Changes to Incident Management in NSW: Updated Approaches & Legislation

 
Changes to incident
management in NSW
 
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When things go wrong
 
Clinical Excellence Commission
 
Our guiding principles
 
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We act immediately when
patients are harmed or at risk
of harm.
 
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We are open with patients
when things go wrong.
We review to learn and make
changes to improve our
system.
We share our learnings.
 
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We are caring
We acknowledge the distress
of all who are affected.
We have an open and just
culture.
 
New legislation ….
a new chapter in our
approach to incident
review and
management
 
Clinical Excellence Commission
 
Link to the legislation: 
Legislative changes
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In the new Incident Management policy
 
Four key changes
1.
Preliminary risk assessment
2.
Separation of findings and recommendations
3.
Enlisting more team members to assist with the recommendations
4.
Alternate review methodologies
 
1. Preliminary risk
assessment (PRA)
 
Clinical Excellence Commission
 
Preliminary risk assessment
 
Clinical Excellence Commission
 
6
 
Advice to Chief Executive to guide the response to an incident
 
A PRA is undertaken following a reportable incident (clinical Harm Score 1 incident) or a clinical
incident the CE believes may be due to a serious systemic problem.
The CE appoints a small team of PRA assessors to gather early information to guide the
incident response
The PRA team provides advice to the CE in a PRA report
A PRA must be completed within 48 to 72 hours or sooner of the incident notification.
 
Undertaking a PRA
 
Clinical Excellence Commission
 
The process
 
The PRA team:
Visit the site where the incident took place
Review files
Speak to staff
Take photos
Work through the PRA report template
provide an understanding of the events
identify immediate actions for people and the environment to be safe and supported
ensure outstanding risks are escalated for action
check on wellbeing of key staff
guide the response to an incident
ensure media interest and reputational risk are managed
ensure immediate notifications are made e.g. Coroner, TGA
confirm the Harm Score
finalise the Reportable Incident Brief (RIB).
 
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Mandatory - complete PRA report in ims
+
Not mandatory - PRA action log to track actions arising from the PRA.
 
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Dedicated family contact
 
Clinical Excellence Commission
 
9
 
 
The PRA team assign a dedicated family contact
This staff member:
 
provides a consistent point of contact for families
maintains regular communication with the family
 
 
Tasks of the dedicated family contact
 
Clinical Excellence Commission
 
10
 
 
establish a preferred communication approach with the family
raise any questions or concerns
ensure the family receive the support they need by engaging other resources e.g. interpreters, social
work, accommodation
explain the incident management process
scope 
 
of the review
steps involved
timeframes
opportunities to communicate or engage
arrange for the family to meet with the open disclosure and / or review team at defined time periods
 
Dedicated family contact engagement with family
 
Clinical Excellence Commission
 
11
 
Making contact with family
 
2. Separation of
findings and
recommendations
 
Clinical Excellence Commission
 
Determining findings
 
Clinical Excellence Commission
 
13
 
 
A serious adverse event review (SAER) is completed for all clinical Harm Score 1 incidents.
The SAER team gather information from a range of sources and undertake interviews to:
Determine what happened
Determine factors that caused or contributed to the incident.
Identify any practices, processes or systems that could be reviewed.
 
The SAER team write these up in a findings report
 
Findings report
 
Clinical Excellence Commission
 
14
 
 
Written using the template in the Incident Management Policy (Appendix E)
Due to CE within Health Service timeframe (before 60 days)
Once approved by CE,  findings can be shared with the family by the Open Disclosure team.
(Dedicated family contact helps to organise this).
 
Recommendations report
 
Clinical Excellence Commission
 
15
 
 
There will not always be a recommendations report
CE decides if the report is needed.
CE may appoint additional experts to the SAER team to prepare this report
Must be finalised and submitted to Ministry of Health within 60 days of incident notification
 
3. Enlisting more
team members to
assist with
recommendations
 
Clinical Excellence Commission
 
More people on the SAER team?
 
Clinical Excellence Commission
 
17
 
 
The Chief Executive or delegate (e.g. Director Clinical Governance) decides whether to appoint
additional members  to the team to prepare recommendations report.
Expertise may include a:
Human factors expert
Redesign / Improvement expert
Senior manager
Manager from another service/facility/agency to support feasibility e.g. eHealth NSW for
digital health tools such as the eMR
Manager/ from another service/facility/agency responsible for implementing a
recommendation e.g. NSW Ambulance, Ministry of Health, eHealth NSW.
 
