study agencies reported that risk management training is not adequate.
NSW Treasury provides agencies with direction and guidance on risk management through policy and guidelines. In line with better practice, NSW Treasury's principles-based policy acknowledges that individual agencies are in a better position to understand their own risks and design risk management frameworks that address those risks. Nevertheless, there is scope for NSW Treasury to refine its guidance material to support a better risk culture in the NSW public sector.
Recommendation
By May 2019, NSW Treasury should:
- Review the scope of its risk management guidance, and identify additional guidance, training or activities to improve risk culture across the NSW public sector. This should focus on encouraging agency heads to form a view on the current risk culture in their agencies, identify desirable changes to that risk culture, and take steps to address those changes.
Appendix one - Response from agencies
Appendix three - About the audit
Appendix four - Performance auditing
Parliamentary reference - Report number #298 - released 23 April 2018
Mental health post-discharge care
On 17 December 2015 the NSW Acting Auditor-General, Tony Whitfield, released a report on the care that is provided to mental health patients in the first seven days after they are discharged from acute mental health units.
The audit examined models of care provided by five Local Health Districts: Northern NSW, Sydney, Western Sydney, Central Coast, and Murrumbidgee. The audit looked at how well these Local Health Districts implemented the Ministry of Health’s policy directive on the transfer of mental health patients from hospitals to the community.
Parliamentary reference - Report number #263 - released 17 December 2015
Volume Ten 2015 Health
NSW Health, on average, met the emergency department triage response time targets across all triage categories in 2014-15 for the second consecutive year. However, fewer health entities met all triage targets in 2014-15, according to a report released by the New South Wales Acting Auditor-General, Tony Whitfield.
NSW Health improved its emergency department treatment performance in 2014-15, but did not achieve its target of 81 per cent of patients being admitted, transferred or discharged within four hours of presenting. In 2014-15, the State average was 74.3 per cent compared to 73.9 per cent in 2013-14. Only five local health districts achieved the 81 per cent target in 2014-15.
Managing length of stay and unplanned readmissions in NSW public hospitals
NSW Health has achieved considerable success over recent years in reducing average length of stay despite increasing pressure on hospital admissions by older and chronically ill patients. This success has been driven by changes in the way health services are delivered, such as the increasing use of same day care for treatments that previously required overnight hospital stays.
There is a good level of length of stay information available and this information is actively used to manage the time patients spend in hospital.
Available data suggest that the rate of unplanned readmissions has not reduced in NSW despite various statewide and local strategies. NSW Health is undertaking research to better understand unplanned readmissions, their causes and the best ways to address them.
There are many local and statewide initiatives that aim to reduce length of stay and unplanned readmissions. However, the impact of some local and statewide initiatives on length of stay and unplanned readmissions are not well understood and quantified due to the lack of evaluations conducted.
Parliamentary reference - Report number #250 - released 23 April 2015
Areas of focus from 2014
Purchasing Hospital Supplies: Follow-up of 2002 Performance Audit
Periodically we review the extent to which agencies have changed their practices as a result of our audits. This gives Parliament and the public an update on the extent of progress made.
In this follow-up audit, we examine changes following our September 2002 report, to assess whether NSW Health has improved its buying of hospital supplies using electronic systems.
NSW Health spends over $1.3 billion on hospital supplies. It is the largest expenditure area after employee costs. Reform of this area has the potential to make significant savings that could be redirected to frontline services.
As part of our series of audits in the area of e-government, our previous audit looked closely at the extent to which technology was being used to deliver potentially major savings in purchasing hospital supplies. This is a key area of so-called “process re-engineering” in the “e” field, and NSW Health provided an ideal case study.
Whilst implementing large-scale e-procurement has many technical aspects, it is not chiefly a technical issue. The key requirements for success reside in effective change management, in particular being clear as to who has the authority to make change decisions and be held accountable.
This audit looks at NSW Health’s successes to date, and its frustrations and challenges in making further progress in this field. Many of the issues raised in this report may provide lessons for any agency that is seeking to drive a significant change program.
Parliamentary reference - Report number #145 - released 23 November 2005
Emergency Mental Health Services
It is estimated that one in five people will be affected at some stage by a mental health problem or illness. The increasing prevalence of mental illness means that at some point in time most of us will either be affected or we will know of someone who is.
Although most people with mental illness can be treated in the community, at times some may require emergency treatment or admission to hospital for shortterm intensive therapy.
Not only are more mental health patients presenting to an emergency department for treatment than ever before, they are reportedly sicker and a greater number require admission to a hospital bed for further treatment. And, because of its very nature, those suffering from acute mental illness may not understand what is wrong or be able to communicate their problems clearly.
This makes access to emergency mental health services a significant issue for government that requires continuing attention.
The focus of this report is on the provision of 24-hour crisis services to adults. Emergency mental health services play a vital role in providing timely and appropriate care. Without proper treatment the severity of the illness may escalate, increasing the risk of self-harm or harm to others.
There have been many changes to mental health services over the last decade to deal with increasing demand. Much has been done to improve access to, and the quality of emergency services through significant increases in funding, the opening of new beds and the employment of more mental health staff.
Yet recent reviews have highlighted problems with accessing mental health beds and inadequate levels of psychiatric support in rural areas.
I believe that our report will provide valuable assistance to area health services on alternative models of emergency mental health care that better manage patient risk and further improve service quality.
Parliamentary reference - Report number #136 - released 26 May 2005
Hospital emergency departments: Delivery services to patients
There have been notable changes in the provision of emergency department services over the last decade, principally by increasing the number, seniority and training of staff and upgrading facilities. More recently, programs have focussed on achieving improvements in emergency department waiting times (the time taken to see a doctor) and access block (delay in accessing a hospital bed). However, these programs have had limited effect. Although waiting times for seriously ill patients have decreased, waiting times for around 95% of emergency department patients have increased or remain unchanged and performance against benchmarks for access block has declined each year.
Although The Audit Office identified opportunities to improve patient flow in the emergency department, benefits will be limited by access block and the congestion caused by being unable to move patients to a ward. Only a better balance of resources between inpatient access programs (that is booked and emergency department patients) will bring about improvements in access block.
Parliamentary reference - Report number #72 - released 15 March 2000
