The Framework does not sufficiently explain what individual agencies need to do to manage SSRs they share with others. It lacks detail on what they should include in their own risk management frameworks and what they need to do when they take a lead role for an SSR.

The Framework does not clarify what the Risk Committee and the Secretaries' Board need to do to support agencies or to advise government on SSRs. It also does not explain what DTF, the Department of Premier and Cabinet (DPC) and the Insurance Authority need to do for SSRs.

The Framework sets out minimum requirements and guidance for individual agencies to manage their own risks. It also sets out the arrangements for agencies to manage risks they share with others, including SSRs.

The Framework describes SSRs and agency roles and responsibilities for coordinating their responses. It sets out the roles and responsibilities for 2 cross-agency coordinating groups ‒ the Risk Committee and the Secretaries' Board. 

This section summarises our key findings. The numbered sections detail our complete findings, including supporting evidence.

When reaching our conclusions, we consulted with the audited agencies and considered their views. The agencies’ full responses are in Appendix A.

We made 5 recommendations to address 3 issues. The relevant agencies have accepted our recommendations in full or in principle.

Download a PDF copy of Appendix E: Experience of different population groups.

Download a PDF copy of Appendix D: Performance data for 2023–24 (quarters 1 to 3).

Download a PDF copy of Appendix C: Audit scope and method.

Download a PDF copy of Appendix B: Abbreviations, acronyms and glossary.

Download a PDF copy of Appendix A: Submissions and comments.

DH’s regular performance monitoring enables the collection of important data from health services and Ambulance Victoria on their short-term performance. Longer-term performance data is also important for the public because it provides greater insights into trends over time and improves the accountability and transparency of public health services.

DH is improving its ability to monitor patient safety trends and is working with health services to capture real-time hospital data, and to better use data insights to make improvements at health services.