INCIDENT MANAGEMENT POLICY AND PROCEDURE

Policy Code WHSP006.01

Person Responsible Directors

Status (Draft/Released) Released

Date Last Updated 1 April 2020

1.0 PURPOSE AND SCOPE

This policy and procedure provides guidelines for reporting, investigating and applying appropriate control measures when an accident, incident (including critical incidents) or near miss occurs. It addresses both client and staff incidents.

This policy and procedure applies to the Directors, and any additional staff, students, contractors and volunteers.

This policy and procedure should be read in conjunction with the Preventing and Responding to Abuse, Neglect and Exploitation Policy and Procedure.

This policy excerpts information from the Client Incident Management Guide (CIMS Guide) published by the Department of Health and Human Services (Vic). The CIMS Guide is available at: http://providers.dhhs.vic.gov.au/cims

2.0 DEFINITIONS

Accident – an unforeseen event that causes damage to property, injury or death.

Client Incident – (under the CIMS) an event or circumstance that:

• occurred during service delivery (current or historical; with Crewther Care or another service provider); and

• resulted in harm to a client.

If the client is suspected of committing a criminal act, the matter should be referred to Victoria Police. Only incidents which meet the above definition of a ‘client incident’ must be reported under the CIMS.

Client incident management system (CIMS) – an initiative of the Department of Health and Human Services (Vic) that outlines the approach and key actions to manage client incidents.

The CIMS consists of five phases:

• Response to the incident and identification of the incident category;

• Reporting of the incident to the Department of Health and Human Services via their webform;

• Investigation of major impact incidents;

• Review of major impact incidents; and

• Analysis and learning, including analysis of broader incident trends via the on-line data-analysis function.

The CIMS includes accountability mechanisms to support the safety and wellbeing of clients by ensuring that service providers effectively discharge their responsibilities in regards to client incident management. These accountability mechanisms are also designed to foster a culture of continuous improvement within service providers and across the broader client incident management system.

Incident – an occurrence that causes (or could have caused, in the case of a ‘Near Miss’) damage to property, injury/illness or death.

Incident investigation – A formal process of collecting information to ascertain the facts, which may inform any subsequent criminal, civil, disciplinary or administrative sanctions.

The purpose of an incident investigation by a service provider under the CIMS is to determine whether there has been abuse or neglect of a client by a staff member (including a volunteer) or another client, pursuant to an allegation in a client incident report.

An investigation involves the planned and systematic gathering and analysis of all relevant facts by interviewing witnesses, examining documentation, skilled observation and obtaining expert opinion where appropriate.

Incident review – Analysis of an incident to identify what happened, determine whether an incident was managed appropriately, and to identify the causes of the incident and subsequent learnings to apply to reduce the risk of future harm.

Near Miss – any incident that occurred at Crewther Care, which, although not resulting in any injury, illness or damage, had the potential to do so.

Hazard – a situation that has the potential to harm a person (cause death, illness or injury) or environment or damage property.

Hazard identification – A process that involves identifying all foreseeable hazards in the workplace and understanding the possible harm that each hazard may cause.

Hazard management – A structured process of hazard identification, risk assessment and control, aimed at providing safe and healthy conditions for staff members, contractors and visitors while on the premises.

Harm – Includes death, or injury, illness (physical or psychological) or disease that may be suffered by a person as a consequence of exposure to a hazard.

Reportable incident – Incidents may be reportable to an agency or multiple agencies, depending on the nature of the incident (e.g., criminal act, workplace accident, significant near miss) and the person/s involved (e.g., staff member, client with physical disability, client with psychosocial disability, child). All client incidents are reportable to the Department of Health and Human Services (Vic) via the CIMS.

3.0 POLICY

Staff are required to be vigilant in reporting incidents when they occur so that appropriate support can be provided to those affected and the circumstances can be analysed to reduce the likelihood of a similar event occurring again.

All staff, contractors, volunteers and students have a responsibility to ensure that details of any incident are recorded and reported to their immediate supervisor (or Directors, as appropriate).

