What is the outcome that needs to be achieved?
The provider* uses an incident management* system* to safeguard older people and acknowledge, respond to, effectively manage and learn from incidents.
Actions
The provider implements an incident management system to record, investigate, respond to and manage incidents and near misses that occur in connection with the delivery of care and services and reduces or prevents incidents from recurring.
The provider takes timely action to respond to and manage incidents.
The provider supports older people, family and carers to report incidents and encourages their involvement in identifying ways to reduce incidents from occurring.
The provider supports the workforce to prevent, recognise, respond to and report incidents.
The provider collects and analyses incident data. Outcomes are reported to older people and workers and feed into the provider’s quality system to improve the quality of care and services.
The provider regularly reviews and improves the effectiveness of the incident management system.
Why is this outcome important?
Outcome 2.5 explains providers’ obligations to manage and respond to incidents* well. You’re responsible for having an incident management* system* to identify, document, respond to and manage incidents. This includes making sure responses to incidents and near misses* are timely*. This is important to safeguard the health and wellbeing* of older people. This also helps to create an environment that encourages accountability, transparency, trust and safety.
By collecting, analysing and integrating incident data in your quality system*, you can identify organisation-wide issues and trends. This can help you to learn from incidents, strengthen your strategies to mitigate risk and improve the safety of care and services you provide. Managing incidents in this way supports your overall quality system* and drives continuous improvement*.
You need to give focus to:
- supporting and encouraging older people and workers to:
- report incidents
- identify ways to stop incidents from happening
- incident management* responsibilities for workers.
Key tasks
Providers
Providers
Put in place an incident management* system*.
At a minimum, make sure your incident management* system* outlines:
- clear and documented processes*, roles and responsibilities* on how you:
- acknowledge incidents*
- record incidents
- assess and investigate incidents
- respond to incidents
- manage incidents
- resolve incidents
- learn from incidents, to prevent or reduce future incidents from happening again.
- categories to define an incident*. Be clear about what an ‘incident*’ or ‘near miss*’ includes. This definition needs to be clear about what an incident is in the context of the organisation’s scope of services. Include situations that have, or could, cause harm to a person. The categories need to be in line with the Serious Incident Response Scheme (SIRS). They also need to include harm or possible harm to:
- an older person
- a member of their family
- a worker*
- another person providing care and services.
Incidents can be clinical or non-clinical. Incidents can also relate to worker* safety.
Use your incident management* system* to report and respond to incidents.
Have clear processes* to respond to each type of incident* that can happen when you deliver care and services. Outline who needs to be involved and the timeframe when you need to carry out key activities. Key activities can include reporting, investigations and sharing information.
Incidents that you need to report include near misses*, as well as incidents that:
- have happened
- are alleged or suspected, even if you can’t confirm the incident*.
Serious incidents must be reported following the Serious Incident Response Scheme (SIRS) process. These are incidents where older people have been harmed or were at risk of harm.
Have clear processes* to record and report different types of incidents. Include:
- who reports incidents
- how to document an incident* report
- what level of detail to put into an incident* report
- how to submit the incident* report
- how long you have to submit an incident* report.
After an incident*:
- be clear who is responsible for deciding on immediate actions to keep older people and workers safe
- review an older person’s care and services plan* if an incident involves them (Outcomes 3.1 and 5.4)
- investigate the cause of an incident*. Make sure incidents are investigated. This is to find and manage the underlying cause of an incident* and prevent it from happening again. Be open about the outcome* of the investigation. Share this with the older person, their families and carers if the older person chooses to.
- look for trends to find organisation-wide issues and ways to improve. Do this as part of your broader performance monitoring activities (Outcome 2.3). For example, an organisation wide issue could be:
- aspects of care which aren’t delivered well. These may suggest that your organisation needs additional worker* training.
- older people regularly* fall in a particular spot at the service delivery location and you need to redesign the area to be safer.
- use your incident management* system* to monitor and review the strategies you have to manage the cause of the incident and the risk of it happening again.
If you receive a complaint* after an incident* or near miss* , integrate this information with your feedback* and complaints* management system* (Outcome 2.6).
Have an incident* reporting form and incident* register. Record key information about each incident* that has happened.
Put in place strategies to help workers manage incidents well.
Put in place policies* and procedures* that support you to use your incident management* system*. Make sure these are:
- current and informed by the latest contemporary, evidence-based practices*
- regularly* reviewed
- clear and accessible for workers and relevant people.
Provide workers with guidance and training on how to use the incident management* system* (Outcome 2.9). This needs to be in line with:
- the organisation’s policies* and procedures*
- workers’ roles and responsibilities*.
Make sure workers understand:
- their role in the incident management* system*
- how to use the system* to manage incidents when delivering care and services to older people.
The guidance for Outcomes 2.8 and 2.9 has more information on workforce* planning and human resource management.
Monitor how well you use the incident* management system*.
Regularly* review your incident* management system* to make sure it works well. Look for ways to improve the system*.
To check if your incident* management system works well, you can review:
- older people’s care and service documents (Outcome 3.1)
- complaint*s and feedback* (Outcome 2.6)
- information about incidents*
- worker* performance and how well they’re using the incident management* system*. You can do this through quality assurance and system* reviews (Outcome 2.9).
- policies* and procedures*.
Also, talk with older people, their families and carers about the care and services they receive (Outcome 2.1). Ask them if they feel their provider supports them to report incidents and involves them in finding ways to reduce incidents. These conversations can then inform continuous improvement* actions and planning (Outcome 2.1).
If you find any issues or ways you can improve through your reviews and assessments, you need to address them. If things go wrong, be open about it. Share what went wrong with older people, their family, and carers (Outcome 2.3). Put in place strategies to mitigate the risk of things going wrong again.
The guidance for Outcome 2.3 has more information on monitoring the quality system*.
