PD2005 293

Policy Directive
Department of Health, NSW

73 Miller Street North Sydney NSW 2060
Locked Mail Bag 961 North Sydney NSW 2059
Telephone (02) 9391 9000 Fax (02) 9391 9101
http://www.health.nsw.gov.au/policies/
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Safety and Security Release of the Health Facility Guideline -

Working Draft
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Document Number PD2005_293
Publication date 27-Jan-2005
Functional Sub group Corporate Administration - Asset Management
Corporate Administration - Security
Summary Purpose of document is to assist health facility planners and designers to
minimise the risk of opportunities for violence and crime by the provision
of appropriate facilities, work spaces, building services and systems.
Author Branch Asset Management Services
Branch contact Richard Pye 9391 9452
Applies to Area Health Services/Chief Executive Governed Statutory Health
Corporation, Board Governed Statutory Health Corporations, Affiliated
Health Organisations, NSW Dept of Health
Distributed to Public Health System, NSW Department of Health
Review date 27-Jan-2010
File No. 02/1249-2
Previous reference 2003/13
Issue date 27-Feb-2003
Status Active
Director-General
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Compliance with this policy directive is mandatory.
CIRCULAR
File No 02/1249-2
Circular No 2003/13
Issued 27 February 2003

Richard Pye (02) 9391 9452
Contact
Asset and Procurement Management
Release of the Health Facility Guideline - Safety and Security, as a Working Draft.
NSW Health is committed to providing a safe environment for its staff, clients and the public.
Effective planning and design is required to minimise and, where possible, eliminate
foreseeable risks associated with the facility design to staff and others.
In July 2001 the NSW Minister for Health established the Taskforce on Prevention and
Management of Violence in the Health Workplace. The objective of the Taskforce was to
develop strategies for the prevention and management of violence in the health workplace. This
Health Facility Guideline has been developed in response to the recommendations of the
Taskforce and in consultation with the Security Infrastructure Working Group, a sub-group of the
Taskforce.
This Guideline expands the principles for a safe and secure workplace as outlined in the NSW
Health Safety and Security Manual, 1998 (currently under review), Workplace Health and
Safety; A Better Practice Guide (Circular 2001/22) and Effective Incident Response: A
Framework for Prevention and Management in the Health Workplace (Circular 2002/19). This
Guideline is complementary to these documents. In addition, this Guideline supports other
violence prevention and management initiatives.
This document should be utilised in the planning, design and construction of NSW Health
Facilities.
The Guideline is being released as a Working Draft for a period of twelve months. During this
period Department of Health and Area Health Service staff who utilise the document are
encouraged to comment. Comments should be forwarded to:
Richard Pye,
Director, Asset Management Services
Phone: (02) 9391 9452
Fax: (02) 9391 9522
Email: ripye@doh.health.nsw.gov.au
Robyn Kruk
Director-General
Distributed in accordance with circular list(s):
A 13 B C 9 D E 73 Miller Street North Sydney NSW 2060

F G H I J Locked Mail Bag 961 North Sydney NSW 2059
K L M N P Telephone (02) 9391 9000 Facsimile (02) 9391 9101
In accordance with the provisions incorporated in the Accounts and Audit Determination, the Board of Directors, Chief Executive Officers and their
equivalents, within a public health organisation, shall be held responsible for ensuring the observance of Departmental policy (including circulars and
procedure manuals) as issued by the Minister and the Director-General of the Department of Health.
DESIGN SERIES (DS)
HEALTH FACILITY GUIDELINE -

SAFETY AND SECURITY
PREPARED FOR:
NSW HEALTH
ASSET AND PROCUREMENT MANAGEMENT
DIRECTORATE
OCTOBER 2002
WORKING DRAFT Revision Date 03.10.02

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ACKNOWLEDGMENTS

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HEALTH FACILITY GUIDELINE - SAFETY AND SECURITY
CONTENTS
1.0 PRINCIPLES OF THIS GUIDELINE.................................................................6
1.1 INTRODUCTION...........................................................................................................6
1.2 PURPOSE AND SCOPE ..............................................................................................6
1.3 LEGISLATIVE RESPONSIBILITIES .............................................................................7
1.4 OPERATING POLICIES ...............................................................................................7
1.5 EMERGING TECHNOLOGY & CLINICAL WORK PRACTICES ..................................7
1.6 PLANNING ECONOMY ................................................................................................7
1.7 RECURRENT COSTS ..................................................................................................8
2.0 STRUCTURE OF THIS GUIDELINE ................................................................9

2.1 DEFINITION OF 'SAFETY AND SECURITY'................................................................9
2.2 ANALYSIS BY FUNCTIONAL AREAS..........................................................................9
2.3 RISK ANALYSIS AND RISK MANAGEMENT...............................................................9
2.4 CRIME PREVENTION THROUGH ENVIRONMENTAL DESIGN...............................10
2.5 ADDITIONAL INFORMATION ....................................................................................11
2.6 APPLICATION OF THE GUIDELINES........................................................................12
3.0 FUNCTIONAL AREAS ................................................................................... 13

3.1 ADMINISTRATION / ACCOUNTS ..............................................................................13
3.2 ADMINISTRATION / DISCHARGE AREA ..................................................................14
3.3 BIO-MEDICAL WORKSHOP ......................................................................................15
3.4 DIETETICS .................................................................................................................16
3.5 EMERGENCY .............................................................................................................17
3.6 CENTRAL STERILISING DEPARTMENT ..................................................................19
3.7 OPERATING THEATRES / RECOVERY DAY PROCEDURES .................................20
3.8 RENAL ........................................................................................................................21
3.9 KITCHEN ....................................................................................................................22
3.10 MATERNITY ...............................................................................................................23
3.11 MEDICAL IMAGING....................................................................................................24
3.12 MEDICAL RECORDS .................................................................................................25
3.13 PAEDIATRIC...............................................................................................................26
3.14 PHARMACY................................................................................................................27
3.15 PODIATRY..................................................................................................................28
3.16 REHABILITATION.......................................................................................................29
3.17 SOCIAL WORKER......................................................................................................30
3.18 STRESS TESTING .....................................................................................................31
3.19 OUTPATIENT AREA...................................................................................................32
3.20 ICU / CCU / HDU ........................................................................................................33
3.21 LIBRARY / EDUCATION.............................................................................................34
3.22 SURGICAL..................................................................................................................35
3.23 MAIN ENTRY ..............................................................................................................36
3.24 WARDS.......................................................................................................................37
3.25 METHADONE CLINIC ................................................................................................38

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3.26 NEEDLE / SYRINGE EXCHANGE..............................................................................39

3.27 RETAIL AREA.............................................................................................................40
3.28 CARPARKING / EXTERNAL AREAS .........................................................................41
3.29 MORTUARY................................................................................................................42
3.30 DENTAL CLINIC .........................................................................................................43
3.31 PATHOLOGY..............................................................................................................44
4.0 CHECKLISTS................................................................................................. 45
4.1 ADMINISTRATION / ACCOUNTS ..............................................................................46
4.2 ADMINISTRATION / DISCHARGE AREA ..................................................................47
4.3 BIO-MEDICAL WORKSHOP ......................................................................................48
4.4 DIETETICS .................................................................................................................49
4.5 EMERGENCY .............................................................................................................50
4.6 CENTRAL STERILISING DEPARTMENT ..................................................................52
4.7 OPERATING THEATRES / RECOVERY DAY PROCEDURES .................................53
4.8 RENAL ........................................................................................................................54
4.9 KITCHEN ....................................................................................................................55
4.10 MATERNITY ...............................................................................................................56
4.11 MEDICAL IMAGING....................................................................................................57
4.12 MEDICAL RECORDS .................................................................................................58
4.13 PAEDIATRIC...............................................................................................................59
4.14 PHARMACY................................................................................................................61
4.15 PODIATRY..................................................................................................................62
4.16 REHABILITATION.......................................................................................................63
4.17 SOCIAL WORKER......................................................................................................64
4.18 STRESS TESTING .....................................................................................................65
4.19 OUTPATIENT AREA...................................................................................................66
4.20 ICU / CCU / HDU ........................................................................................................67
4.21 LIBRARY / EDUCATION.............................................................................................69
4.22 SURGICAL..................................................................................................................70
4.23 MAIN ENTRY ..............................................................................................................72
4.24 WARDS.......................................................................................................................74
4.25 METHADONE CLINIC ................................................................................................76
4.26 NEEDLE/SYRINGE EXCHANGE................................................................................77
4.27 RETAIL AREA.............................................................................................................78
4.28 CARPARKING ............................................................................................................79
4.29 MORTUARY................................................................................................................80
4.30 DENTAL CLINIC .........................................................................................................81
4.31 PATHOLOGY..............................................................................................................82
APPENDICES
A. NSW Health Design and Technical Guidelines