4.0 PROCEDURE

Responding to Incidents

Staff and Client Incidents

• Assess the situation to ensure a safe and secure environment. Remove the source of danger or the person from the source of danger if safe to do so.

• In urgent cases, call Victoria Police and other emergency services should be called immediately (e.g., where a crime is suspected or alleged, or where there is ongoing danger).

• If any person requires immediate medical attention, a medical practitioner or ambulance should be called, or the client conveyed to the nearest hospital accident and emergency department.

• The site where the incident occurred should not be disturbed until WorkSafe Victoria, Victoria Police or the Directors lift the requirement to preserve the area.

• Where injuries do not require immediate attention, support the person to see a doctor for assessment and treatment of any injuries, including psychological trauma.

Client Incidents

• Assure the client that the incident will be taken seriously, discuss their options with them and ask them how they would like to be supported throughout the process.

• If a staff member is accused or suspected of harming the client, they should be removed from contact with all clients pending an investigation. Where the client is a child, report the matter under the Reportable Conduct Scheme to the Commission for Children and Young People.

• Where a client is accused or suspected of harming another client, they should be removed from contact with other clients, where possible, pending an investigation

• Consider the impact of the incident on the other clients within the setting and provide them with appropriate support. It is important that they are not treated simply as potential witnesses.

• If they can provide informed consent to contact and receive specialist services, the client (or, if not, his or her key support person) should be asked whether he or she wishes to contact specialist/victim support services such as crisis care, counselling, advocacy, a legal information service or a lawyer.

• Notify other service providers known to be working with that client, if appropriate. Refer to section 3.7 of the Client Incident Management Guide (DHHS) for further information.

• Agreed actions for the client’s immediate and ongoing needs must be recorded on the Client Support Plan. This must include:

• steps being taken to ensure the client’s ongoing safety and wellbeing

• treatment or counselling the client may access to address their safety and

wellbeing

• modifications in the way services are provided (for example, same gender care

or placement)

• how best to support the client through any action the client takes to seek justice

or redress, including making a report to police

• any ongoing risk management strategy required where this is deemed

appropriate.

Reporting Staff Incidents

• All incidents and near misses must be reported to the Directors (or delegate) as soon as practicable and within 24 hours through completion of an Incident Report.

• The Directors will inform:

▪ the Victorian Police Service and/or other relevant authorities;

▪ SafeWork Victoria, by phone immediately after becoming aware of the incident and in writing within 48 hours.

• If an incident is Reportable (or it is not certain whether it is Reportable) it must be reported to the Directors immediately. Information required includes the:

▪ name and address of the person giving notice;

▪ date and time of the event;

▪ place where the event happened;

▪ apparent cause;

▪ nature and extent of the damage;

▪ work that was being carried out at the time of the incident; and

▪ name and contact details of any injured or affected parties.

• The Directors must ensure that all incidents are reported to the relevant agency or agencies.

• Under the Occupational Health and Safety Act 2004 (Vic) Crewther Care may be obliged to notify WorkSafe in the event that there is an incident at a workplace. For more information, refer to the WorkSafe website: https://www.worksafe.vic.gov.au/

• Accidents, incidents and near misses are to be reported to the Management Team monthly by the Directors as part of their WHS reporting.

• The Directors will track progress and outcomes of accidents, incidents and near misses in the Incident Report Register and refer any relevant items for inclusion in the Continuous Improvement Plan.

Investigating and Resolving Staff Incidents

• The Directors will work with WorkSafe Victoria and/or other relevant authorities to investigate the incident.

• The Directors or their nominated representative will:

▪ commence investigations immediately upon receiving a completed Incident Report

▪ (where a staff member is injured), involve them in the investigation;

▪ implement the most effective controls practicable that do not introduce other hazards, and monitor and review these;

▪ consult with staff who are, or are likely to be, directly affected;

▪ provide information and feedback to the Management Team; and

▪ track all relevant information in the Incident Register.

• Upon completion of the investigation the Directors must finalise the relevant Incident Report form and record the outcomes in the Incident Register.

• The completed Incident Report should be stored on the relevant staff member’s file.