 
Developing recommendations
 
Clinical Excellence Commission
 
18
 
SAER team process
 
If additional experts are needed, a request is sent to the CE for approval and new members are
formally appointed.
• The team leader sends the additional members a copy of the findings report
• The team meet (face-to-face where possible) and the team leader updates the new members
about the review to date.
 
 
4. Alternate review
methodologies
 
Clinical Excellence Commission
 
Serious adverse event reviews
 
Clinical Excellence Commission
 
20
 
 
A serious adverse event review (SAER) must be completed for clinical Harm Score 1
incidents.
In the past, a root cause analysis (RCA) was the only type of SAER allowed, however the
amended legislation allows for alternate 
review methods in addition to RCA
 
Serious adverse event review
 
Clinical Excellence Commission
 
21
 
Four approaches
 
The Chief Executive determines the review method for each incident from approved methods outlined in
the Regulations:
1. Root cause analysis Adopted from industry
Recommended for use with Australian Sentinel Events
Recommended for use with inpatient suicides
Recommended for use with homicides
Recommended for use with suicides within 24 hours of discharge from Emergency Department or contact with mental health
clinician
2. 
Systems analysis of clinical incidents - London Protocol (LP)
Recommended for use with inpatient falls
 
3. NSW Health Concise incident analysis
Recommended for use with community suicides
 
4. NSW Health Comprehensive incident analysis
Recommended for use with community suicides with complexity
 
Review methodologies toolkits
 
Clinical Excellence Commission
 
22
 
 
Toolkits including templates, factsheets, and information packs are available on the Clinical
Excellence Commission’s Serious Incident Investigation and Management web page.
https://www.cec.health.nsw.gov.au/Review-incidents/Upcoming-changes-to-incident-
management
 
What about corporate HS 1 incidents?
 
Clinical Excellence Commission
 
23
 
Not in the legislation but super important
 
Have a PRA completed
Assign dedicated family contact for incident involving death of a staff member
Corporate Harm Score 1 review completed (used to be called “corporate RCA”)
Privilege does not apply to corporate incidents
 
Clinical Excellence Commission
 
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Clinical Excellence Commission
 
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1 Reserve Road, St Leonards NSW 2065
Slide Note

Welcome to this brief webinar on changes to incident management in NSW

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Explore the transformative changes in incident management in NSW, emphasizing immediacy, accountability, and kindness. Learn about the new legislation affecting incident review and management, including key policy adjustments and the implementation of preliminary risk assessment. Discover the proactive steps taken to address incidents promptly and ensure patient safety, guided by principles of clinical excellence and compassionate care.


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  1. Changes to incident management in NSW Immediacy, accountability, kindness <These slides can incorporated into / adapted for use in local education sessions or training programs. There is also a brief version available for those wanting less detail>

  2. When things go wrong Our guiding principles Accountability We are open with patients when things go wrong. We review to learn and make changes to improve our system. We share our learnings. Kindness We are caring We acknowledge the distress of all who are affected. We have an open and just culture. Immediacy We act immediately when patients are harmed or at risk of harm. Clinical Excellence Commission

  3. New legislation . a new chapter in our approach to incident review and management Link to the legislation: Legislative changes Clinical Excellence Commission

  4. Changes to the legislation In the new Incident Management policy Four key changes 1. Preliminary risk assessment 2. Separation of findings and recommendations 3. Enlisting more team members to assist with the recommendations 4. Alternate review methodologies Immediacy Accountability Kindness

  5. 1. Preliminary risk assessment (PRA) Clinical Excellence Commission

  6. Preliminary risk assessment Advice to Chief Executive to guide the response to an incident A PRA is undertaken following a reportable incident (clinical Harm Score 1 incident) or a clinical incident the CE believes may be due to a serious systemic problem. The CE appoints a small team of PRA assessors to gather early information to guide the incident response The PRA team provides advice to the CE in a PRA report A PRA must be completed within 48 to 72 hours or sooner of the incident notification. Clinical Excellence Commission 6

  7. Undertaking a PRA The process The PRA team: Visit the site where the incident took place Review files Speak to staff Take photos Work through the PRA report template provide an understanding of the events identify immediate actions for people and the environment to be safe and supported ensure outstanding risks are escalated for action check on wellbeing of key staff guide the response to an incident ensure media interest and reputational risk are managed ensure immediate notifications are made e.g. Coroner, TGA confirm the Harm Score finalise the Reportable Incident Brief (RIB). Clinical Excellence Commission

  8. Documentation Mandatory - complete PRA report in ims+ Not mandatory - PRA action log to track actions arising from the PRA. PRA Report PRA action log