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PRINCIPLES OF THIS GUIDELINE

INTRODUCTION
NSW Health is committed to providing a safe environment for its staff, clients and the
public.
However, unexpected and unusual incidents do happen in the workplace. Effective

planning and design is required to minimise and, where possible, eliminate
foreseeable risks associated with the facility design to staff and others.
This Guideline expands the principles for a safe and secure workplace as outlined in
both the Safety and Security Manual and Effective Incident Response: A Framework
for Prevention and Management in the Health Workplace (Circular 2002/19). This
Guideline is complementary to these two documents. In addition, this Guideline
supports other violence prevention and management initiatives.
This document should be utilised in the context that it is one of a series of Design and
Technical Guidelines published by NSW Health to be utilised in the planning, design
and construction of NSW Health Facilities. A full listing of current Guidelines is
included in Appendix A. The requirements of this Guideline should be applied in
conjunction with the requirements of all other Guidelines applicable to the Facility
being addressed.
PURPOSE AND SCOPE
The purpose of this document is to assist health facility planners and designers to
minimise the risk of opportunities for violence and crime by the provision of
appropriate facilities, work spaces, building services and systems.
This document is intended as a guideline to assist in the identification of potential

areas of risk which must be addressed during the planning, design and construction
phases of a health facility project.
This Guideline has been prepared at a time when the issue of staff, client and visitor
safety and security has become a major focus of the design process. The Guideline
is therefore directed towards the achievement of a safe, functional and affordable
solution to the planning and design of health buildings.
The planning and design standards outlined in the Health Building Design Guidelines
should be regarded as minimum standards. It is recognised that in a number of
circumstances, departure from the Guideline will be necessary to meet operational
requirements or to manage any unusual risks that might be specific to a particular
circumstance or location. These "departures" will normally be subject to documented
justification and the subsequent Departmental approval process.

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LEGISLATIVE RESPONSIBILITIES
Employers under the NSW Occupational and Safety Act 2000 have a duty of care for
the health and safety of all people in the workplace. This requires employers to:
(a) Ensure premises controlled by the employer where people work are safe and
without risk to health;
(b) Ensure that systems of work and the working environment are safe and without
risk to health;
(c) Ensure that any equipment or substance provided for use by the employees at
work is safe and without risk to health when properly used;
(d) Provide necessary information, instruction, training and supervision for the
health and safety of their employees;
(e) Provide adequate facilities for the welfare of the employees at work; and
(f) Ensure that people (other than employees) are not exposed to risks to their health
and safety in the workplace.
In addition, there is a duty for employers to consult with their employees to enable
employees to contribute to the making of decisions affecting their health, safety and
welfare at work.
Employees are required to cooperate with the employer in their efforts to comply with
health and safety requirements. Employee cooperation ensures their own health and
safety and the health and safety of others in the workplace.
OPERATING POLICIES
Operational Policies have a major impact upon the design requirements and,
subsequently, capital and recurrent costs of health facilities. Planning and design
teams should be constantly reviewing their design proposals with this in mind and be
able to demonstrate that the capital and recurrent cost implications of proposed
operational policies have been fully considered and evaluated and that the most cost-
effective solutions are being proposed.
EMERGING TECHNOLOGY & CLINICAL WORK PRACTICES
In determining specific requirements and design, the impact of new technology and
clinical work practices should be reviewed in relation to safety and security prior to
adoption.
PLANNING ECONOMY
Facility design should ensure that the space allocation for safe and secure circulation
within and between units is efficient and appropriate for the functional activities of the
space, having regard to the allowance provisions defined in the relevant Health
Building Guideline.

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RECURRENT COSTS
"It has been estimated that recurrent costs (ie. running costs) over two years are
equal to the initial capital expenditure. Design teams therefore have a responsibility
always to be conscious of the operating costs as well as the capital cost implications
of any decisions they make". Tim Clark, Kevin Croncher and Paul Stoddard,
"Pointing the Way", The Health Journal, 26 January 1989, P105.
Departmental policy requires that recurrent costs of new facility proposals are fully
analysed and estimated at feasibility and master plan stages in the planning process,
and then progressively refined as the project proceeds. It is critical that client groups
and designers ensure that future facilities are sized for provision of only those
services for which recurrent funds will be available under the Department's future
funding and resource allocation projections.
The issue of 'recurrent costs' should be considered in the context of the provision of
an appropriately designed and constructed safe working environment in a health
facility. That is, the safety and security issues should be addressed during the
planning process and incorporated into the 'structure' of the facility. If the planning
and design process follows the requirements of this Guideline and undertakes an
appropriate level of consideration of safety and security issues, there should be no
significant increase in recurrent costs.
Designers and managers need to recognise that recurrent costs also include injuries
to staff, patients or other, or damage to property that may arise from poor design. In
the case of safety and security issues, this includes the direct and indirect costs
associated with crime and violence.

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STRUCTURE OF THIS GUIDELINE

DEFINITION OF 'SAFETY AND SECURITY'
NSW Health is concerned with minimising risk in the public health care system, by
the provision of a safe and secure environment for patients, staff and visitors.
Therefore, the definition of "safety and security" for this Guideline specifically relates
to the working environment.
The "terms" for the preparation of this Guideline relates specifically to the health
facility infrastructure through which effective design supports a safe and secure
working environment and minimises the potential for violence in the workplace.
Therefore, for the implementation of this Guideline, the term "safety and security"
relates specifically to the provision of a safe and secure physical environment for
health care workers, patients and visitors. This "physical environment" includes the
infrastructure of the facility plus the building services operational systems to support
that physical infrastructure. The definition also includes the provision of building
services to support management of acts of violence, should they occur.
ANALYSIS BY FUNCTIONAL AREAS
This Guideline consists of an analysis of a 'Health Facility' undertaken on a

"functional area" basis. That is, the analysis consists of assessments of generic
individual Department within a Facility on the basis that the Department is a 'stand
alone' Department.
It is recognised that each Facility will not have all of the Departments included in this
Guideline. Manager, Planners, Designers need only incorporate those Departments
which are incorporated in their Facility.
Notwithstanding the above, the design of a particular Department/Functional Area

can only be partially determined in isolation from its actual location within the Facility
and within its geographical location in the community. Therefore, in undertaking the
risk analysis referenced in Section 2.3 below, users of this Guideline should take
account of both Department location within the Facility, including external grounds
and carparks, and the Facility location within its neighbourhood.
RISK ANALYSIS AND RISK MANAGEMENT
The basis of this Guideline is the implementation of an appropriate risk analysis of

both the total Facility and the individual Health Units within the Facility. The risk
analysis is to identify potential risks and potential areas of risk within the Facility.
The identification of potential risk can be enhanced by coordination with the local
Area Crime Prevention Officer from the NSW Police Service and, where applicable,
input from personnel in the 'Safer by Design' program. NSW Police are able to
provide statistical data and "local knowledge" through their involvement with other
agencies and organisations. This coordination must occur during the preparation of