Debrief and Support

• For all persons involved in an accident, incident or near miss, if required, the Directors must:

▪ facilitate an informal debrief amongst supervisors, colleagues or peers; and

▪ ensure appropriate support and access to counselling is made available.

• See also the Return to Work Policy and Procedure.

Client Incidents

Reporting alleged criminal acts

If a suspected criminal act has occurred, report the incident to Victoria Police.

While some discussion may be required to establish safety and a basic understanding of what has occurred, do not question the alleged perpetrator or victim without Victoria Police approval.

If the client needs to talk about what happened, listen and support the client and reassure the client that they did the right thing by talking about the abuse.

Client Incident Management System (CIMS)

Client incidents must be reported through the Client Incident Management System.

Online access to CIMS IT requires registration and the use of a secure password.

Online access to CIMS IT allows organisations to:

▪ submit Client incident reports

▪ access the data analysis framework.

For CIMS help: Phone: 1300 024 863

Email: CIMS@dhhs.vic.gov.au

The CIMS consists of five phases:

• Response to the incident and identification of the incident category (immediate);

• Reporting of the incident to the Department of Health and Human Services via their webform (within 24 hours);

• Investigation of major impact incidents (investigative screening submitted within 72 hours);

• Review of major impact incidents (Case reviews within 21 working days; RCAs within 60 working days); and

• Analysis and learning, including analysis of broader incident trends via the on-line data-analysis function (at completion of review and on-going).

Responding to Client Incidents

See: Responding to Incidents: Staff and Client Incidents, above.

Identifying Client Incidents

There are two processes for managing a client incident, determined by whether the incident resulted in:

• a major impact to the client, or

• a non-major impact to the client.

Determining Impact: Major and Non-major Impact Client Incidents

The Directors is responsible for confirming (to the CIMS) the categorisation of impact.

The Directors (or delegate) will determine whether an incident is major impact or non-major

impact, taking into account the following factors:

• Client experience

• How might specific characteristics influence the client’s experience of an

incident

• Was the client physically, emotionally or psychologically harmed in the

incident? To what extent? What level of treatment or care did they require as a

result of the incident?

• Is the client still at risk of further harm from this incident?

• Severity of outcome

• What was the nature and extent of the harm suffered?

• What was the level of distress or suffering caused to the client?

• Does the client have a history of incidents of this nature?

• Vulnerability of client

• Does the client’s age and stage of development, culture or gender increase the

severity of suffering and trauma experienced?

• Does the balance of power or position between the alleged perpetrator and

victim affect the impact of the incident on the client?

• Does the client’s individual mental and/or physical capacity, understanding of

potential risks or communication skills affect the impact of the incident?

• Does the client have a history of trauma or other co-factors which increase the

impact of the incident? For example, homelessness, social isolation, health

status (particularly poor health or other incapacity), poverty or discrimination.

• Pattern and history of behaviour

• Some clients may have a habit of dangerous actions that is understood and

being managed by the service provider. In such cases, the service provider

should classify incidents of such behaviour as non-major impact incidents,

unless the incident is linked to either of the following:

– an escalation in the severity or frequency of dangerous actions

– actions outside the known behavioural patterns of that client.

For assistance in identifying client incidents, consult the CIMS Guide, Appendix A.

Reporting Client Incidents: CIMS

Under the CIMS, a client incident must have occurred during service delivery. Historical disclosures are reportable under the CIMS if they occurred during service delivery.

Multiple Service Providers (shared clients)

Only one client incident report should be submitted per incident.

It may be necessary for Crewther Care to share information with other service providers:

• to ascertain their awareness of an incident or allegation affecting a shared client or their organisation;

• to ensure the safety and wellbeing of the client;

• to determine which provider is most appropriate to:

- submit the client incident report;

- conduct an investigation, review, report etc..

Where permissible under applicable laws, including the Privacy and Data Protection Act 2014, the Health Records Act 2001 and any other legislation applicable to the relevant service, the service provider that has responsibility for completing the incident report should consider whether it is appropriate to alert other service providers known to be working with that client that the incident has occurred.