  9. Dedicated family contact The PRA team assign a dedicated family contact This staff member: provides a consistent point of contact for families maintains regular communication with the family Clinical Excellence Commission 9

  10. Tasks of the dedicated family contact establish a preferred communication approach with the family raise any questions or concerns ensure the family receive the support they need by engaging other resources e.g. interpreters, social work, accommodation explain the incident management process scope of the review steps involved timeframes opportunities to communicate or engage arrange for the family to meet with the open disclosure and / or review team at defined time periods Clinical Excellence Commission 10

  11. Dedicated family contact engagement with family Making contact with family When? Why? Introduce self and role Arrange any practical assistance Explain incident management process Answer questions Link family in with open disclosure team and review team Pass on family queries or recollections to review team member Explain next steps Link family in with open disclosure and /review teams as appropriate After the preliminary risk assessment After completion of findings report Explain next steps Link family in with open disclosure team After completion of recommendations report As per the family s wishes Make contact in keeping with a family s wishes during the review process and sometimes beyond the review process Clinical Excellence Commission 11

  12. 2. Separation of findings and recommendations Clinical Excellence Commission

  13. Determining findings A serious adverse event review (SAER) is completed for all clinical Harm Score 1 incidents. The SAER team gather information from a range of sources and undertake interviews to: Determine what happened Determine factors that caused or contributed to the incident. Identify any practices, processes or systems that could be reviewed. The SAER team write these up in a findings report Clinical Excellence Commission 13

  14. Findings report Written using the template in the Incident Management Policy (Appendix E) Due to CE within Health Service timeframe (before 60 days) Once approved by CE, findings can be shared with the family by the Open Disclosure team. (Dedicated family contact helps to organise this). Clinical Excellence Commission 14

  15. Recommendations report There will not always be a recommendations report CE decides if the report is needed. CE may appoint additional experts to the SAER team to prepare this report Must be finalised and submitted to Ministry of Health within 60 days of incident notification Clinical Excellence Commission 15

  16. 3. Enlisting more team members to assist with recommendations Clinical Excellence Commission

  17. More people on the SAER team? The Chief Executive or delegate (e.g. Director Clinical Governance) decides whether to appoint additional members to the team to prepare recommendations report. Expertise may include a: Human factors expert Redesign / Improvement expert Senior manager Manager from another service/facility/agency to support feasibility e.g. eHealth NSW for digital health tools such as the eMR Manager/ from another service/facility/agency responsible for implementing a recommendation e.g. NSW Ambulance, Ministry of Health, eHealth NSW. Clinical Excellence Commission 17

  18. Developing recommendations SAER team process If additional experts are needed, a request is sent to the CE for approval and new members are formally appointed. The team leader sends the additional members a copy of the findings report The team meet (face-to-face where possible) and the team leader updates the new members about the review to date. Clinical Excellence Commission 18

  19. 4. Alternate review methodologies Clinical Excellence Commission

  20. Serious adverse event reviews A serious adverse event review (SAER) must be completed for clinical Harm Score 1 incidents. In the past, a root cause analysis (RCA) was the only type of SAER allowed, however the amended legislation allows for alternate review methods in addition to RCA Clinical Excellence Commission 20

  21. Serious adverse event review Four approaches The Chief Executive determines the review method for each incident from approved methods outlined in the Regulations: 1. Root cause analysis Adopted from industry Recommended for use with Australian Sentinel Events Recommended for use with inpatient suicides Recommended for use with homicides Recommended for use with suicides within 24 hours of discharge from Emergency Department or contact with mental health clinician 2. Systems analysis of clinical incidents - London Protocol (LP) Recommended for use with inpatient falls 3. NSW Health Concise incident analysis Recommended for use with community suicides 4. NSW Health Comprehensive incident analysis Recommended for use with community suicides with complexity Clinical Excellence Commission 21

  22. Review methodologies toolkits Toolkits including templates, factsheets, and information packs are available on the Clinical Excellence Commission s Serious Incident Investigation and Management web page. https://www.cec.health.nsw.gov.au/Review-incidents/Upcoming-changes-to-incident- management Clinical Excellence Commission 22

  23. What about corporate HS 1 incidents? Not in the legislation but super important Have a PRA completed Assign dedicated family contact for incident involving death of a staff member Corporate Harm Score 1 review completed (used to be called corporate RCA ) Privilege does not apply to corporate incidents Clinical Excellence Commission 23

  24. Serious Incident Investigation and Management Clinical Excellence Commission E CEC-SIIM@health.nsw.gov.au W cec.health.nsw.gov.au 1 Reserve Road, St Leonards NSW 2065 Clinical Excellence Commission

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