Serious corporate incident management processes Immediacy,

Serious corporate incident management processes Immediacy, accountability, kindness

Which incidents? Clinical Excellence Commission

Corporate Harm Score 1 incidents ims incident management system Unexpected death of a worker or visitor Complete loss of service Clinical Excellence Commission 3

Incident Management Policy Clinical Excellence Commission

NSW Health Incident Management Policy Revised policy commences 14 December 2020 Revised incident management process ims incident management system and Harm Score New requirements for corporate Harm Score 1 incidents Clinical Excellence Commission 5

Revised Incident Management Process Steps 1. Identify incident 2. Ensure safety of people and the environment 3. Notify incident in ims 4. Escalate incident 5. Review incident 6. Implement and monitor actions 7. Feedback to staff and patients, carers and families. Clinical Excellence Commission 6

What’s different? Current versus revised Incident Management Policy PD2020 020 PD2020 047 Corporate SAC 1 requirements: Corporate Harm Score 1 requirements: 1. Reportable incident brief 1. Reportable incident brief 2. Corporate root cause analysis 2. Safety Check 3. Corporate Harm Score 1 review RIB Clinical Excellence Commission Safety check Corporate Harm Score 1 review 7

Reportable incident brief (RIB) Corporate Harm Score 1 requirement RIB author is a nominated staff member The RIB is in 2 parts The Chief Executive or delegate approves the RIB for submission to the Ministry of Health (MoH) RIB Part A is due to the MoH within 24 hours of incident notification in ims RIB Part B is due to the MoH within 72 hours of incident notification in ims Information from the safety check is used to complete RIB Part B The RIB is completed within ims A RIB template is available on the CEC website for downtime or for organisations not using ims Element Reportable incident brief (RIB) Part A – basic information Part B – further information Clinical Excellence Commission Timeframe Submit to 24 hours 72 hours or sooner MoH MoH 8

Safety check Corporate Harm Score 1 requirement Undertaken by safety check team appointed by the Chief Executive The purpose of a safety check is to guide and record immediate steps of post incident management and to address the needs of staff, patients or visitors involved. The NSW Health safety check template is completed The safety check and action log is being built into ims and a template is accessible on the CEC website The report is due to the Chief Executive within 72 hours of incident notification in ims For incidents involving staff death, a dedicated family contact assigned at this stage. Element Timeframe Submit to 72 hours or sooner Chief Executive Safety check Safety check report Clinical Excellence Commission 9

Corporate Harm Score 1 review Corporate Harm Score 1 requirement A review team is appointed by the Chief Executive to undertake a corporate Harm Score 1 review The review team: Gather information from a range of sources Undertake interviews Visit the incident location where appropriate Analyse findings and develop recommendations as needed Consider any suggested recommendations from others involved or concerned Write up findings and recommendations into a report that is due to the Ministry of Health within 60 days of incident notification in ims Clinical Excellence Commission 10

Corporate Harm Score 1 review Methodology & report template The review team uses a review method chosen by the Chief Executive that is Determined by the type of incident and advice from the safety check Undertaken using corresponding review processes set out in a relevant NSW Health Policy, or the NSW Health Incident Management Policy. The review team use the NSW Health Corporate Harm Score 1 Review Report template which includes: An incident description ims incident number A summary of the findings Any underlying factors as to why the incident occurred Any recommendations to prevent and minimise the risk of recurrence. Clinical Excellence Commission 11

Sharing findings with the family Open disclosure Following a corporate Harm Score 1 incident involving staff death or suspected suicide, what is known is to be shared with the family as it comes to hand. Any communications or documents arising from a safety check or corporate Harm Score 1 review are not privileged. A dedicated family contact can arrange meetings for the family and open disclosure team As per the family’s wishes After the safety check At completion of the corporate Harm Score 1 review. Clinical Excellence Commission 12

Managing a corporate Harm Score 1 incident START OD team discuss safety check with family – meeting arranged by DFC CE appoints review team Harm Score 1 incident identified RIB Part B submitted Corporate Harm Score 1 review undertaken END Clinician disclosure Safety check completed & DFC assigned for staff death Draft report completed System wide learning Immediate action to ensure people and environment are safe and supported CE appoints safety check team Report approved Feedback to staff and notifiers RIB Part A submitted Start implementing and monitoring recommendations OD team discuss report with family – meeting arranged by DFC ims notification 13 Clinical Excellence Commission

Resources Clinical Excellence Commission

CEC website Upcoming changes to incident management Clinical Excellence Commission 15

Toolkits & Templates http://www.cec.health.nsw.gov.au/Review-incidents/Upcoming-changes-to-incident-management ‘Managing serious corporate incidents’ toolkit Clinical Excellence Commission 16

Questions Governance team at your District Email the CEC - [email protected] Clinical Excellence Commission 17