For further information, see the CIMS Guide, 3.7.

Responsibilities for Reporting

In reporting a client incident, Crewther Care must:

• Collect required information regarding major impact and non-major impact incidents

• Complete reporting requirements to divisional offices, including confirming categorisation and classification of incidents

• Identify trends regarding non-major impact incidents

• Document actions undertaken, and actions planned, in response to the client incident, and record on the client file

• Maintain a client incident register that captures the minimum required information for reporting

• Respond to follow-up requests from the divisional office as appropriate

Major impact and non-major impact incidents

Incident reports should be submitted as follows:

• Major impact incidents require service providers to notify divisional offices of the incident within 24 hours. The service provider must also record details on their client incident register.

• Non-major impact incidents require service providers to capture key details regarding the incident in their client incident register. Incident data for non-major impact incidents must be provided to the divisional office in a batch on a monthly basis.

Major Impact Reporting Process

Step 1. Client incident report (CIMS) and Incident Register

The Directors (or delegate) will electronically report all major impact incidents within 24 hours of the incident occurring or the service provider becoming aware of the incident (via the department’s CIMS IT webform or Crewther Care’s IT system).

All client incidents must also be recorded in the Client Incident Register, within 24 hours of becoming aware of a major impact incident.

Step 2. Recording the incident

The client incident report will form the basis of any subsequent investigation and review; it must be completed to a high standard by the most senior person present when the incident was disclosed or occurred, the most senior witness to the incident or, if there were no witnesses, the staff member to whom the incident was disclosed.

The information provided in the report must be accurate, comprehensive and clear. Any witnesses, physical evidence, persons of relevance or other information necessary for a future investigation must be recorded in the incident report.

Incident reports must be factual and use objective language. Guidance and advice on completing incident reports can be accessed by:

• referring to the CIMS toolkit: https://providers.dhhs.vic.gov.au/cims.

• contacting the divisional office of the department for guidance or advice as needed.

• consulting the CIMS Guide, Appendix E.

Step 3. Recording Crewther Care’s response to the incident

The Directors (or delegate) will review the incident report submitted by their staff member and complete:

• a brief description of the incident (20 words or less)

• report additional actions completed, for example notification to Victoria Police if required

• a quality check of the client incident report, ensuring that appropriate incident type, category, client and location details were recorded.

The Directors (or delegate) must approve the incident report prior to submission to the divisional office.

Step 4. Submitting the completed client incident report (within 24 hours)

The Directors (or delegate) will submit the fully completed client incident report to the designated divisional office as soon as possible, and within 24 hours of the incident occurring or being disclosed. This includes reporting on weekends or public holidays.

Incident reports and supporting information must also be attached to the individual client’s file. This supports the appropriate management and follow-up of the incident.

Step5. Department divisional office response

The Department divisional office may make contact to follow up on the incident in order to:

• enquire about the safety of clients;

• enquire about the management of the incident;

• confirm that appropriate actions are being planned and undertaken to ensure the safety of the client;

• request the service provider to provide further information and details regarding prior incidents to further understand the context and any contributing factors.

Once any follow-up is completed to the satisfaction of the divisional office, they will endorse the incident for their records.

Non-Major Impact Incident Reporting

Non-major impact incidents must be reported electronically (via the department’s CIMS IT webform or Crewther Care’s IT system) and recorded in the service provider’s client incident register.

The non-major impact incident data contained in the register is required to be reported to the department in a batch on a monthly basis.

Other Reporting

Incidents may require reporting to multiple bodies.

Multiple investigations may operate on different timeframes. Investigations should avoid unnecessary duplication and overlap, where possible.

• Alleged criminal acts: Report to Victoria Police. Where Victoria Police conducts an investigation, they may request the service provider to put investigative processes on hold. Service providers should not interview staff or clients without direction from Victoria Police that it is safe to proceed, or without undertaking screening of the incident (as described below).

