Overview
The final step when managing incidents is closing the loop. Here you examine issues, barriers, how they have been addressed, the successes and adjustments made along the way. This also helps identify gaps, drive continuous improvement, and communicate findings to those affected.
You will complete an end-to-end review of the process on both a macro and micro level to look at how the process was followed during the incident and an overall review to examine any changes to the process. After an incident, your focus will be on the continuous improvement process, where you use your IMS incident data to conduct a high-level examination of across your service.
Overview
The final step when managing incidents is closing the loop. Here you examine issues, barriers, how they have been addressed, and the successes and adjustments made along the way. This also helps identify gaps, drive continuous improvement, and communicate findings to those affected.
Management will complete an end-to-end review of the process looking both at the process itself and how it was applied during an incident. You may be asked for feedback to help drive continuous improvement and further down the line to see if the changes have made a difference.
Key actions
-
Make sure a holistic review is conducted of the end-to-end process for each incident
-
Make sure policies and procedures clearly outline how to close the loop effectively
-
Ensure those impacted by the incident are engaged and updated throughout the resolution process, including findings and actions implemented
-
Make sure you regularly conduct formal IMS data reviews, to analyse incidents, patterns, trends and promote continuous improvement
Key actions
-
Learn from incidents
-
Review your service’s policies and IMS procedures
-
Share feedback with your manager both after an incident and after changes have been implemented
Your role
Before closing the loop, you must complete a holistic review of the incident management process.
You are also responsible for regularly assess, review, and monitor your IMS data to ensure your IMS is effective and reliable. This is critical as your IMS provides valuable insight into future risks and improvements necessary.
Your role
To close the loop management will review the process end to end, this can involve asking for your feedback as a staff member. Working with consumers in their home and offsite means that you are likely to have experiences and a point of view that is valuable to improving the process as you will see any changes made put into practice.
Share feedback with your service to help make changes that can improve the quality of care for consumers and others associated with aged care.
How do we improve?
The key aims of the incident management process are to learn from incidents and near misses, to know what can be done to prevent them from occurring again and build trust with workers and your system.
By analysing all the IMS data, it helps to:
-
identify and address systemic issues in the quality of care provided
-
identify repeated occurrences (including alleged/suspected occurrences) of similar incidents or near misses
-
analyse trends and identify patterns of incidents (e.g. behaviours)
-
provide feedback and educate staff about prevention and management of incidents
-
provide information to the Commission when requested.
Are the correct resources and people used to prevent and manage incidents?
Analysing incident trends and data
Your service’s IMS must allow the collection of data and other information relating to incidents. The process should:
- identify and address systemic issues in the quality of care provided
- identify repeat incidents— including alleged occurrences
- analyse trends and identify incident patterns
- allow for feedback and training on preventing and managing incidents
- provide information to the Commission when requested.
Incident data should be regularly reviewed and analysed to help inform improvements. Part of the broader risk management process in identifying risks the following should be considered:
- incident trends
- incident causes
- common or repeat incidents
- feedback from consumers, workers and others.
Your voice is important, ask questions and provide feedback to your manager.
Evaluate the outcome
Once the incident has been defined, the cause determined, actions identified and implemented, the final step in the 5-step problem solving process is to evaluate the outcome.
You should ask yourself these questions:
-
Have we accomplished what we set out to achieve?
-
Has the introduced change improved practice and/or reduced future risks?
-
What work is required to ensure continual improvement is made across your service?
-
What was the impact and result for the consumer and impacted parties?
05. Evaluate the outcome
-
Is the solution effective and has it been sustained?
Learning from Incidents
The key aims of the incident management process are to learn from incidents and near misses, to know what can be done to prevent them from occurring again and build trust in your service’s system.
Information should be shared to help you and others avoid repeating incidents. Your management should share results of an incident investigation with you along with the board, the leadership team, those affected by the incident and the public.
Reflecting on the incident analysis
Your service’s IMS needs to be regularly checked to ensure that it is working as required. Regular review helps to find areas for further improvement. If you have feedback do not wait for your manager to request it, share changes you think might be needed as they appear.
Everyone has a role in improving the quality of incident analysis and actions.
-
Do you know how to recognise an incident?
-
Was it clear how to react when an incident occurred?
-
Is there any area you feel you were unsure about?
-
Were the actions taken able to reduce further harm?
-
Does management listen to yours and others feedback?
-
Were you able to learn from the incident investigation?
If there are areas of improvement you think management should know about, share your thoughts and concerns.
Open Disclosure
Your service should be practicing open disclosure. Part of the final step in incident management review checks that consumers and their family or representatives have been made aware of any incident that has occurred. It is a requirement under the quality standards and is an opportunity to involve consumers in the process of any changes made.
Results communicated
Ensure you maintain open communication channels and engage with key parties impacted by the incident. This includes providing relevant updates and discussing outcomes. You should ensure that any organisational changes made in response to an incident are well communicated to consumers and their representatives, workers and other third parties.
Example
George, a consumer living in the memory support unit, was reported as absent from care without explanation by personal care worker Kelly after she did not see him for an hour, and he could not be located following a search of the facility. Police were contacted immediately, and the family notified. George was found not far from the facility at the local shops. He was not injured but was very confused and agitated. Due to the seriousness of the incident, management conducted an internal investigation.
As part of this investigation, you examined George’s history of wandering and the incident details. You determined that George's cognitive impairment and a staff member leaving a door open contributed to this incident. Actions, including some changes to the service's processes in the memory support unit, have been implemented.
The final step in the problem-solving process requires you to evaluate the outcome to check if your solution was effective and confirm if it is still working.
Your evaluation findings examine:
-
feedback from George and his family, which confirmed actions implemented were working effectively
-
feedback from staff and management confirm staff training has directly improved behaviour and practices
The service’s management continues to monitor feedback and reporting to identify areas for continuous improvement. There have been no repeat incidents and no other issues reported.
You determine the actions implemented have been successful and recommend management continue to monitor progress with scheduled reviews.
Contact us
If you have a question about the SIRS, you can call us on 1800 081 549. This phone line is open 9 am to 5 pm (AEST) Monday to Friday and 8 am to 6 pm (AEST) Saturday to Sunday.
You can also email us at sirs@agedcarequality.gov.au.
Facilitated workshops
The Commission provides facilitated workshops to sector participants. All current workshops are available on the Commission’s Workshop page.
Online learning
The Commission’s Aged Care Learning Information Solution, Alis provides free online education for employees of Commonwealth-funded aged care providers, including modules covering reportable incidents and the eight reportable incident types.
You can access Alis at learning.agedcarequality.gov.au
Disclaimer
The information contained on this page is intended to provide you with general guidance; however, it is your responsibility to be aware of your legislative requirements.
