Closing the loop

The final stage of incident management is continuous improvement. This includes how you:

• apply and adapt your processes
• address any gaps or barriers that arise
• use Incident Management System (IMS) data to review your processes
• communicate your findings to those affected.

Strong incident management with a focus on continuous improvement will help you to:

• learn from incidents and near misses
• understand how to prevent incidents from happening again
• build trust with your workers.

Key actions

1. Conduct an end-to-end process review after each incident.
2. Make sure policies and procedures outline how to close the loop effectively.
3. Communicate with those involved in the incident throughout the resolution process.
4. Review your service’s policies and IMS procedures.
5. Give feedback to your manager after the incident and after you implement changes.
6. Conduct regular IMS data reviews to understand incidents, patterns and trends.
7. Learn from incidents.

Management responsibilities

If an incident occurs, you must conduct an end-to-end process review. This should involve using IMS data to examine your process and any changes you make.

After an incident, your focus must be on continuous improvement measures such as:

• implementing actions to address the issue
• communicating with those involved in the incident
• providing ongoing feedback and training.

You must regularly assess, review and monitor your IMS data. This will help ensure that data is accurate and informs further improvement.

Analysing your IMS data

IMS data plays a vital role in your process review. If your data is accurate and reliable, it offers great insights into future risks and improvements.

Analysing all your available IMS data helps you to:

• identify and address systemic issues with care quality
• determine if an incident or near miss has happened more than once
• analyse incident trends and causes
• develop incident management and prevention training
• give us any information that we request.

Reflecting on IMS data analysis

Everyone has a role in improving the analysis of IMS data and actions.

As a worker, ask yourself these questions:

• Do I know how to recognise an incident?
• Is it clear how to react if an incident occurs?
• Is there any area I feel unsure about?
• Do the actions I take help reduce further harm?
• Does management listen to feedback from me and other workers?
• Did I learn from the incident investigation?

If these questions give you any ideas or feedback, please share them when needed.

Evaluating the outcome

Evaluating the outcome is the final step in the 5-step problem-solving process.

Ask yourself these questions:

• Have I achieved what I set out to do?
• Has the change improved practices and reduced future risks?
• What work will ensure continuous improvement across the service?
• What was the impact and result for the person receiving aged care and relevant parties?
• What's different?
• Is the solution effective?

Communicating your findings

If there's an incident, you must keep open communication with:

• workers
• board members
• organisational leadership
• the public
• those involved in the incident
• people receiving aged care and their representatives.

Examples of communication may include:

• giving progress updates
• discussing outcomes
• advising relevant parties of any changes you make in response.

Open disclosure

The Aged Care Quality Standards require your organisation to practice open disclosure. This means disclosures should be timely and honest when reviewing incidents.

Open disclosure helps ensure that all relevant parties are aware of any incidents. It's also essential to involve them in any changes to your processes.