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the Project Feasibility Plan and the Procurement Definition Plan to ensure all issues
are adequately addressed and funded.
Having identified and documented the relevant risks the planning process must then
eliminate or minimise those risks by the application of risk management through
suitable planning and design solutions.
It is recognised that the theft of equipment, stores, goods, drugs, etc, is a 'generic'
risk throughout the whole of the Facility. That is, that the opportunity to illegally
remove these items may place staff in a position of potential risk. This risk is not
identified in each individual Functional Area listed in the following Sections of the
Guideline, but is rather regarded as an underlying issue to be addressed in each
Functional Area.
Of more significant consequence is the "generic risk" associated with client initiated
violent incidents which occur within the workplace and which place the safety of staff,
clients or the public at risk. To take account of workplace incidents the planning and
design team must address the issues raised in the NSW Health document Effective
Incident Response: A Framework For Prevention and Management in the Health
Workplace, issued as Circular No. 2002/19, and the Safety and Security Manual.
It is not intended that the contents of this Guideline will identify all risks in all facilities
and users should not rely on this document to list all risks. Planners, designers and
managers are expected to utilise this document as a generic base for undertaking a
detailed risk analysis of their facility, taking into account the location and all of the
circumstances that are appropriate to that facility.
In undertaking the risk analysis and the risk management process, facility managers
and planners should take into account the differences between remote/rural facilities
and metropolitan facilities. Issues such as response times to violent events must be
addressed not only by the facility design but also by operational policies.
CRIME PREVENTION THROUGH ENVIRONMENTAL DESIGN
Crime Prevention through Environmental Design (CPTED) is a situational crim

prevention strategy that focuses on the design, planning and structure of cities and
neighbourhoods. It aims to reduce opportunities for crime by employing design and
place management principles that minimise the likelihood of essential crime
ingredients from intersecting in time and space.
CPTED is widely recognised as an important crime prevention tool. But like any tool,
it must suit the job and be used in the right way to be effective.
In 1993, the New South Wales Police Service developed the Community Safety
Management Plan. The plan promoted interagency strategies that address social
factors contributing to criminal behaviour, and a two-pronged situational crime
prevention package known as the Safer by Design program. This latter program
focuses on relationships between crime and the built environment.

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The proactive arm of Safer by Design is a cooperative initiative involving the NSW
Police Service, several local councils, state government departments and private
sector organisations. Principally, officers trained in Crime Prevention through
Environmental Design (CPTED) are invited by consent authorities to review the
safety and security implications of project designs, planning proposals or
development applications. When reviewing larger developments, police, council
planners and other qualified persons conduct formal crime risk assessments (known
as Safer by Design Evaluations).
The identification of potential risk can be enhanced by coordination with the local
Area Crime Prevention Officer from the NSW Police Service and, where applicable,
input from personnel in the 'Safer by Design' program. NSW Police are able to
provide statistical data and "local knowledge" through their involvement with other
agencies and organisations. This coordination must occur during the preparation of
the Project Feasibility Plan and the Procurement Definition Plan to ensure all issues
are adequately addressed and funded.
ADDITIONAL INFORMATION
This document should also be read in conjunction with the following:
- The Process of Facility Planning, NSW Health Department, 1989.

- Workplace Health and Safety - A Better Practice Guide, Circular 2001/22.
- Effective Incident Response: A Framework for Prevention and Management in the
Health Workplace, Circular 2002/19.
- NSW Health Safety and Security Manual, 1998.
- Guide to the Delineation of Roles of Area Health Services and Hospitals, NSW
Health Department, 2nd edition, 1992.
- Building Code of Australia.
- NSW Police Service Crime Prevention Through Environmental Design (CPTED)
and Safer by Design crime prevention programs.
- AS4485.1 - 1997, Security for health care facilities Part 1: General requirements.
- AS4485.2 - 1997, Security for health care facilities Part 2: Procedures Guide.
- NSW Occupational Health and Safety Act, 2000.
- OHS Regulation, 2001.
Whilst this document is primarily designed for the NSW health industry, it is also of
use to wider range of users. To aid both those in the NSW sector as well as those
from other states or overseas, there is some documentation of options or design
considerations. These may either serve to more fully describe the base Health
Building Guideline information or allow the user to adapt the information to their own
use.
Users of this Guideline should also refer to the Design Guideline DS 26, Mental
health Facility Planning Guideline. This document specifically addresses the issues
raised in this Guideline in respect of Mental Health Facilities.

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APPLICATION OF THE GUIDELINES
RISKS AND CHECKLISTS
This Guideline has been prepared in two sections:
1. Section 3.0 is a generic assessment of the potential risk to safety and security
by Functional Area/Department. This assessment is based on the function of
the area and the consequent risk that may arise from those functions. For
example, while Administration may in itself be seen as a low risk area, the fact
that monies may be retained in this area may create a risk that needs to be
defined through the risk analysis process.
As a consequence of the assessed generic risks, a number of potential

solutions are provided.
2. Section 4.0 is a "checklist" for each Functional Area/Department.
The team of personnel responsible for the planning, design and construction of
a new or refurbished Facility will be responsible for the implementation and
completion of the relevant checklists for their Facility.
However, the Facility Manager, the Project Director and the Design Consultant
are jointly responsible for the adequacy and appropriateness of the completed
checklists and risk analysis and will sign-off on each checklist. The Design
Consultant will include in the Scheme Design Report the signed-off checklists
as a record of compliance with the requirements of this Guideline, Operational
Policies, and other statutory requirements. The checklists should subsequently
be utilised as an aide memoir by the project team for the subsequent planning,
design and consultation processes.

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Functional Areas
ADMINISTRATION / ACCOUNTS
GENERIC SAFETY AND/OR SECURITY RISKS POTENTIAL SOLUTIONS

1. This area is used to facilitate / manage all the 1. Minimise entry and exit doors. Lockable
Hospital Clinical and Support Areas. It contains main entry doors,
confidential documents, which relate to the 2. Receptionist to control access during
hospital and staff. Access by unauthorised person "normal" working hours.
could lead to a breach in confidentiality.
SPECIFIC SAFETY AND/OR SECURITY RISKS POTENTIAL SOLUTIONS

1. Hospital Employee Files 1. Staff records kept in secure area.
Key with Manager of area.
2. If any electronic files are produced,
locate in restricted area of hard drive.
2. Financial Records used by various Administration 1. Financial records kept in secure
personnel in this area area. Key with Manager of area.
2. Personnel working on these must
return to secure area after use.
3. Money 1. Keep cash to a minimum.
2. Limit number of staff with access.
3. Minimise locations where money
kept.
4. Petty cash draw/safe in secure area.
5. Use of strong rooms or safes, if
appropriate.
6. Money handling (eg, cash counting)
should be out of view of the public.
4. Meeting Room for use in tele-conferencing and 1. Keep A/V equipment in lockable
general meetings cupboard.
2. Door to area to remain locked when
not in use.
5. Furniture fittings and equipment including 1. Non-removable 'Asset No.' on all
Computers and Office Equipment equipment above a predetermined value.
2. Keep equipment in lockable area.
6. Staff personal effects 1. Provision for lockers in staff areas and
lockable desk drawer to keep small
personal effects.
7. Hospital personnel safety (after hours) 1. Staff working after hours to have
knowledge of where the fixed duress
system is located and/or use a mobile
duress pendant.

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ADMINISTRATION / DISCHARGE AREA

1. Area for interview of patients prior to day of 1. Design safe interview rooms with counter
surgery and on discharge. This involves interview or screen division of area with easy
with Booked Admissions. escape routes for staff.

1. Close contact with public being admitted to 1. Fixed duress system attached to
hospital and relatives. every interview desk.
2. Minimise amount of relatives in
interview room by ensuring an adequate
waiting area.
3. Provide rooms with an alternate
means of egress for staff.
4. Design shape of interview rooms and
location of desks, etc, in such a way that
minimises risk to health personnel.
5. Provide storage and store items not
in constant use that could be used as
weapons. (Operational Policy).
6. Minimise furniture that can be used
as a weapon, ie, picked up and thrown.
2. Confidentiality of Medical records. 1. Records stored in secure area.
When not working on records staff must
return to secure area or return to Medical
Records Department.
duress pendant.
5. Staff personal effects 1. Provision for lockers in staff areas
and lockable desk drawer to keep small
personal effects.