• Reportable Conduct (Child Abuse): The Reportable Conduct Scheme requires centralised reporting to the Commission for Children and Young People of allegations of child abuse made against workers or volunteers. Within three business days of becoming aware of a reportable allegation, heads of organisations must notify us that a reportable allegation has been made against one of their workers or volunteers. They must also investigate allegations and provide updates within 30 days. Further information can be found at the Commission for Children and Young People website: https://ccyp.vic.gov.au/.

• Reportable Deaths: a statutory obligation to report deaths to the Coroner may apply. Refer to the Coroner's Court website: http://www.coronerscourt.vic.gov.au/.

• Mental Health Reportable Deaths: a statutory obligation to report the death of any person receiving mental health services may apply under the Mental Health Act. For more information on the definition of a ‘reportable death’, the scope of mental health service providers required to report mental health reportable deaths and the procedures for reporting refer to the Chief Psychiatrist’s website: https://www2.health.vic.gov.au/about/key-staff/chief-psychiatrist/chief-psychiatrist- guidelines.

• Child Deaths: The death of a child who was a child protection client either at the time of death or within the 12 months before their death must be reported by the Secretary to the Commission for Children and Young People and the Commission for Children and Young People must conduct an inquiry in relation to that death. See the Commission for Children and Young People website: https://ccyp.vic.gov.au/.

Where an incident results in the death of a child who was not a child protection client either at the time or within 12 months before their death, senior management of the service provider should consider what action may be required and whether the matter should nevertheless be reported to the department and/or the Commission for Children and Young People relevant factors to consider include:

▪ the length of time elapsed since child protection’s involvement with the child

▪ the extent of child protection’s involvement

▪ the sensitivities of the case

▪ the potential for public, political or legal scrutiny

▪ the particular facts and circumstances.

• Occupational Health and Safety: Under the Occupational Health and Safety Act 2004 (Vic) the employer may be obliged to notify WorkSafe in the event that there is an incident at a workplace. For more information, refer to the WorkSafe website: https://www.worksafe.vic.gov.au/

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Investigating Client Incidents: Major Impact

Investigation Process and Responsibilities

The investigation process under the CIMS is documented in the Client Incident Management Guide (DHHS). Crewther Care must comply with the CIMS investigation process by:

o Identifying incidents that require screening for investigation

o Screening incidents to determine the appropriate investigative action

o Carrying out or commissioning the investigation

o Providing assurance that the investigation has adequately explored the incident and all relevant information

o Reviewing the investigation report and preparing a response plan

o Ensuring any response actions are implemented and monitored

An investigation must:

o be in proportion to the nature and significance of the incident and any associated allegations;

o include the identification of any previous relevant allegations that should be considered regarding the relevant individuals;

o include a degree of independence appropriate to the seriousness of the incident;

o adopt a person-centred and rights-centred approach, taking into account what is important to the client;

o abide by the standard principles of good investigations

▪ procedural fairness

▪ confidentiality and privacy

▪ appropriate interview techniques

▪ evidence based

▪ properly documented

▪ result in an investigation report (consult CIMS guide for full details)

Where an incident relates to potential staff-to-client abuse or poor quality of care, some degree of independence is required for the investigation. Depending on the nature of the incident and the organisation, one of the following may be appropriate to conduct the investigation:

o an area of the organisation that is sufficiently independent from staff who are the subject of any allegations, such as another division or an independent investigative function

o another service provider independent from the staff who are the subject of any allegations

o an external investigative body.

Screening Major Impact incidents

Incident investigations, under the CIMS, determine whether there has been abuse or neglect of a client by a staff member (including a volunteer) or another client.

Major Impact client incidents will, in most cases, need to be investigated.

Major Impact Incidents must be screened to determine the appropriate investigative action if they include:

o physical abuse

o sexual abuse

o financial abuse

o emotional/psychological abuse

o poor quality of care

o injury – unexplained (in order to determine whether there has been any abuse or neglect that caused the injury).

Major impact incidents that do not fall into the above categories must be subject to an incident review.

Investigation Manager

An ‘Investigation Manager’ must be appointed with the responsibility for screening the incident to determine what investigation action is appropriate.

