When an incident occurs, there may be ‘remedial’ steps necessary to prevent similar incidents from happening in the future.
These are generally identified while analysing the incident. These actions aim to resolve a specific incident, improve the service or care provided, shape training and reduce future risk or harm.
When implementing actions, solutions need to be implemented and monitored, and the outcome communicated and recorded.
When an incident occurs, your service may need to take steps to prevent similar incidents from reoccurring.
These are generally identified during element 4 analysing the incident on the IMS cycle. These actions look to resolve a specific incident, improve the service or care provided, shape training, and reduce future risk or harm.
These steps are also known as solutions and need to be implemented, monitored and the outcome communicated and recorded.
Key actions
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Make sure policies outline how to identify, implement and review the most effective solution(s)
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Make sure policies outline how to create and implement a remedial action plan
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Make sure policies and procedures clearly define the analysis (review) process, including how to measure success and adjust actions as needed
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Where the Commission has been notified, provide updated information to the Commission on solution(s) implemented
Key actions
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Know your role in implementing actions
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Review progress regularly to measure success and adjust actions when not successful
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Engage affected parties to communicate findings, progress and outcomes for each action
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Where the Commission has been notified, provide updated information on solutions implemented to the Commission
Your role
You are responsible for managing an incident and overseeing the implementation of remedial actions.
Solutions identified during the analysis phase can be broken down into a series of actions and implemented by your team and at times, applied in sequential order.
Your role
You are responsible for supporting the solution for the incidents.
Solutions can be broken down into a series of actions or steps. It may be the responsibility of one or several people within your team and at times these solutions need to be applied sequentially.
When implementing actions, your manager should first design an action plan outlining clear expectation, responsibilities and expected results. This will also include regular check-in points with you to ensure continued success, make changes as needed or to provide additional support. You should provide timely updates when an action has not been successful, and changes are needed. In this case, you will record these changes in your IMS and communicate them with the relevant parties.
Determining appropriate remedial actions
Whenever an incident occurs, you should consider whether:
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it could have been prevented or its impact reduced if some actions had been taken
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there is an ongoing risk to consumers, visitors, workers, or others after the incident
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there are actions that can be taken to prevent or reduce the risk of it occurring again.
The next step in the 5-step problem-solving approach, introduced on analysing the incident, is step 4 ‘select and implement a solution’. This step looks to implement appropriate actions or solutions identified during the analysis or investigation of the incident.
04. Select and Implement a solution.
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What are we trying to accomplish?
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Is this action appropriate?
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How will we know that the solution has improved the situation?
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What changes can we make that will result in continual improvement?
Note: not all identified actions from an analysis or investigation may be appropriate to introduce. You must understand the impact and relevance of the action(s) for your service when making these determinations.
What do remedial actions look like?
Remedial actions may include:
- providing or mandating individual and/or service-wide staff training or re-training
- making changes to your organisational or clinical governance frameworks
- reviewing and updating your practices and procedures or developing new procedures to support staff to manage risks
- making changes to your environment or equipment
- taking actions to promote a safe culture of care
- making additional staff available to assist consumers with certain activities
- seeking specialist assistance and/or implementing alternate strategies
- updating care planning documents to address the cause or impacts of the incident.
- attending training or re-training
- understanding changes made by your service relating to the service and care delivered
- changing or adjusting work practices and keeping up to date with procedural changes.
- making changes to your environment or equipment
- participating in activities to build a culture of safety
- adjusting practices to best meet needs of consumers, this may include working with other workers when doing certain activities
- knowing when to seek third party help e.g. specialist help to introduce alternate solutions or strategies
- updating care planning documents to address the cause or impacts of the incident.
Disciplinary actions
In parallel with other actions, there may also be human resources responsibilities to consider and action. This may include appropriate disciplinary action(s) when managing your team.
You should ensure that any organisational changes made in response to an incident are well communicated to consumers and their representatives, other workers and any other affected third parties.
Disciplinary actions
There may be performance or disciplinary actions that need to be addressed after an incident. This may include performance management, implementing a probationary period, standing down pending the outcome of an investigation or in some cases termination of employment.
You need to work with your manager to set clear expectations for incident management, including who communicates progress updates to impacted parties and who determines alternate solutions if initial actions have not been successful.
How to implement a ‘remedial’ action plan
Once you have determined the most effective course of action to take, your next step is to create a remedial action plan.
Ensure workers are aware of the importance of remedial actions and their role and expectations in this process. This should be reflected in your policies and procedures. Having regular check-ins with workers will allow for continued success.
When creating and implementing a ‘remedial’ action plan ensure you:
How to implement a ‘remedial’ action plan
Once you have determined the most effective course of action to take, your next step is to create a remedial action plan.
Make sure you are aware of the importance of remedial actions and your role in this process. This should be reflected in your policies and procedures. Having regular check-ins with your manager will allow for continued success.