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BIO-MEDICAL WORKSHOP

1. Area utilised for repair and maintenance of all bio- 1.
medical equipment. ontrol access.

1. Staff security. 1. Access doors to be locked at all times
with key or card access provided to
appropriate staff and monitoring system
for personnel requiring access.
2. High Tech Equipment 1. Workshop lockable at all times when not
staffed.
personal effects.

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DIETETICS

1. Area used for dieticians working within the Hospital 1.
and outside in community. ontrol access to this area.

1. Staff security. 1. Access doors to be locked at all
times with key or card access provided to
appropriate staff.
2. High Tech Equipment (if applicable) 2. Area lockable at all times when not
staffed.
4. Security of Medical records. 1. Records are stored in secure area.
When not working on records staff must
return to lockable storage areas.
5. Close contact with public being admitted to 1. Fixed duress system attached to every
hospital and relatives. interview desk.
2. Minimise numbers of relatives by
ensuring an adequate waiting area.
3. Provide bench seating selected so that
the personal space of waiting people is
not invaded.
4. Provide rooms with an alternate means
of egress for staff.
6. Provide storage and store items not in
constant use that could be used as
7. Minimise furniture that can be used as a
weapon, ie, picked up and thrown.
personal effects.

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EMERGENCY

1. 24 hours a day / 7 days per week access to this 1.
Department. secure environment separating waiting
from clinical areas.
2.
ppropriately-sized waiting area including
adequate vending machines, public
telephones, toilet facilities including baby
change facility, comfortable seating, etc.
3.
inimise entry and exit doors with close
observation of these doors.

1. Conflict with patients and relatives 1. Install CCTV with video playback in
security office where necessary, provide
additional monitor in staff station.
2. Install CCTV on 'after hours' access
points to allow clinical staff to monitor this
area.
3. Provide video and/or intercom points to
'after hours' access points.
4. Provide staff with appropriate security
barrier/screens including appropriate
provisions for patient contact and
document transfer.
5. Provide staff with access to both 'fixed'
and 'mobile' duress systems.
6. Provide good visibility from staff areas
into waiting areas.
7. E.D. waiting room should not have
access to other areas of facility 'after-
hours'. This should be controlled by
security doors/barriers.
2. Access to Department 1. Control of patient/visitor access as
above.
2. Provide alternate access/egress to
Department for staff - not through Waiting
area.
3. Manage Ambulance Entrance to prevent
unauthorised access.
4. Access to treatment and staff areas
possible only through key-card access
system.
3. Patient Files 1. Personnel working on these files
must return to secure area after use or
return to Medical Records Department.
2. The provision of internal lockable
post boxes to facilitate secure storage.
Computers, Office and Medical Equipment equipment above a predetermined value.
5. Mental Health patients 1. Concealed medical services panel
including electrical points behind the
locked cabinet.

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2. Alternate exit door for staff in case of

emergency.
6. Presence of Police guns. 1. Provision of a gun safe in an
appropriate location.
7. Drugs storage 1. Dangerous drug safe within the clean
utility area.
8. Furniture in Waiting Area 1. Ensure seating, etc, is either
permanently fixed or is of sufficient 'bulk'
to prevent its use as a weapon, ie cannot
be picked up and thrown.
2. Do not include furniture of fittings
that may be utilised as weapons.
3. Provide bench seating selected so
that the personal space of waiting people
is not invaded.
personal effects.

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CENTRAL STERILISING DEPARTMENT

1. Access to this area out of hours to retrieve sterile 1.
goods to departments. ontrol access.

1. Staff security. 1. Access doors to be locked at all times
2. After hours usage with minimal staff within a 1. Duress alarm.
remote location 2. Intercom system.
personal effects.
duress pendant.

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OPERATING THEATRES / RECOVERY DAY PROCEDURES

1. To receive and return patients after undergoing 1.
surgery. inimise entry and exit doors and restricted
area through to sterile areas.

1. Presence of drugs 1. Dangerous drug safe within the clean
utility area.
2. Staff security. 1. Access doors to be locked at all
times with key or card access provided to
4. Hospital personnel safety 1. Staff working in this area to have
duress pendant.
2. Restrict/minimise access by relatives
to recovery area.
personal effects.

Page 20 of 85
RENAL

1. Area used to treat patients requiring dialysis. 1.
ontrol access to this area.

2. Patient medical records files 1. Personnel working on these records
utility area.
duress pendant.
2. Access doors to be locked at all times
personal effects.

Page 21 of 85
KITCHEN

1. Food preparation, handling and return of trays for 1.
dishwashing in this area. ontrol access to this area.

1. Food storage 1. Lockable cool rooms and freezers
which comply with OHS requirements
regarding confined spaces, access, and
viewing panels.
2. Inventory of stock in and out.
personal effects.
4. Staff Security 1. Access doors to be locked and
monitoring system for personnel requiring
access.

Page 22 of 85
MATERNITY

1. Pre-natal, birthing, post natal, mothers with sick 1.
and well baby's nursery. inimise entry and exit doors to all areas
with newborn babies, minimising the risk
of illegal removal of babies.

1. Relatives / Visitors – includes risk of violence from 1. Staff station at main entrance to allow
non-custodial, alcohol or drug affected staff to monitor access and egress.
parents/visitors. 2. Good visibility from staff station to
nursery.
3. Minimise number of relatives/visitors
admittance in the area by restricting
number of relatives/visitors attending at
any one time and/or restricting visiting
hours to set times.
4. Implement appropriate specific security
procedures in respect of the risk
associated with illegal removal of babies.
5. If appropriate, install system in hallways
to monitor all personnel entering wards.
6. Courtyards, where provided, to be
securely screened/fenced and adequately
monitored (from Staff Station, CCTV,
etc.)
2. Illegal removal of babies 1. Minimise entry/exit doors.
2. Controlled access of entry/exit doors.
3. No external opening doors/windows.
4. All egress past staff station.
5. CCTV on entry/exit doors.
3. Patient files 1. Personnel working on these files
utility area.
2.
eep equipment in lockable area.
6. Safety of Hospital personnel 1. Staff working in this area to have
duress pendant.
personal effects.

Page 23 of 85
MEDICAL IMAGING

1. Area where outpatients and inpatients come for 1.
treatment. ontrol access.

2.
2. Patient files 1. Personnel working on these must
return to secure area after use or return
to Medical Records Department.
utility area.
duress pendant.
2. Provide appropriate after-hours
access and security, including secure
access from all parts of the facility.
personal effects.

Page 24 of 85
MEDICAL RECORDS

1. Area where patient records are maintained 1.
including active and archival files. inimise entry and exit doors with lockable
area at all time.

must return to secure area after use.
2. Medico-legal files 1. Keep in lockable area with staff
access only.
Computers and Office Equipment equipment above a predetermined value..
duress pendant.
2. Provide appropriate after-hours
access and security, including secure
access from all parts of the facility.
personal effects.

Page 25 of 85
PAEDIATRIC

1. Ward area to house paediatric patients. 1. Control access.

1. Relatives / Visitors 1. Nurses station located at entrance to
monitor access and egress.
2. Good visibility from staff station to ward.
3. Minimise number of relatives/visitors
number of relatives/visitors attending at
any one time and/or restricting visiting
hours to set times.
4. Implement appropriate specific security
procedures in respect of the risk
associated with illegal removal of
children.
5. Install appropriate surveillance system to
monitor access to wards.
6. Courtyards, where provided, to be
securely screened/fenced and adequately
monitored (from Staff Station, CCTV,
etc.).
7. Control access to play areas to restrict
unsupervised activities.
2. Patient Files 1. Personnel working on these must
return to secure area after use or return
to Medical Records Department
utility area.
2.
duress pendant.
personal effects.