The Investigation Manager must:

o coordinate and direct the screening process and any subsequent investigation;

o have the appropriate decision-making authority to do so; and must

o be separate from staff working with the client or involved in the incident.

The Investigation Manager must recommend an investigative action to the divisional office within 72 hours of becoming aware of the incident. The divisional office will review the proposed investigative action and either endorse it or, if required, modify it in consultation with Crewther Care.

The investigation manager must determine which one of the following four options is appropriate in the given case, with advice from other staff members if appropriate:

o No further investigative action – where it can be clearly established that the report of the incident is inaccurate or there is no basis for concerns about the safety of the client or their quality of care, no further investigative action need be taken. The decision not to undertake an investigation must be supported and recorded with persuasive reasoning backed up by evidence. The major impact incident must then be the subject of a review (case review or root cause analysis review).

o Monitoring and support required – Certain information may raise issues that do not necessarily warrant an investigation, but nevertheless require changes in practices. These issues may be managed by monitoring and supporting affected staff members or clients, and documenting this on the staff and client files. The major impact incident must then be the subject of a review (case review or root cause analysis review).

o Internal investigation – Crewther Care may investigate the incident where it has the capability to do so without compromising the independence of the investigation. This may not be possible in smaller organisations without separate business units or an independent investigative function.

o External investigation – In other cases, Crewther Care may commission an investigation by an external party to ensure the investigation is robust, objective and expert. The service provider may commission an investigator, or a person from another organisation with relevant expertise.

Crewther Care may request an investigation to be jointly managed with the Divisional Office if one or more of the following criteria have been met:

o the allegation relates to a pattern of similar serious allegations;

o it is not possible to undertake an independent investigation because of the seniority of staff involved; or

o there has been a demonstrated lack of capability by the service provider in their capability to conduct or commission an investigation that meets these standards.

If an investigation is to be undertaken, the incident investigation must be completed and the investigation report finalised within 28 working days of receiving confirmation from the divisional office regarding the appropriate investigative action. This excludes any time that the investigation is put on hold by Victoria Police.

For further details on conducting the investigation, consult the Client Incident Management Guide published by the Department of Health and Human Services (Vic).

For investigations where the alleged victim is a person with an intellectual disability or cognitive impairment, refer to the Disability Services Commissioner’s website: http://www.odsc.vic.gov.au/.

Investigating Non-Major Impact Client Incidents

Non-Major Impact client incidents of alleged abuse, poor quality of care or unexplained injury should be investigated.

Investigations should:

o be structured according to the 5-step process for Major-Impact client incident investigations – with due consideration given to the appropriate type of investigation or review;

o be conducted with procedural characteristics in line with Major-Impact client incident investigations: proportionate to the incident and accusations, procedurally fair, confidential, independent, person-centred, focused on outcomes, etc. (see Investigation Process and Responsibilities, above);

o produce conclusions and outcomes, where possible; in particular, improved quality assurance outcomes;

o be recorded appropriately; for example:

▪ in the Client Incident Register

▪ in the Continuous Improvement Plan

▪ in the Risk Management Plan

o result in the production of achievable quality assurance plans;

o have their conclusions reported to the people involved; and

o have their conclusions open to appeal where appropriate.

Where Non-Major client incident investigations reveal more serious problems, Crewther Care will consult with the Department of Health and Human Services

Investigation Report

The investigation should result in an investigation report which includes:

o details of the allegation(s) / unexplained injury

o the scope of the investigation

o the list of procedures performed in the investigation, including any procedures that could not be performed and the reasons why

o the witnesses interviewed

o documentary evidence considered

o summary of the key evidence

o (in instances of abuse or neglect) conclusions and findings based on the salient evidence and an assessment as to whether or not these incidents types can be substantiated based on the civil standard of proof (the balance of probabilities)

o (in instances of unexplained injury) conclusions and findings based on the salient evidence.

The investigation report must be provided to the divisional office for review and quality assurance. The divisional office will endorse this report if it has been completed satisfactorily and in accordance with the standards outlined above.

