Department of Human Services

Disability Services

Promoting Better Outcomes -

Systemic Improvement Procedure:

Managing and reviewing adverse events

(Formerly known as the “Promoting Better Outcomes: Adverse Events Management Procedures”)

July 2012

Index

28

Disability Services Promoting Better Outcomes: Systemic Improvement Procedure

Context Statement 3

Objective of Procedure 4

Authority 4

Definitions 5

Purpose 7

Risk management of adverse events 9

Phase 1 – Risk Management (Assessment and Review) 10

1.1 Assessment for possible disciplinary issues 10

1.2 Risk Analysis 11

1.2.1 Desktop assessment of an Adverse Event 12

1.3 Review of Adverse Events 14

1.3.1 Methodology 14

1.3.2 Level of Review 15

1.3.2.1 Critical Risk Adverse Events 15

1.3.2.2 High Risk Adverse Events 19

1.3.2.3 Medium Risk Adverse Events 20

1.3.2.4 Low Risk Adverse Events 20

Phase 2 – Reporting and Progression to Closure 22

Phase 3 – Quality Management 24

Phase 4 – Improvements in Policy/Procedures 24

Related Legislation, Policy and Procedures 25

Contacts 26

Approved 26

Appendix 1 Disability Service Quality Improvement Group (DSQIG) 27

Appendix 2 Disability Services – Practice Review Advisory Group 29

Appendix 3 Lead Reviewer and Practice Review Working Group 30

Appendix 4 Risk Classification Worksheet 32

Appendix 5 Sample Practice Review 33

Appendix 6 Sample Practice Review Task Plan 35

Appendix 7 Sample Practice Review Report 37

Appendix 8 Risk Reduction Action Plan 38

Appendix 9 Sample Confidentiality Clause Undertaking 39

28

Disability Services Promoting Better Outcomes: Systemic Improvement Procedure

Context

The Promoting Better Outcomes - Systemic Improvement procedure: Managing and reviewing adverse events (PBOSI Procedure) has been developed to assist key stakeholders to understand the processes in the effective management of adverse events.

The effective management of adverse events by disability service providers requires the commitment and involvement of all stakeholders, including the Disability Services Division (the division), Department of Human Services (the department) regions, community service organisations (CSO), people with a disability and their families.

The division has a commitment to the management of adverse events within a quality focused framework and to use information on adverse events in a constructive manner to continuously improve the quality, safety and accessibility of disability services.

This involves promoting a learning culture and identifying needs and opportunities for improvement in a systematic and planned way. It involves improving service quality and responsiveness to clients and other stakeholders through changes designed to better meet their needs and preferences.

Please note this procedural document is complementary to departmental policies in relation to incidents, complaints and significant or serious events.

This document should be read in conjunction with Promoting Better Outcomes - Systemic Improvement Policy: Managing and reviewing adverse events (PBOSI Policy), which defines roles and responsibilities in the systemic management of adverse events.


Objective of Procedure

The PBOSI Procedure has been developed to provide a contemporary framework for disability service providers (department and CSOs), managers and staff to inform the management of adverse events.

The objective of systemically managing an adverse event is to determine what happened, why it happened, what can be done to reduce the risk of reoccurrence and the impact of such an event.

There are four key procedural phases to systemically managing adverse events –

Phase 1 - Risk management (Assessment and Review)

Phase 2 - Reporting and Progression to Closure

Phase 3 - Quality Management

Phase 4 - Improvements in policy/procedure

These four key procedural phases will assist stakeholders to:

·  apply a methodology that guides and supports the systemic management of adverse events

·  implement mechanisms for state-wide aggregation and analysis of trends identified from adverse events

·  establish appropriate mechanisms for departmental representatives and all disability service providers to evaluate adverse event data, analyse trends and share relevant information to ensure that quality improvement activities can be targeted towards identified problem areas.

Authority

This policy statement is issued in accordance with section 39(1)(a) of the Disability Act 2006.

Definitions

Adverse Event

An adverse event is an event that leads to negative consequences for individuals and/or groups directly or indirectly attributable to the disability service provision.