Page 26 of 85
PHARMACY

1. Entry for personnel visiting or working within the 1. CCTV monitoring of en
clinic. 2. Intercom on
3. Use of reed switches on all external do

1. Client / Visitor access 1. Client access to secure dispensing
counter but not to 'secure' areas utilised
to store and dispense drugs.
2. Keep equipment
duress pendant.
2. Locked doors between dispensing areas
and clients.
3. Dispensing Counter to be constructed to
prevent unauthorised client entry/access.
4. Determine risk of hold-up/break-in and
design facility to meet risk.
personal effects.
5. Drugs storage 1. Drugs safe to be located in area that
can be monitored by staff.
2. Safes to comply with the Poisons Act
in respect of secure storage provisions.

Page 27 of 85
PODIATRY

1. Area used to treat outpatients. 1.
ontrol access.

2.
personal effects.
4. Hospital Personnel Safety 1. Staff working in this area to have
duress pendant.
2. Locked doors between patient and work
areas.

Page 28 of 85
REHABILITATION

1. Area to treat inpatient and outpatient 1.
ontrol access.

2. Furniture Fitting and Equipment including 1. Non-removable 'Asset No.' on all
2.
personal effects.
4. Hospital Personnel Safety 1. Staff working in this area to have
duress pendant.
2. Locked doors between patient and work
areas.
5. Patient "wandering" 1. Appropriate alarm system on doors
and/or personal locater system.
6. Hydrotherapy Pools 1. More then one staff member to be
always present to provide assistance.
2. Strategic location of fixed duress buttons
to summon assistance.
3. Alternate means of egress.

Page 29 of 85
SOCIAL WORKER

1. Interviews with inpatients and outpatients within an 1.
office environment. ontrol access.
2.
ood visibility from offices.

1. Relatives / Visitors 1. Adequate waiting area.
must return to secure area after use or to
the Medical Records Department.
2.
duress pendant.
2. Interview rooms to have suitable
alternate means of egress for staff.
personal effects.

Page 30 of 85
STRESS TESTING

1. Treatment and diagnostic area. 1.
ontrol access.

2.
2. Patient files 1. Personnel working on these must
return to secure area after use or to the
Medical Records Department.
personal effects.

Page 31 of 85
OUTPATIENT AREA

1. Treatment area. 1.
inimise entry and exit doors.

return to the Medical Records
Department.
2.
utility area.
duress pendant.
2. Appropriately designed waiting area
including, where possible:
- barrier between staff and patients,
- bench seating,
- ensure no loose fittings which can be
utilised as a weapon,
- vending machines.
weapons.
personal effects.

Page 32 of 85
ICU / CCU / HDU

1. Ward area to house intensive care and coronary 1.
care patients. inimise entry and exit doors.
2.
ecurity of entry via intercom and remote
release button.
3.
taff entry via keypad or swipe card, this
being a separate entry from visitors /
relatives.

1. Relatives / Visitors 1. Good visibility from staff station to
ward.
2. Manage relatives/visitors admittance
in the area by restricting visiting hours
and/or number of visitors.
return to Medical Records Department
2.
f any electronic files are produced, locate
in restricted area of hard drive.
2.
utility area.
duress pendant.
2. Provision of an adequate waiting
area for relatives/visitors that may be in
the area "out of hours". This area to be
able to be secured and monitored by
staff.
personal effects.

Page 33 of 85
LIBRARY / EDUCATION

1. Study and education area for staff and hospital 1.
personnel. ontrol access.

2.
2. Out of hours usage (if applicable) 1. Staff working after hours to have
duress pendant.
duress pendant.
personal effects.

Page 34 of 85
SURGICAL

1. Ward area for surgical patients. 1.
inimise entry and exit doors.

ward.
2. Minimise relatives / visitors
visiting hours.
2.
f any electronic files are produced, locate
in restricted area of hard drive.
3. Furniture fittings equipment including Computers, 1. Non-removable 'Asset No.' on all
Office and Medical Equipment equipment above a predetermined value.
2.
utility area.
duress pendant.
weapons.
personal effects.

Page 35 of 85
MAIN ENTRY

1. Entry by all relevant personnel visiting or working 1.
within the Hospital. CTV with video playback.
2.
fter hours remote switch and intercom.
3.
se of reed switches on all external doors
and swipe card entries.
4.
ecurity personnel accommodated in this
area to monitor all areas via TV monitor.
5.
ontrol of access "after hours".

1. Relatives / Visitors 1. Staff separated from public by an
appropriate screen with slit for document
transfer, and appropriate voice transfer
"system".
2.
duress pendant.
personal effects.
5. Cash Handling 1. Keep cash to a minimum.
2. Limit number of staff with access.
3. Minimise locations where money kept.
4. Petty cash draw/safe in secure area.
5. Use of strong rooms or safes, if
appropriate.
6. Money handling (eg, cash counting)
should be out of view of the public.

Page 36 of 85
WARDS

1. Entry by all relevant personnel visiting or working 1. CCTV monitoring of Ward
within the Hospital. 2. After hours remote switch a
3. Use of reed switches on all exter

ward.
2. Manage relatives/visitors admittance
in the area by restricting visiting hours
and/or number of visitors.
2. Keep equipment
duress pendant.
personal effects.

Page 37 of 85
METHADONE CLINIC

1. Entry of personnel visiting or working within the 1. CCTV monitoring of entry and exit
clinic. doorways.
2. Intercom on entry doors.
3. Use of reed switches on all external
doors and swipe card entry to staff areas.
4. Public accessible spaces to be designed
to eliminate spaces conducive to illegal
activity.

1. Client / Visitor access 1. Client access to Clinic but not to
'secure' areas utilised to store and
dispense drugs.
2. Keep equipment
duress pendant.
2. Locked doors between Clinic dispensing
areas and clients.
3. Interview rooms to have alternate means
of staff egress.
4. Dispensing Counter to be constructed to
prevent unauthorised client entry/access.
5. Waiting area furniture to be designed to
be unlikely to be utilised as a weapon.
personal effects.
2. Safes to comply with the Poisons Act
in respect of secure storage provisions.

Page 38 of 85
NEEDLE / SYRINGE EXCHANGE

1. Entry by all relevant personnel visiting or working 1. Determine most appropriate methodolo
within the Hospital.

1. Client access 1. Provide secure environment for
exchange or procurement of clean
injecting equipment.
2. Keep equipment
duress pendant.
2. Only authorised Needle/Syringe
Program personnel to dispense clean
injecting equipment and collect used
needles and syringes.
3. Option of syringe dispensing
machines.
4. Staff to be provided with appropriate
'sharps' containers / "Used" injecting
equipment not to be touched by staff -
clients to place in 'sharps' containers.
5. All staff to wear appropriate safety
clothing/equipment.
personal effects.

Page 39 of 85
RETAIL AREA

1. Access by all personnel visiting or working within 1. CCTV monitoring of en
the Hospital. 2. No after ho

1. Staff/Patient/Visitors access 1. Design to minimise opportunities for
people to loiter.
2. Furniture fittings and equipment 1. Where applicable, non-removable 'Asset
No.' on all equipment above a
predetermined value.
3. Public Telephone locations 1. Locate in a position that does not
allow people to use pretence of public
phone utilisation to monitor retail area.
4. Hospital personnel safety 1. Where applicable, Staff working in
this area to have knowledge of where the
fixed duress system is located and/or use
a mobile duress pendant.
personal effects.
2. 2. Do not include staff lockers/etc in
areas accessible by Public.
6. Cash Management 1. Minimise cash in cash registers.
2. Drop-safe located in high-visibility area.

Page 40 of 85
CARPARKING / EXTERNAL AREAS

1. Secure access for facility personnel from car to 1. CCTV monitoring.
security of the facility. 2. Carpark location in respect of staff
access doors.
3. Security.
4. Fencing.
5. Lighting.
6. Nominated staff parking.