Responding to the Investigation Report

The investigation manager should carefully consider:

o whether the investigation report meets the standards required in the Client Incident Management Guide;

o whether the investigation is complete;

o whether the findings and recommendations made are sound and based on accurate consideration of all the facts.

If not:

o Crewther Care should consider whether additional investigation is appropriate in the circumstances.

If so:

o The investigation manager should also attest to, or provide assurance that, the investigation has adequately explored the incident and all relevant information.

The investigation manager should prepare a response plan based on the investigation report, including:

o determined outcomes for staff or clients who were involved;

o any actions to ensure the safety of clients in the future, and

o any practice improvements that may have been identified.

Crewther Care must log any determined actions against the incident and record when they have been carried out. Actions relevant to the client’s ongoing service provision should also be recorded on a client file.

Once any actions required as a follow-up to the investigation have been implemented, the service provider can complete the incident investigation.

Review of the decision: Appeal

A written request for a decision review can be made to the chief executive officer or Crewther Care within 14 working days of parties being notified of the outcome of the investigation. The decision review must be completed within 28 working days of the written request.

A decision review request may appeal either:

• a decision that substantiates abuse, or

• a decision that determines that abuse did not occur.

Within 48 hours of receipt of the written request, Crewther Care must:

• send a return letter acknowledging receipt of the request for a decision review; and

• notify the department in writing that a request for decision review has been received.

When a decision review request is made, Crewther Care will be required to lead the decision review.

Crewther Care will appoint a lead decision reviewer who is as independent as possible from:

• the investigation manager who led the initial investigation

• staff involved in the original incident and

• staff involved in the original investigation

Where such independence is not achievable, the lead decision reviewer may be sourced from the staff of another service provider.

Reviews

An Incident Review seeks to answer one or both of the following key questions:

• Did the service provider respond with appropriate actions to manage the incident? (Focus on quality assurance, accountability and client outcomes.)

• Why did the incident happen, and what can be changed to reduce the likelihood of similar or related incidents in the future? (Focus on continuous improvement.)

An Incident Review may be conducted where:

• a non-major impact client incident involved abuse, poor quality of care or unexplained injury;

• a major impact client incident did not involve abuse, poor quality of care or unexplained injury;

• an incident was reported but an investigation was neither recommended nor required

• an incident was reported and screening recommended monitoring and support

• the investigation report was incomplete or inconclusive.

Reviews may be conducted

• by Crewther Care

• external bodies or

• jointly by Crewther Care and the department.

In conducting a review, Crewther Care will:

• adopt a person-centred and rights-based approach

• consider how the client’s experience and welfare could be improved and

• seek client input regularly and throughout the review process as appropriate

• provide the support needed for the client to participate in the review process, including through engagement with a key support person if desired.

Two types of Reviews

There are two types of incident review that are required under the CIMS:

• Case review – a review led by the service provider following a client incident to identify what happened and any process and system issues. This is a less structured and resource-intensive review than a root cause analysis review. A case review may include a document review and interviews with staff members, the client and managerial staff.

• Root cause analysis (RCA) review – a structured review process for identifying the basic or causal factor(s) that underlie an incident, in order to facilitate learning from that incident. It requires trained staff and appropriate resourcing and time, and therefore is only required in certain defined cases.

Nature of major impact incident Review required

Service processes or systems were not, or do not appear to be, a significant causal or contributing factor to the incident.

Service provider to carry out a case review meeting the standards set out in section 5.3. The review must be planned and undertaken by the service provider.

The review report is not required to be submitted to the divisional office but must be retained on the client’s file.

Nature of major impact incident Review required

Service processes or systems were, or appear to be, a significant causal or contributing factor to the incident occurring.

Service provider must undertake a review using root cause analysis methodology, meeting the standards set out in section 5.3.

The RCA review report is required to be submitted to the divisional office.

In exceptional cases, the divisional office may opt to jointly manage the review – see guidance at section 5.2.2.

