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Recommendation 39: Fully embedding workplace safety and equality in risk management and health and safety systems

The recommendation

Ambulance Victoria – led by its Board – should review, further develop and use its risk management and health and safety systems to:

  1. ensure the drivers of workplace harm identified in this review are identified, visible and escalated at an enterprise level
  2. reduce the risks to workplace equality and safety and enable continuous improvement.

What we are doing

  • Review independent risk management framework and maturity assessment report on AV
  • Define identified drivers of unlawful and harmful workplace conduct and undertake a thorough assessment through a risk lens, building on historical and contemporary data (considering linkages to the prevention plan)
  • Identify and diversify data sources to enable effective monitoring of relevant enterprise risks
  • Review and unpack relevant enterprise risks and develop an appropriate risk profile
  • Finalise the risk registrar and risk treatment plans for the Equality & Workplace Reform program
  • Clearly communicate Board risk appetite and indicators relating to workplace equality
  • Ongoing risk monitoring, analysis and reporting
  • Assess current health and safety system, in consultation with key internal and external partners and having regard to prior assessments
  • Develop an implementation plan to address any identified gaps and, once endorsed, implement changes
  • Prepare supporting materials and collateral and train relevant groups

Where we are up to


AV has undertaken a process to identify risk controls across the organisation (including the Your AV Program), which will impact the management and continuous improvement of the ‘organisational culture’ risk. In November 2023, the controls were presented to a Board sub-committee and further work has been undertaken to ensure the risk is not overly reliant on any one control and, more importantly, supported across a range. The outcomes will inform a comprehensive list of key risk indicators across AV for monitoring and continuous improvement.

AV has developed a psychosocial risk management framework as part of its health and safety systems to support and inform the continuous review of risk causes and associated controls. Additionally, a risk register has been developed for the Your AV program. This register is reviewed by the governance bodies established under the Your AV roadmap to provide oversight for program delivery and enable continuous monitoring and improvement.


  • In late 2020, after allegations emerged that led to the Independent Review into Workplace Equality in Ambulance Victoria, AV re-categorised its existing ‘organisational culture’ risk from a divisional to an enterprise risk, assigned ownership to the CEO, and developed an initial risk treatment focused on considerations related to the review.
  • Since the Victorian Equal Opportunity & Human Rights Commission published its final report, AV has been working to update the risk treatment plan, using a ‘bowtie’ risk assessment framework – in which risks are visualised in one, easy to understand picture that is shaped like a bow tie, creating a clear differentiation between proactive and reactive risks. To do this, we sought advice from the Commission to ensure we have a clear understanding of the drivers identified in its final report.
  • We are now in the process of mapping which reforms detailed in the Your AV roadmap (and which respond to the Commission’s recommendations) will act as controls to address each of these causes. Noting the complexity and pervasive nature of these causes, further work is underway to map how other critical strategies and actions plans (such as the Gender Equality Action Plan) address these risk causes.
  • As part of determining the sources of assurance of the effectiveness of AV’s risks controls for this enterprise risk, AV has also undertaken an environment scan of the available data sources (and gaps) related to the Your AV program. This work is being finalised and will support AV to diversify its evidence base into the future and avoid overreliance on limited data sources.
  • In addition, AV has developed a detailed risk register for the Your AV program of work, with oversight from the governance bodies established under the governance framework in the Your AV roadmap, as well as the Board’s Equality & Workplace Reform Committee.


  • AV has developed a risk register and risk treatment plans for the Equality & Workplace Reform work program and, in July 2022, submitted the register to the Board for noting. An immediate review of the register and treatment plans are planned after staff in the Equality & Workplace Reform Division are recruited.
  • Further work will take place once key staff are recruited.


Q3 FY24

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