1. Hospital personnel safety. 1. Provision of 'non-public'/staff parking
area adjacent to staff entrance/s.
2. Minimise, if possible, public access to
staff carparking areas.
3. Eliminate landscaping that could be
utilised as a place of concealment by
personnel.
4. Ensure appropriate level of lighting at
night.
5. Provide highly visible fixed duress alarm
points.
6. Monitor carpark by CCTV.

Page 41 of 85
MORTUARY

1. Area for temporary storage of deceased patients, 1. Minimise entry and exit doors.
and the provision of viewing facilities for relatives. 2. Security of Entry via intercom.
3. Separation of staff and visitor areas.

1. Relatives / Visitors 1. Manage relatives/visitors admittance to
the viewing area by restricting number of
persons.
2. Separate viewing area from staff area by
physical barrier.
3. Provision of an adequate waiting area for
relatives/visitors that may be in the area
"out-of-hours". This area to be able to be
secured and monitored by staff.
duress pendant.
3. Theft of patient personal effects 1. Provision of suitable secure area/
cabinet/etc for the storage of patient
personal effects.
4. Staff personal effects 1. Provision of lockers in staff areas and
personal effects.

Page 42 of 85
DENTAL CLINIC

1. Area used to provide dental treatment to patients. 1. Control access to this area.

2. Patient medical records files 1. Personnel working on these records
3. Drugs storage 1. Drug safe within the clean utility area or
other appropriate area.
4. Hospital personnel safety 1. Provide suitable working area for
patients, but prevent unauthorised
access from waiting area to treatment
area.
2. Restrict number of patients/relatives in
treatment area.
3. Staff working in this area to have
duress pendant.
4. Access doors to be locked at all times
personal effects.

Page 43 of 85
PATHOLOGY
1. Access for personnel working in the area and 1. Control access to patient reception area.
patients obtaining test results, etc. 2. Use of reed switches on all external
doors and swipe card entry to staff areas.

1. Patient access 1. Patient access to secure reception
counter but not to 'secure' areas utilised
to undertake testing.
duress pendant.
2. Locked doors between reception counter
and work area.
3. Reception Counter to be constructed to
prevent unauthorised patient
entry/access.
personal effects.
5. Drugs storage 1. Drugs safe to be located in area that can
be monitored by staff.
2. Safes to comply with the Poisons Act in
respect of secure storage provisions.

Page 44 of 85
Checklists

Page 45 of 85
ADMINISTRATION / ACCOUNTS
FACILITY: DEPARTMENT: Administration/Accounts

RISK ISSUE DESIGN RESPONSE
1. Do staff have access to both fixed and
mobile duress systems ?
2. How is access to patient records restricted to
staff entitled to that access ?
3. How is after hours access provided for staff ?
4. How are the offices secured during and after
hours ?
5. How is money secured ?
6. Are there lockable storage areas available for
specialised equipment ?
7. Is lockable furniture provided for staff
personal effects storage ?
8. Are money handling facilities secure and not
in public view ?
DESIGN COMMENTARY/NOTES DESIGN SIGN-OFF

Name: ………………..
Position: ………………..
Signature: ………………..
Date: ………………..
Name: ………………..
Date: ………………..
Name: ………………..
Date: ………………..

Page 46 of 85
ADMINISTRATION / DISCHARGE AREA
FACILITY: DEPARTMENT: Administration/Discharge

3. How is after hours access provided for staff?
hours?
6. How is money secured?
specialised equipment?
8. Is lockable furniture provided for staff
personal effects storage?
9. Are interview rooms appropriately designed
with specific reference to staff egress,
furniture selection, furniture location,
provision for storage of equipment, etc.

Name: ………………..
Date: ………………..
Name: ………………..
Date: ………………..
Name: ………………..
Date: ………………..

Page 47 of 85
BIO-MEDICAL WORKSHOP
FACILITY: DEPARTMENT: Bio-Medical Workshop

hours ?
3. Is lockable furniture provided for storage of
staff personal effects ?
4. How is access monitored ?

Name: ………………..
Date: ………………..
Name: ………………..
Date: ………………..
Name: ………………..
Date: ………………..

Page 48 of 85
DIETETICS
FACILITY: DEPARTMENT: Dietetics

1. Do staff have access to both fixed and mobile
duress systems ?
3. Is a system implemented to prevent theft of
equipment, files, personal possessions, etc ?
hours?
furniture selection, furniture location, provision
for storage of equipment, etc.

Name: ………………..
Date: ………………..
Name: ………………..
Date: ………………..
Name: ………………..
Date: ………………..

Page 49 of 85
EMERGENCY
FACILITY: DEPARTMENT: Emergency

1. Has a CCTV System been considered to
monitor the waiting area and/or access to the
public access points in the waiting area ?
2. How is 'after hours' access provided for
patients and how is this access point
monitored ?
3. Has a secure "barrier" been installed
between staff and the waiting area to:
(a) monitor the waiting area;
(b) provide staff contact with patients;
(c) provide adequate visual and audible
communication; and
(d) allow for document and item transfer.
5. Is access to patient records restricted to
6. Is a system implemented to prevent theft
of equipment, files, personal possessions,
etc ?
7. How does the ED address assessment /
treatment of potential Mental Health patients
in the ED ?
8. Is a gun safe required and is it
incorporated in the design ?
9. Are drug safes installed in accordance
with current regulations ?
10. Is the waiting area furniture incapable of
being utilised as a "weapon" ?
11. How is unauthorised access prevented
from Ambulance entrance ?
12. Is there a means of access/egress for
staff other than through the Waiting Area ?
13. How is after hours access provided for
staff ?
14. How is this area secured during and after
hours, and is access prevented to other
areas of the facility after hours ?
15. Are there lockable storage areas
available for specialised equipment ?
16. Is lockable furniture provided for storage
of staff personal effects ?
17. Is appropriate bench seating provided for
patients/visitors/relatives ?
18. If a TV is provided in waiting area, is it
securely fixed and out of reach of visitors,

Page 50 of 85
etc. ?
Name: ………………..
Date: ………………..
Name: ………………..
Date: ………………..
Name: ………………..
Date: ………………..

Page 51 of 85
CENTRAL STERILISING DEPARTMENT
FACILITY: DEPARTMENT: Central Sterilising

duress systems ?
duress systems ?
4. How is after hours access provided to staff?
hours?
staff personal effects?

Name: ………………..
Date: ………………..
Name: ………………..
Date: ………………..
Name: ………………..
Date: ………………..

Page 52 of 85
OPERATING THEATRES / RECOVERY DAY PROCEDURES
FACILITY: DEPARTMENT: Operating Theatres/ Recovery

Day Procedures
duress systems ?
2. Is access to patient records restricted to staff
entitled to that access ?
4. Are drug safes installed in accordance with
current regulations ?
hours?
10. How is access by relatives/visitors managed
and monitored ?

Name: ………………..
Date: ………………..
Name: ………………..
Date: ………………..
Name: ………………..
Date: ………………..

Page 53 of 85
RENAL
FACILITY: DEPARTMENT: Renal

monitored ?
duress systems ?
hours?

Name: ………………..
Date: ………………..
Name: ………………..
Date: ………………..
Name: ………………..
Date: ………………..

Page 54 of 85
KITCHEN
FACILITY: DEPARTMENT: Kitchen

duress systems ?
hours?

Name: ………………..
Date: ………………..
Name: ………………..
Date: ………………..
Name: ………………..
Date: ………………..

Page 55 of 85
MATERNITY
FACILITY: DEPARTMENT: Maternity

monitored ?
duress systems ?
hours?
10. How does this Department address the
security of babies ?
11. What systems are utilised to monitor access
to rooms/wards by patients/visitors ?

Name: ………………..
Date: ………………..
Name: ………………..
Date: ………………..
Name: ………………..
Date: ………………..

