This is a public facing document
Open Disclosure Policy
Policy Index: Management
- Relevant Legislation, Standards and Agreements
The following Legislation applies to this policy and supporting documentation:
Charter of Human Rights and Responsibilities Act 2006– (Vic)
Disability Act 2006 – (Vic)
Freedom of Information Act 1982– (Vic)
Mental Health Act 2014– (Vic)
National Disability Insurance Scheme Act 2013– (Cth)
Privacy and Data Protection Act 2014– (Vic)
Victorian Civil & Administrative Tribunal Act 1998– (Vic)
Wrongs Act 1958– (Vic)
The following Standards apply to this policy and supporting documentation:
Human Services Standards
Standard 1 – Empowerment
Standard 2 – Access and Engagement
Standard 3 – Wellbeing
Standard 4 – Participation
National Standards for Disability Services
Standard 4 – Feedback and Complaints
National Quality Standard (ACECQA)
Quality Area 7 – Leadership and Service Management
Standard 7.3,Element 7.3.4 - processes are in place to ensure that all grievances and complaints are addressed, investigated fairly and documented in a timely manner.
The following Agreements apply to this policy and supporting documentation:
Department of Health& Human Services (DHHS) - Funding and Service Agreement
Department of Education and Training (DET) - Funding and Service Agreement
Relationship to Yooralla’s Values and Strategic Directions:
In practising open disclosure Yooralla will:
a)focus on positive person-centred solutions = customer focused
b)communicate honestly = authentic
c)handle feedback responsibly = accountable
d)respect choices = respectful
e)disclose where Yooralla’s service had an adverse outcome = courageous
- Purpose
The purpose of this policy is to:
a)enable Yooralla to communicate openly with customers, their family and carers when an adverse event occurs
b)provide a framework for open disclosure that supports staff and ensures that practice aligns with the principles of the framework; and
c)ensure a consistent approach to open disclosure across Yooralla services that adheres to the principles of the Australian Open Disclosure Framework.
- Scopeof Policy
This policy applies to all communication with customers, their families and carers following harm from an adverse event across all areas of Yooralla.
While this policy focuses on adverse events, the harm suffered by a customer does not have to be permanent or serious for open disclosure principles to apply.
- Definitions
Any defined terms below are specific to this document
Adverse event – An incident in which unintended harm resulted to a person receiving Yooralla’s services.
Apology – An expression of regret (that the person has had a poor experience).
Expression of regret – An expression of sorrow for the person’s experience or the harm experienced by the person. Expressing regretis not the same as admitting liability. As a result of the Ipp Report published in 2002 (Review of the Law of Negligence), most states and territories in Australia have enacted legislation stating that an apology does not constitute an admission of liability. In Victoria an amendment to this effect was made during 2003 by adding section 14J to the Wrongs Act 1958 – (Vic)
Harm – Impairment of structure or function of the body and/or any deleterious effect arising there from, including disease, injury, suffering, disability and death. Harm may be physical, social or psychological. Examples of social and psychological harm include not having dignity, autonomy or beliefs respected, or a customer being demeaned or insulted.
High level response – Type of response required for major impact incidents.
Incident – An event or circumstance that resulted, or could have resulted, in unintended and/or unnecessary harm to a person, loss or damage.
Insurer – Refers to the Victorian Managed Insurance Authority (VMIA).
Internally reportable incident – An incident that threatens the safety, health or wellbeing of a customer but does not cause harm to a customer or occurs outside of service delivery. Yooralla records and reports internally such incidents and near misses because they provide an opportunity to learn from, and where possible, prevent future occurrence of incidents. For example a customer experiencing a deterioration of a known medical illness will generally be an internally reportable incident.
Low level response – Type of response required for non-major impact incidents and internally reportable incidents.
Major impact incident – An incident occurring during service delivery that in the professional judgement of the most senior staff member present causes a major level of harm to a customer. Major impact incidents include physical abuse, sexual abuse, sexual exploitation, neglect, escape from a secure facility, misuse of psychotropic medicines administered by a staff member, unexpected death, suicide or attempted suicide, and a pattern of incidents related to one client that, taken together, are sufficient to suggest that the client is at further risk of harm.
Non-major impact incident – An incident occurring during service delivery that involves minimal harm to a customer. Non-major impact incidents may include inappropriate sexual behaviour, missed medication, and injury requiring first aid or short-term medical attention.
- Policy Statement
Open disclosure is:
a)a customer’s right
b)a core professional requirement and obligation
c)a normal part of support should the unexpected occur and a critical element of communication; and
d)an important part of quality improvement.