When creating and implementing a ‘remedial’ action plan ensure you:
Communicating updates & findings
Ensure you maintain open communication channels and engage with key parties impacted by the incident. This includes providing progress updates and also discussing outcomes. You should ensure that any organisational changes made in response to an incident are well communicated to consumers and their representatives, staff and other third parties.
When talking to consumers and their representatives about incident findings and actions, use open disclosure and consider:
Communicating updates & findings
When communicating incident findings and actions to consumers, their representatives, use open disclosure and consider:
- the level of impact and appropriate response can be different for someone with dementia, mental health diagnoses or intellectual disabilities
- psychological distress may not be obvious, and has the incident had an impact on the consumer's usual wellbeing
- the views of the affected person, as well as their representative/s and other people who know them well (e.g. workers and health professionals)
- attaching relevant supporting documents, such as your internal incident form.
Where third parties, such as the NDIS Quality and Safeguards Commission, were notified of a reportable incident, they will also need to be consulted when solutions have been implemented.
Example
George, a resident living in the memory support unit, was reported as absent from care without explanation by personal care worker Kelly. She had 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 following actions were identified from the internal investigation:
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review George’s Behaviour Support Plan (BSP)
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discuss the incident and the service’s investigation and actions with George’s next of kin; this includes a recommendation to discuss care plan updates
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deliver worker education focused on health and safety obligations and ensuring everyone knows and uses relevant policy and procedures
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review organisational procedures to ensure there are no gaps.
Using the problem-solving framework, you examine the identified actions from the investigation and confirm the actions are appropriate and beneficial to implement.
You create a remedial action plan to include:
1. Review George's Behaviour Support Plan (BSP)
*You discuss George's changed care needs with his substitute decision maker and relevant medical practitioners. You make changes to George’s schedule and care routine to provide more structure and involvement in meaningful activities.
2. Discuss the incident and the service’s investigation and action with George’s family. This includes a recommendation to discuss care plan updates
*You provide information on the incident and the service's actions to George's sister, discussing proposed changes to his care, including more regular visual checks to be performed by care workers and
*You circulate an email to notify of changes across your service to those affected.
3. Deliver worker education focused on health and safety obligations and relevant policy and procedures
*You schedule training and roster workers to attend accordingly.
4. Review organisational procedures to ensure there are no gaps
*You review procedures and identify an issue with workers not closing the door due to a lack of access cards. Spare key cards for workers to use for their shifts are ordered.
*You also set up an access report so management can see how the cards and doors are used.
*Signs on doors are updated to emphasise the importance of securing exits to the facility.
Example
A consumer, Hudson, has a chronic medical condition that requires time-critical medication. Luke, one of Hudson’s care workers, regularly drives him to the shops to do his grocery shopping. It is documented in Hudson’s care plan that care workers must always have his time-critical medication with them, so Hudson can take it anytime he needs it, including when he is out.
One morning, as they were finishing the shopping and waiting at the checkout, Hudson told Luke he was feeling tired and pointed out the bench he would go to, to rest. When Hudson went outside, he noticed some of his friends sitting in the park and crossed the road to say hello. While chatting, they offered him a ride home and he accepted this kind offer but forgot about Luke. When Luke stepped out of the shop, Hudson was not where he had said he would be.
Luke returned to Hudson’s house and waited outside for 30 minutes. As Hudson had not returned and Luke did not have any means to locate or contact him, Luke decided to call the next of kin and the home service provider. Luke was concerned due to Hudson’s medical condition and the need for him to take his time-critical medication.
The service, in consultation with the next of kin, decided they would wait another two hours before contacting the police. Hudson arrived home safely two hours after he went missing from the shops.
You identify the following actions from your internal investigation:
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set expectations with Hudson while on outings
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consider other methods for shopping to provide more opportunities for social outings
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discuss the incident with Hudson and his next of kin
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change the time of the outings so that Hudson can take his medication either before or after the outing and update the care plan to reflect this
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discuss Hudson buying a mobile phone so that he can be contacted when he is out with a care worker.
Using the problem-solving framework, in line with step 4, you examine the identified solutions from the investigation and confirm your next actions. Then, you specifically look at which actions are appropriate to implement.
You then create a remedial action plan to include the following:
1. Discuss expectations with Hudson and next of kin about the times when he is out with a care worker.
The service advised Hudson that he should not leave without telling his care worker and that the two of them need to be communicating while out together. This includes outlining when his medication is due to be taken, especially when this coincides with an outing.
2. Discuss the incident with Hudson and next of kin
With Hudson’s consent, a meeting was set up with his case manager, Hudson and his daughter to discuss the incident and what happened. Hudson and his daughter were informed that the incident was recorded in the service’s IMS and reported to the Commission even though he made it safely home later. They also discussed how the incident happened, and some other actions that may help prevent it from happening again in future.
3. Change time of the outings to a new agreed time
Hudson agreed to change the time of his shopping outings, so he could take his time-critical medication before going out.
4. Change method of grocery shopping
Hudson decided he wanted to trial home delivery for his groceries so that he could use his outings to catch up with friends more frequently.
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.