Page 56 of 85
MEDICAL IMAGING
FACILITY: DEPARTMENT: Medical Imaging

monitored ?
duress systems ?
hours?
9. Has a secure waiting area been planned in
this area that allows for the public to present
at a counter, sign forms, wait and then receive
photocopies of relevant records as
requested?
10. How is after-hours access provided to staff
and patients ?

Name: ………………..
Date: ………………..
Name: ………………..
Date: ………………..
Name: ………………..
Date: ………………..

Page 57 of 85
MEDICAL RECORDS
FACILITY: DEPARTMENT: Medical Records

duress systems ?
hours?
8. How is after-hours access provided for staff,
including access from all other areas of the
facility ?
9. Has a secure waiting area been planned in
this area that allows for the public to present
at a counter, sign forms, wait and then receive
photocopies of relevant records as
requested?

Name: ………………..
Date: ………………..
Name: ………………..
Date: ………………..
Name: ………………..
Date: ………………..

Page 58 of 85
PAEDIATRIC
FACILITY: DEPARTMENT: Paediatric

monitored ?
duress systems ?
hours?
10. What system has been implemented to
prevent the illegal removal of children ?
12. What surveillance/monitoring system will be
implemented to monitor access to
rooms/wards ?

Page 59 of 85

Name: ………………..
Date: ………………..
Name: ………………..
Date: ………………..
Name: ………………..
Date: ………………..

Page 60 of 85
PHARMACY
FACILITY: DEPARTMENT: Pharmacy

1. Has a secure "barrier" been installed between
staff and the dispensing area to:
(a) monitor the dispensing area; and
(b) provide staff contact with patients.
duress systems ?
current regulations and the Poisons Act ?
6. Is the dispensing area furniture incapable of
hours?
11. Has the potential risk of hold-up and/or break-
in been addressed in the design ?

Name: ………………..
Date: ………………..
Name: ………………..
Date: ………………..
Name: ………………..
Date: ………………..

Page 61 of 85
PODIATRY
FACILITY: DEPARTMENT: Podiatry

equipment, files, personal possessions, etc, ?
hours ?
duress systems ?

Name: ………………..
Date: ………………..
Name: ………………..
Date: ………………..
Name: ………………..
Date: ………………..

Page 62 of 85
REHABILITATION
FACILITY: DEPARTMENT: Rehabilitation

duress systems ?
hours?
7. Has a system been included to address
'patient wandering' ?

Name: ………………..
Date: ………………..
Name: ………………..
Date: ………………..
Name: ………………..
Date: ………………..

Page 63 of 85
SOCIAL WORKER
FACILITY: DEPARTMENT: Social Worker

monitored ?
duress systems ?
3. Do interview rooms provide for alternate
forms of egress for staff ?
4. Has furniture in interview rooms been
minimised, and selected as appropriate for
this area ?
hours?

Name: ………………..
Date: ………………..
Name: ………………..
Date: ………………..
Name: ………………..
Date: ………………..

Page 64 of 85
STRESS TESTING
FACILITY: DEPARTMENT: Stress Testing

hours?

Name: ………………..
Date: ………………..
Name: ………………..
Date: ………………..
Name: ………………..
Date: ………………..

Page 65 of 85
OUTPATIENT AREA
FACILITY: DEPARTMENT: Outpatient Area

hours?
7. Is waiting area appropriately designed to
include, where appropriate:
-barrier between patients and staff,
-appropriate seating for patients,
-absence of loose fittings,
-vending machines,
- TV

Name: ………………..
Date: ………………..
Name: ………………..
Date: ………………..
Name: ………………..
Date: ………………..

Page 66 of 85
ICU / CCU / HDU
FACILITY: DEPARTMENT: ICU / CCU / HDU

monitored ?
staff and the waiting area to:
(a) monitor the waiting area; and
duress systems ?
8. Is the waiting area furniture incapable of being
utilised as a "weapon" ?
hours?

Page 67 of 85

Name: ………………..
Date: ………………..
Name: ………………..
Date: ………………..
Name: ………………..
Date: ………………..

Page 68 of 85
LIBRARY / EDUCATION
FACILITY: DEPARTMENT: Library / Education

duress systems ?
3. If applicable, how is after hours access
provided for staff?
hours?

Name: ………………..
Date: ………………..
Name: ………………..
Date: ………………..
Name: ………………..
Date: ………………..

Page 69 of 85
SURGICAL
FACILITY: DEPARTMENT: Surgical

monitored ?
duress systems ?
hours?

Page 70 of 85

Name: ………………..
Date: ………………..
Name: ………………..
Date: ………………..
Name: ………………..
Date: ………………..

Page 71 of 85
MAIN ENTRY
FACILITY: DEPARTMENT: Main Entry

monitored ?
(b) provide staff contact with patients/visitors.
duress systems ?
hours?
10. How does money get secured?

Page 72 of 85

Name: ………………..
Date: ………………..
Name: ………………..
Date: ………………..
Name: ………………..
Date: ………………..

Page 73 of 85
WARDS
FACILITY: DEPARTMENT: Wards

monitored ?
duress systems ?
hours?
11. How is the security of patient's valuables
managed?

Page 74 of 85

Name: ………………..
Date: ………………..
Name: ………………..
Date: ………………..
Name: ………………..
Date: ………………..

Page 75 of 85
METHADONE CLINIC
FACILITY: DEPARTMENT: Methadone Clinic

duress systems ?
6. Is the waiting area furniture unlikely to be
7. Where applicable, how is after hours access
provided for staff?
hours?

Name: ………………..
Date: ………………..
Name: ………………..
Date: ………………..
Name: ………………..
Date: ………………..

Page 76 of 85
NEEDLE / SYRINGE EXCHANGE
FACILITY: DEPARTMENT: Needles/Syringe Exchange

duress systems ?
5. Where applicable, are drug safes installed in
accordance with current regulations ?
7. Where applicable, how is after hours access
provided for staff?
hours?

Name: ………………..
Date: ………………..
Name: ………………..
Date: ………………..
Name: ………………..
Date: ………………..

Page 77 of 85
RETAIL AREA
FACILITY: DEPARTMENT: Retail

1. How is this area monitored ?
2. Have public phones been positioned so that
they cannot be utilised as an excuse to loiter
and monitor retail area, eg, in a discrete area
separate to the retail area ?
3. Do staff have access to appropriate (ie, fixed
and/or mobile) duress systems ?
4. How is cash secured ?
hours?
6. Where appropriate, is lockable furniture
provided for storage of staff personal effects?
7. How is cash managed to ensure minimum
amounts of cash "on hand" ?
8. Are drop safes/teller machines in highly
visible area ?

Name: ………………..
Date: ………………..
Name: ………………..
Date: ………………..
Name: ………………..
Date: ………………..

Page 78 of 85
CARPARKING
FACILITY: DEPARTMENT: Carparking

1. How is safe/secure carparking provided for
staff ?
2. Has the option of 'secure' parking for staff
been considered ?
3. Has the option of nominated staff parking
areas been considered for afternoon and
night shift staff ?
4. Has landscaping in carparks been considered
as potential areas of concealment for
personnel ?
5. Is lighting adequate to fully illuminate all staff
parking areas ?
6. Has CCTV been considered to monitor
carpark ?
7. Is access to facility from carpark via a specific
staff entrance (to eliminate potential of non-
staff presence) ?

Name: ………………..
Date: ………………..
Name: ………………..
Date: ………………..
Name: ………………..
Date: ………………..

Page 79 of 85
MORTUARY
FACILITY: DEPARTMENT: Mortuary

1. Has a waiting area been provided for
relatives/visitors which can be secured and
monitored by staff ?
2. Has a secure viewing area been provided that
does not allow access by relatives/ visitors to
staff areas ?
3. How is "after hours" access provided for
relatives/visitors ?
4. Has a secure barrier been installed between
a) monitor the waiting area; and
b) provide staff contact with relatives/ visitors
?
duress systems ?
6. Has a "secure area" been provided for the
storage of patients' personal effects ?
7. How is after hours access provided for staff ?
utilised as a 'weapon' ?
9. How is the area secured during and after
hours ?
10. Are lockable storage areas available for

Name: ………………..
Date: ………………..
Name: ………………..
Date: ………………..
Name: ………………..
Date: ………………..