Yooralla recognises the importance of supporting staff through the open disclosure process.
Yooralla adopts a “No-Blame” approach to adverse event investigation.
Yooralla will consider and implement appropriate recommendations to improve practice.
There are eight general principles for open disclosure that guide Yooralla’s responses:
Principle 1: Open and timely communication
If things go wrong, the customer, his/her family and carers should be provided with information about what happened in a timely, open and honest manner. If the customer has no family or carer, consideration should be given to providing appropriate support e.g. customer relations team or referral to an external advocate. The open disclosure process is fluid and will often involve the provision of ongoing information.
Principle 2: Acknowledgement
All adverse events should be acknowledged to the customer, his/her family and carers as soon as practicable. Yooralla will acknowledge when an adverse event has occurred and initiate open disclosure.
Principle 3: Apology or expression of regret
As early as possible, the customer, his/her family and carers should receive an apology or expression of regret for any harm that resulted from an adverse event. An apology or expression of regret should include the words ‘I am sorry’ or ‘we are sorry’, but must not contain speculative statements, admission of liability or apportioning of blame.
Principle 4: Supporting, and meeting the needs and expectations of customers, their family and carer(s)
The customer, his/her family and carers can expect to be fully informed of the facts surrounding an adverse event and its consequences, treated with empathy, respect and consideration, and supported in a manner appropriate to his/her needs.
Principle 5: Supporting, and meeting the needs and expectations of staff
Yooralla creates an environment in which all staff are encouraged and able to recognise and report adverse events, prepared through training and education to participate in open disclosure, and supported through the open disclosure process.
Principle 6: Integrated risk management and systems improvement
Thorough service review and investigation of adverse events and adverse outcomes will be conducted through processes that focus on the management of risk and quality improvement. Outcomes of these reviews will focus on improving systems and be reviewed for their effectiveness. The information obtained about incidents from the open disclosure process will be incorporated into quality improvement activity.
Principle 7: Good governance
Open disclosure requires good governance frameworks, and risk management and quality improvement processes. Through these systems, adverse events will be investigated and analysed to prevent them recurring. Good governance involves a system of accountability through Yooralla’s senior management, executive or governing body to ensure that appropriate changes are implemented and their effectiveness is reviewed. Good governance will include internal performance monitoring and reporting.
Principle 8: Confidentiality
Yooralla’s policies and procedures fully consider the customer’s, their family and carers, and staff privacy and confidentiality, in compliance with relevant law.
- Legal and Insurer Advice
All written correspondence containing an acknowledgement of an adverse event must be approved by Yooralla’sChief Practitioner prior to being sent. Advice should be sought from VMIA (Yooralla’s Insurer) where appropriate.
Legal advice about the wording of an apology can be sought from Yooralla’s Chief Practitioner where appropriate. Sufficient time should be allowed to seek approval from VMIA if necessary.
Yooralla’s Chief Practitioner or VMIA may advise that a letter should not be sent.
Where there is a concern that a person has sustained injury as a result of Yooralla’s negligent acts or omissions, prior to engaging in open disclosure, advice should be sought from Yooralla’s Chief Practitioner and VMIA must be notified of the adverse event.
- Yooralla’s Open Disclosure Procedure
Yooralla has a detailed Open Disclosure Procedure, which is located at the end of this policy. Refer to Appendix 1 below for the summary process flow.
- Responsibility for Implementation, Compliance Monitoring, Measuring and Continual Improvement
These management positions are responsible for implementation and compliance monitoring of the policy in their work areas:
a)Chief Practitioner
b)All Managers
- Related Documents and Links
Australian Commission on Safety and Quality in Health Care
Australian Open Disclosure Framework
Choice and Advocacy Policy
Clinical Governance Policy
Confidential Information Protection Policy
Customer Feedback and Complaints Policy and Procedure
Human Rights Policy
Management of Customer Incidents Policy
Open Disclosure Procedure
Open Disclosure for Victorian Health Services: AGuidebook.Melbourne: State of Victoria, Department of Human Services.
Post Incident Response Staff Support Policy
Privacy Policy
Quality and Customer Empowerment Policy
Risk Management Policy
Appendix 1Open Disclosure Process Flow
This document is uncontrolled when printed, please refer to the Policies and Procedures Portal for the current controlled versionAccountable: Chief Practitioner / Effective Date: 4/06/2018 / Review Date: 9/05/2019
Responsible: Director of Quality / Version Number: 16
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