Case Review

Case reviews should be initiated within 72 hours of receiving confirmation from the divisional office regarding the appropriate review action. They must also be completed by service providers within 21 working days of receiving confirmation, and include the following information at a minimum:

• summary of the incident

• assessment of the appropriateness of the management of the incident

• contributing factors / causes of the incident

• actions to be taken to reduce the risk of similar incidents occurring, including staff

member responsible for each action and the target date for completion

• administrative information

– incident frequency (one-off / pattern for staff / pattern for client)

– name and position of person who conducted the review

– date of the review.

The Directors must:

• ensure that the Case Review meets the standards set out in the CIMS Guide;

• sign off the Case Review;

• enter determined actions against the incident in the Incident Register

• record relevant service changes in the client’s file;

• communicate the findings of the review to the people involved in the incident.

In some instances, a case review will indicate the need for, and can inform, a subsequent RCA.

RCA Reviews

An RCA review reports must be completed and submitted to the divisional office within 60 working days of receiving confirmation from the divisional office regarding the appropriate review action, and can be undertaken by service providers or commissioned from an external provider.

RCA reviews should include the following key steps:

• verify the incident and define the problem

– provide a clear understanding of the problem required to be addressed

– the scope of the review

– the consequences of the incident for the individual client

• map a timeline, including causal factors

• identify critical events

• analyse critical events (cause and effect)

• identify root causes

• support each root cause with evidence

• identify and select the best solutions

• develop recommendations

• complete written report.

Recommendations: recommendations drawn from the RCA should be evaluated against: the identified root cause; the level of associated risk; the hierarchy of control / scale of effectiveness; achievability; the perceived value to the organisation.

Report: The report should be written after the recommendations have been evaluated for effectiveness, and should include the following elements: executive summary; event map; cause and effect chart; conclusions and supporting evidence; recommendations.

Risk reduction plan: A risk reduction action plan should be developed, which converts the causal statements developed in the RCA review into risk statements. The risk reduction action plan should include a description of:

o Who is accountable for the risk?

o What action is to be taken?

o Who is responsible for the action?

o When the action is to be completed by?

o A measureable performance target.

Risk reduction plans developed in the RCA should be logged in the Risk Register for monitoring and review.

Response: Recommendations approved by, or generated by, the divisional office should be transferred to the Continuous Improvement Plan for implementation and monitoring as regulated by the Internal Review and External Audit Schedule.

Data Analysis Framework

The data analysis component of the CIMS IT is designed to support continuous improvement through the ongoing identification of issues and implementation of changes that result in improved services and better outcomes for client safety and wellbeing, including changes in relation to case management, practice changes and policy changes.

The Directors, or delegate, will regularly consult the CIMS IT data analysis function to inform continuous improvement. https://hns.dhs.vic.gov.au/CIMS/

Supporting Clients through the Justice Process

Service providers should support clients through the justice process, including police investigation, prosecution and crimes compensation processes as appropriate. This may include:

• Ensuring the client has access to appropriate communication aides and tools to facilitate disclosures and the provision of evidence.

• Ensuring the client has access to an interpreter should they be from culturally or linguistically diverse backgrounds.

• Ensuring the client has access to a key support person of their choosing.

• Alerting police to the need for an Independent Third Person or Independent Person and the client's particular communication support needs, and the need for timely interviews to facilitate the recall of information.

• Facilitating arrangements with police for interviews and examination of evidence.

• Facilitating arrangements with specialist support services.

• Working proactively with the client to consider whether they will provide a witness statement, including making sure they understand they have time to make their decision if they are initially reluctant and the right to seek independent legal advice (in some instances Victoria Police may be better placed to provide this information).

Criminal injuries compensation and victim support

Application for compensation from the Victims of Crime Assistance Tribunal may be pursued by the client or their legal administrator after the incident has been reported to Victoria Police.

In relation to sexual abuse, a Centre Against Sexual Assault counsellor/advocate can support clients who wish to pursue compensation.

The alleged victim may also wish to contact:

• Victims of Crime: https://www.victimsofcrime.vic.gov.au/

• Court Network on 1800 681 614 or http://www.courtnetwork.com.au

End of policy document. Uncontrolled when printed.