Update: Service Check Register

THE SERVICE CHECK Register (SCR) is a state-wide database used to support effective recruitment screening and misconduct processes across all NSW Health organisations. The existence of a SCR record does not preclude a staff member from being employed or engaged.

The revised NSW Health Policy Directive, the Service Check Register for NSW Health (PD2021_017) sets out the mandatory requirements for creating, updating and removing SCR records. It replaces the 2013 NSW Health Policy Directive (PD2013_036). AMA (NSW) participated in the review process of the Policy Directive which resulted in a number of important changes.

Approval by whom?

The revised NSW Health Policy Directive requires that the Chief Executive or the Secretary personally approve the creation, update or removal of a SCR record. This function can no longer be delegated.

When will a SCR record be created?

The creation of a SCR record is based on ‘serious misconduct’ that has prompted specific action, for the purpose of mitigating any related risks. Two types of SCR records have been introduced: interim records for alleged serious misconduct and final records for substantiated serious misconduct. An interim SCR record is created when it is suspected on reasonable grounds, that a staff member may have engaged in serious misconduct and, to mitigate related risks, one of several specific actions have been undertaken:

• The suspension of a staff member from duty
• The decision to not use a staff member’s services or renew their contract (provided they are a locum doctor or are employed on a casual/agency basis)
• The variation or suspension of a staff member’s clinical privileges

A final SCR record must be created when a finding indicates serious misconduct and one of several specific actions have been taken:

• The termination of a staff member’s employment or engagement
• The decision to not use a staff member’s services or renew their contract (provided they are a locum doctor or are employed on a casual/agency basis)
• The variation or cancellation of a staff member’s clinical privileges

A staff member cannot avoid a record being made simply by resigning or leaving their position, so long as any of the above actions “would have” been taken.

What is serious misconduct?

Serious misconduct involves:

• A serious sex or violence offence
• Reportable (i.e., child-related) conduct (inclusive of allegations relating to conduct outside the workplace)
• Professional misconduct
• A serious criminal offence directly relevant to and/or has an impact on a staff member’s employment
• Conduct by any staff member that presents a serious risk to the safety of patients, other staff, or visitors

Will I be advised and when?

NSW Health organisations must advise staff members if they will be subject to the creation of a SCR record, or if the status of an existing record is to be updated. This advice should be provided to a staff member, together with information detailing what risk management action for alleged serious misconduct or action in response to findings of substantiated serious misconduct will be taken.

Once a record has been created or updated, the NSW Health organisation must send the person a printout of their information contained in the Register, in writing and within 10 business days. Applicants must also be advised that they will be checked against the SCR during the recruitment process.

When will a SCR be removed?

A SCR can only be removed by the NSW Health organisation responsible for its creation. A record must be removed if it was incorrectly created or, upon review, it does not meet the criteria of the revised policy directive.

Interim records must be removed if:

• The risk assessment is updated, and its outcomes no longer meet the criteria
• The investigation or management process is discontinued, closed or finalised (where the allegation of serious misconduct is not substantiated)
• A substantiated finding of serious misconduct has been made, but the action taken in response does not meet the above criteria

Final records must be removed if:

• Upon review, the NSW Health organisation is satisfied that the risks posed no longer exist or have been sufficiently mitigated to warrant a record’s removal
• The variation or cancellation of a staff member’s clinical privileges by a NSW Health organisation (which prompted the creation of a record) has expired or been reversed
• The person with the SCR record has been employed or engaged for 12 months or more (after the date of the serious misconduct) in a similar role elsewhere and no relevant risks have been identified or have required ongoing mitigation

Requirements for local monitoring of SCR records

The Service Check Register records and authorised users accessing the Register must be continuously monitored by NSW Health organisations. As the number of users should be kept to a minimum, NSW Health organisations are to consider the ongoing need for each authorised user. In addition, the number of interim records, how long they have been open and whether they are still required, should be monitored as well as the last review date for all final records (ie. final records must be reviewed every two years).

Article contributed by Dominique Egan and Cassandra Christopher

Need help? Please contact our Workplace Relations Team for advice or assistance on 02 9439 8822 or by email workplace@amansw.com.au