Page 80 of 85
DENTAL CLINIC
FACILITY: DEPARTMENT: Dental Clinic

duress systems ?
hours?

Name: ………………..
Date: ………………..
Name: ………………..
Date: ………………..
Name: ………………..
Date: ………………..

Page 81 of 85
PATHOLOGY
FACILITY: DEPARTMENT: Pathology

staff and the reception counter to:
a) monitor the counter area; and
b) provide staff contact with patients.
duress systems ?
current regulations and the Poisons Act ?
6. Is the reception area furniture incapable of
hours?

Name: ………………..
Date: ………………..
Name: ………………..
Date: ………………..
Name: ………………..
Date: ………………..

Page 82 of 85
APPENDIX A
SCHEDULE OF NSW HEALTH

DESIGN AND TECHNICAL GUIDELINES
DS1 Process of Facility Planning (1993)
DS2 Biomedical Engineering HBG-KIT (1992)
DS3 Central Sterile Supply Unit MBG-KIT (1992)
DS4 Community Health Unit HBG-KIT (1992)
DS6 Design Considerations for Infection Control (1989)
DS7 Emergency Unit HBG-KIT (1992)
DS8 Engineering & Maintenance Unit HBG-KIT (1992)
DS10 Standards for Hospital Planning Units – KIT (1992)
DS12 Inpatient Assessment & Rehab. HBG-KIT (1992)
DS13 Intensive Care / Coronary Care HBG-KIT (1992)
DS14 Linen Handling Unit HBG0KIT (1992)
DS15 Medical Imaging Unit HBG-KIT (1992)
DS16 Medical / Surgical Inpatient Unit HBG-KIT (1992)
DS17 Mortuary / Post Mortuary Unit HBG-KIT (1992)
DS18 Obstetric Unit HBG-KIT (1992)
DS19 Operating Suite / Day Procedures HBG-KIT (1992)
DS20 Medical Records Unit HBG-KIT (1993)
DS21 Pathology Unit HBG-KIT (1993)
DS22 Paediatric Inpatient Unit HBG-KIT (1192)
DS23 Pharmacy Unit HBG-KIT (1992)
DS24 Post-occupancy Evaluations (1994)
DS25 Day Oncology Unit HBG-KIT (1993)
DS26 Mental Health Unit (2001) – Final Draft
DS27 Rehabilitation / Day Hospital Unit HBG-KIT (1992)
DS28 Drug & Alcohol Service HBG-KIT (1992)
DS29 Stores Unit HBG-KIT (1992)
DS31 Guideline for Furniture & Equipment Budgeting
DS32 Improved Access for Health Care Facilities (1994)
DS33 Process of Facility Planning Video (1995)
DS34 Process of Facility Planning – Small Folder (1995)
DS35 Rural Health Service Building Guidelines (2000) CD ROM
TS2 Signposting for Health Care Facilities (1994)
TS3 Hospital Fire Manual 2nd Edition (1988) – HOSPLAN
TS4 Hospital Fire Officer's Handbook (1987) – HOSPLAN
TS5 Emergency Fire Procedures (1990) – HOSPLAN
TS7 Floor Coverings for Health Care Buildings (1988) – HOSPLAN
TS10 Std Procedures for Handling of Accountable Items
TS11 Engineering Services Guidelines – KIT (1994)
TS13 Cost Benchmarking Guidelines – KIT (1994)
TS14 Managing Maintenance Guidelines (1994)
TS15 Health Economic Appraisal Guidelines (1995)
TS16 Reference Code for Conventional Cook Chill (1998)
TS17 Reference Code for extended Shelf Life Cook Chill (1998)
TS18 Asset Strategic Planning Guidelines (1996)
TS19 Asset Strategic Planning Benchmark Support (1997)
TS20 Reference Code for Cook Freeze (1998)
TS21 Reference Code for Cook Serve (1998)

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Policy Directive

Department of Health, NSW

Safety and Security Release of the Health Facility Guideline -

Issued 27 February 2003

Distributed in accordance with circular list(s):

A 13 B C 9 D E 73 Miller Street North Sydney NSW 2060

HEALTH FACILITY GUIDELINE -

WORKING DRAFT Revision Date 03.10.02

WORKING DRAFT Revision Date 03.10.02

2.0 STRUCTURE OF THIS GUIDELINE ................................................................9

3.0 FUNCTIONAL AREAS ................................................................................... 13

WORKING DRAFT Revision Date 03.10.02

3.26 NEEDLE / SYRINGE EXCHANGE..............................................................................39

A. NSW Health Design and Technical Guidelines

WORKING DRAFT Revision Date 03.10.02

PRINCIPLES OF THIS GUIDELINE

However, unexpected and unusual incidents do happen in the workplace. Effective

PURPOSE AND SCOPE

This document is intended as a guideline to assist in the identification of potential

WORKING DRAFT Revision Date 03.10.02

EMERGING TECHNOLOGY & CLINICAL WORK PRACTICES

WORKING DRAFT Revision Date 03.10.02

WORKING DRAFT Revision Date 03.10.02

STRUCTURE OF THIS GUIDELINE

ANALYSIS BY FUNCTIONAL AREAS

This Guideline consists of an analysis of a 'Health Facility' undertaken on a

Notwithstanding the above, the design of a particular Department/Functional Area

RISK ANALYSIS AND RISK MANAGEMENT

The basis of this Guideline is the implementation of an appropriate risk analysis of

WORKING DRAFT Revision Date 03.10.02

CRIME PREVENTION THROUGH ENVIRONMENTAL DESIGN

Crime Prevention through Environmental Design (CPTED) is a situational crim

WORKING DRAFT Revision Date 03.10.02

This document should also be read in conjunction with the following:

- The Process of Facility Planning, NSW Health Department, 1989.

WORKING DRAFT Revision Date 03.10.02

APPLICATION OF THE GUIDELINES

RISKS AND CHECKLISTS

This Guideline has been prepared in two sections:

As a consequence of the assessed generic risks, a number of potential

2. Section 4.0 is a "checklist" for each Functional Area/Department.

WORKING DRAFT Revision Date 03.10.02

GENERIC SAFETY AND/OR SECURITY RISKS POTENTIAL SOLUTIONS

SPECIFIC SAFETY AND/OR SECURITY RISKS POTENTIAL SOLUTIONS

WORKING DRAFT Revision Date 03.10.02

ADMINISTRATION / DISCHARGE AREA

GENERIC SAFETY AND/OR SECURITY RISKS POTENTIAL SOLUTIONS

SPECIFIC SAFETY AND/OR SECURITY RISKS POTENTIAL SOLUTIONS

WORKING DRAFT Revision Date 03.10.02

GENERIC SAFETY AND/OR SECURITY RISKS POTENTIAL SOLUTIONS

SPECIFIC SAFETY AND/OR SECURITY RISKS POTENTIAL SOLUTIONS

WORKING DRAFT Revision Date 03.10.02

GENERIC SAFETY AND/OR SECURITY RISKS POTENTIAL SOLUTIONS

SPECIFIC SAFETY AND/OR SECURITY RISKS POTENTIAL SOLUTIONS

WORKING DRAFT Revision Date 03.10.02

GENERIC SAFETY AND/OR SECURITY RISKS POTENTIAL SOLUTIONS

SPECIFIC SAFETY AND/OR SECURITY RISKS POTENTIAL SOLUTIONS

WORKING DRAFT Revision Date 03.10.02

2. Alternate exit door for staff in case of

WORKING DRAFT Revision Date 03.10.02

CENTRAL STERILISING DEPARTMENT

GENERIC SAFETY AND/OR SECURITY RISKS POTENTIAL SOLUTIONS