For the purposes of this document, an adverse event is the overarching term used to cover a collective group of events and includes an incident, issue or event identified in a complaint or by a notification in relation to the provision of services or supports by a disability service provider.

Adverse Events – Identifiers/Triggers

An adverse event may be identified by:

·  a person affected by the event

·  a staff member during or after the event

·  an unexpected outcome that has taken place

·  expressed dissatisfaction with the service/care provided

·  the incident reporting system

·  detection by carers, family members, advocates, friends or visitors to the service.[1]

·  a complaint, or group of complaints

·  a notification

The responses to, and the management of, an adverse event will be based on departmental policies and practice instructions consistent with the department’s responsibility and obligations associated with the provision of quality services for people with a disability.

Complaint

The definition of a complaint used in disability services is taken from the Australian Standard Customer Satisfaction – Guidelines for complaints handling in organizations (AS ISO 10002:2006).

A complaint is defined as:

“Expression of dissatisfaction made to an organization, related to its products or the complaints-handling process itself, where a response or resolution is explicitly or implicitly expected”

Please note: for the purposes of this policy the following applies:

* Organisation refers to disability service provider.

* Products refers to service or supports provided or failed to have been provided that are likely to have an impact on an individual or group.

Disability Services Quality Improvement Group (DSQIG)

The DSQIG is part of the overall governance in the management of adverse events.

Incident

An event or circumstances that could have resulted, or did result, in:

·  unintended or unnecessary harm to a person

·  potential loss or damage that affects a service provider or organisation.[2]

Notification

A notification refers to information received by The National Disability Abuse and Neglect Hotline (the hotline) in relation to allegations of abuse and neglect of people with a disability accessing government or government funded services.

A notification can also include correspondence received by the department from or via:

·  The Office of the Public Advocate

·  The Minister for Community Services

·  Members of Parliament

Risk Analysis

A systematic use of available information to determine how often a specified adverse event is likely to occur and the potential impact of its consequence.

Risk Management

Risk management involves identifying potential variations from what is planned or intended, and managing these to maximise opportunity, minimise loss and improve decisions and outcomes. Managing risk means identifying and taking opportunities to improve performance as well as taking action to avoid or reduce the chances of something going wrong.[3]

Root Cause Analysis

A systematic process methodology whereby the factors that contributed to an adverse event are identified to prevent reoccurrence. [4]

Please note that Root Cause Analysis is the department’s preferred methodology for reviewing an adverse event. There may be times when the application of another methodology is preferable or required in the review of an adverse event. In these cases please discuss with the relevant contact as documented in this procedure.

Purpose

This procedure has been developed to complement the PBOSI Policy and to provide a procedure to departmental regions and community services organisations in the effective systemic management of all adverse events. It is intended that this procedure be read in conjunction with the PBOSI Policy.

The purpose of this procedure is to provide direction on how to utilise data on adverse events to be proactive in minimising the risk of reoccurrence, and to inform systemic improvements in practice for the provision of safe and healthy environments for people with a disability and the staff that support them. Events can be managed at a number of levels:

·  local level (through processes at an individual disability service provider or outlet)

·  the departmental regional office (through Disability Services Manager or other corporate area)

·  the department’s central office (through Disability Services Division or corporate area).

The purpose in analysing adverse events is to:

·  determine the events leading up to, during and post the event

·  examine policies, procedures, instructions, protocols and guidelines related to service/supports provided to a person with a disability

·  examine staff practice and management aspects of service/support provision, where relevant

·  examine client history, physical health and support plans, where relevant

·  improve policy, practice, instructions, protocols and guidelines

·  improve the quality of services and supports.

The following flowchart illustrates the PBOSI Procedure.[5]



Risk management of adverse events

The following sample case study provides an example of applying the 4 key procedural phases for the risk management of adverse events:

Phase 1 – Risk Management (Assessment and Review)

Phase 1 identifies the development and implementation of a systematic approach to risk managing adverse events which includes:

·  risk analysis of the adverse event, involving a desktop assessment

·  Root Cause Analysis methodology, analysing and reviewing adverse event aggregate information over time to identify lessons and practice implications and make recommendations for improvement.

1.1 Assessment for possible disciplinary issues

In order to determine the need for any action under the relevant certified agreement, the first step of assessment is to consider if the adverse event has the potential to lead to staff disciplinary action. If so, the matter should be managed through the organisation’s disciplinary procedures. The behaviours listed for misconduct and serious misconduct include:

Misconduct:

·  unsatisfactory performance that has been referred to the misconduct stream in accordance with Part 2 of DHS Managing performance and conduct in Disability Services policy

·  failure to follow defined departmental policies, procedures or rules

·  breaches of the Code of conduct, the department’s values or duty of care.[6]

Serious misconduct:

·  wilful or deliberate behaviour by an employee that is inconsistent with the continuation of the employment relationship

·  conduct that causes serious and imminent risk to the health or safety of a person, or the department’s reputation

·  theft, fraud or assault

·  being intoxicated at work by alcohol or other drugs

·  refusal to carry out a lawful instruction that is consistent with the requirements of the job

·  a number of incidents that in isolation may not appear serious, but when considered together may constitute serious misconduct; or a single incident of sufficient seriousness

·  repeated unsatisfactory performance or misconduct. [7]

Figure A: Decision Tree may assist in determining if the event has disciplinary actions that need to be addressed or if the event is likely to be a system-induced violation, a system-induced error or a blameless error.[8] The decision tree refers to a “substitution test” which requires the reviewer to consider what would have occurred had any other comparable staff member or staff group been involved.

To use the decision tree a good knowledge of the relevant polices and procedures (or the ability to source them) is required. [9]

1.2 Risk Analysis

The second step is to undertake a risk analysis of the adverse event, which is a systematic use of available information to determine how often a specified adverse event is likely to occur and the potential impact of its consequence. Risk Analysis involves undertaking a desktop assessment.

1.2.1 Desktop assessment of an Adverse Event

The desktop assessment involves assessing the documentation and information provided on adverse events, which includes the clients file, incident reports, correspondence from families, and correspondence from others including professionals.

The following sets out the recommended desktop assessment process, and highlights guidance resources for each step of the process:

1.  Collect all available information about an adverse event:

-  what happened and who was involved

-  when the event happened including the date, time and location

-  the names of any witnesses

-  any relevant documents or photographs

-  a statement describing the impact of the event

-  any other relevant information.

2.  Assessing the level of risk

In assessing the level of risk, first there is a need to be able to identify the risk. The level of risk is then determined through the combination of likelihood and consequence, as identified below in Figure B.

The first step then in determining risk level is to measure the likelihood of risk (Table 1). The measure of likelihood assists in determining the occurrence and/or reoccurrence of an adverse event. Put simply it considers the risk of the adverse event occurring or reoccurring.

Table 1: Measure of Likelihood[10] - Identifying the likelihood of an Adverse Event Occurring/Reoccurring

Likelihood / Description
Highly likely / Could occur at any time, for example once a week
Likely / Will probably occur in most circumstances, for example once per month
Possible / Might occur at some time, for example once a year
Unlikely / Could happen at some time, for example once every three years
Rare / Could happen, but very rarely, for example once in more than three years

It is important to note that measuring the likelihood of risk may differ from person to person. To be objective take into account the needs of all affected by the adverse event, and also those subjected to the risk. Therefore consider the most probable or expected outcome (not best case or worst case scenario).

.

The next step is to measure the consequence of the risk of an adverse event, to assess the outcome (Table 2).

Table 2: Measure of Consequence – Identifying the outcome of an Adverse Event

Description / Example
Extreme / Cessation of multiple services; multiple deaths or disabling injury of clients and/or employees; adverse media event ie Royal Commission, Parliamentary Inquiry
Major / Disruption to multiple services; death or disabling injury to a client and/or employee; media interest ie Coroner’s Inquest
Moderate / Disruption to service; multiple injuries to clients and/or employee; local media concern
Low / Minimal disruption to service; minor injury to a client and/or employee; minimal media interest
Negligible / No service disruption; no injury to client and/or employee; no public concern