Incident Management

INCIDENT MANAGEMENT

 

Objective

To provide information and outline the key steps, actions and responsibilities for effectively responding, reporting, communicating and reviewing incidents to promote safety, minimize re-occurrence and manage any associated risks at Burke and Beyond.

 

Scope

Incidents include those incidents involving participants, staff, visitors and equipment failure where the safety of people is compromised. All Burke and Beyond staff and volunteers are expected to comply and adhere to the practices outlined in the process and report all incidents. The procedure outlined below covers both Burke and Beyond sites and services provided in the community.

 

Reportable incidents involving participants funded through Victorian Department of Human & Health Services (DHHS) and continuity of care are reported through the Client Incident Management Systems (CIMS) and for all other reportable incidents involving participants; these are done through the NDIS Quality & Safeguards Commission and their website portal. Relevant timelines apply for both processes, refer below.

Non-major incidents will be recorded in the participant’s personal file on Supportability.

Staff/ volunteer incidents are reported through management and a record placed within staff/ volunteer file.

 

At all-times relevant privacy and confidentiality of incidents must be respected and considered during incident review and escalation.

 

Incidents involving staff/volunteer injury require follow up and may need to be reported to Worksafe under the following circumstances: Death, Employees or persons requiring medical treatment by a Doctor (Fractures, administration of a drug or medical treatment) or immediate treatment as an inpatient in a hospital. This must occur within 24hrs.

 

A participant major or reportable incident are incidents where the impact is on the participant/s. The criteria for this are:

  • Death,
  • Serious injury,
  • Alleged abuse, neglect or physical assault of a participation,
  • Sexual exploitation/ unlawful sexual or physical contact
  • Unauthorised restrictive practices.

 

A non-major incident is one where there is less impact to the participant, such as:

  • Behaviour- including: dangerous, disruptive, sexual, self harm, property damage
  • Illness
  • Injury
  • Medical condition (known) deterioration
  • Physical assault- participant to participant
  • Medication error- including: incorrect, missed, refused by client, other

 

 

PROCEDURE:

 

WHO

WHAT

All Staff

  • Following occurrence of an incident, take immediate actions to contain situation and ensure safety for those involved.
  • Alert others and/or senior staff on site
  • Address first aid issues if needed or contact an ambulance if it is an emergency

Ensure management are aware an incident has occurred.

  • Prior to completing an incident report, contact CSM to confirm requirement for incident report.
  • As directed/ supported by management, complete the appropriate participant incident report. Your manager will inform you of the correct one. Staff and Volunteer incidents are to be reported to Coordinator/ Management and an incident report completed. This will be filed on the staff file on supportability and appropriate follow up taken to manage incident.

 

Coordinator

 

  • Check for injuries if applicable, assess the need for medical attention and organise as needed. Ensure participant/staff are safe and comfortable.
  • Ensure relevant follow up actions taken, implement preventative actions and update report accordingly.
  • Consult with CSM/ CEO regarding incident report completion.
  • As relevant file copy of incident in participant/ staff file.
  • Ensure families, carers and/or relevant circles of support of participant are aware of incident
  • Arrange and organise any incident de-briefing and support for participant, staff and/or family involved
  • Assist with any follow up incident reviews and/or investigations
  • Provide feedback to staff regarding outcomes and actions
  • As agreed, with CSM submit incident via CIMS to senior delegate (CSM) or support reporting through the NDIS Commission Portal.

 

 

NDIS funded participant.

 

Coordinator

 

  • If an incident occurs, notify CSM immediately or as soon as practicable following incident.
  • As agreed, ensure an incident report completed outlining events, situation and follow up actions as directed by CSM.
  • Regularly communicate and consult with CSM.

 

Community Services Manager (CSM).

 

  • Assume Co-ordinator/CEO’s role if they are not available
  • Review incident report, quality of information provided, ensure relevant follow up actions are taken and edit/ update as necessary.
  • Confirm NDIS participant and if NDIS:
    • Consult reportable incidents guide.
    • If, reportable, notify NDIS Commission within 24 hours,
    • Provide a more detailed report about incident and actions taken within five working days.
  • If an unauthorised restrictive practice, notify NDIS Commission within five days of key Burke and Beyond staff being made aware of incident.
  • The NDIS Commission will advise if a final report required within 60 working days of submitting the reported submitted within five- days of incident.
  • Maintain a register of participant incidents and those reported to relevant Departments.

 

 

 

 

 

 

 

 

 

 

 

 

Incident Reporting- General.

 

Community Services Manager (CSM).

 

 

 

 

 

 

 

 

 

CEO.

 

 

  • Coordinate/ provide any de- briefing/counselling with participants, staff, families and other stakeholders who may be affected
  • Review all incidents, ensure preventative or corrective actions implemented, maintain an incident folder and as required an incident register
  • Assess whether this incident comes under mandatory reporting requirements and respond accordingly, as relevant consult/discuss with CEO
  • If a restrictive practice, attend to relevant restrictive practices reporting as per participant funding arrangements
  • Where applicable, take to LG meetings for discussion/follow up
  • Assume CSM’s (Community Services Manager) role if they are not available
  • Notify Work-Safe of staff, volunteers or participants’ incidents and injuries as per Worksafe guidelines.
  • Upon receiving notification of Major or Reportable incident:
    • Review incident, severity and possible implications/risks
    • Communicate with relevant key stakeholders and Board
    • Consult and develop any relevant immediate action plans
  • Upon receiving full incident details and any follow up incident investigations/reviews, in consultation, develop any follow up preventative actions/activities

Incident review/ Investigation

  • Incident investigations are following a reportable incident as outlined in scope section above.
  • This may include and/ or require criminal allegations and follow up. An investigation applies to highly complex incidents involving and impacting participant/s, where potential system and process issues underpin the incident, with multiple causes, potential contributing factors suspected and therefore warranting a thorough and more detailed analysis.
  • For further information, expected processes and templates for investigating and reviewing incidents refer to either “Client Incident Management System Operational update 1- 2019, dated 27/5/2019, or NDIS Quality & Safeguards Commission depending on the funding of the participant/ s involved.

 

Community Services Manager

  • If a major impact incident, screen whether incident involves reported incident criteria and as relevant initiate follow up review, investigation and/ or RCA
  • Discuss with Executive Management and determine who internally or externally to conduct investigation.

 

Appointed Investigation Manager

  • Determine type of investigation, whether internal, external or joint investigation.
  • Develop and communicate investigation plan and outcome report with Executive and as relevant external government departments
  • Ensure outcome actions recorded in participant file by CSM or Coordinator
  • Feedback the results of the investigation to the participant

 

Reportable incidents NDIS

Reportable incidents are serious incidents or alleged incidents, which result in harm to an NDIS participant and occur in connection with NDIS supports and services. Specific types of reportable incidents include:

•           The death of a person with disability.

•           Serious injury of a person with disability.

•           Abuse or neglect of a person with disability.

•           Unlawful sexual or physical contact with, or assault of, a person with disability (excluding, in the case of unlawful physical assault, contact with, and impact on, the person that is negligible).

•           Sexual misconduct committed against, or in the presence of, a person with disability, including grooming of the person for sexual activity.

 

The use of a restrictive practice in relation to a person with disability, other than where the use is in accordance with an authorisation (however described) of a State or Territory in relation to the person or a behaviour support plan for the person.

 

The internal process for reportable defined through this procedure still applies.

Non-reportable incidents

Non-reportable incidents are those of a less serious nature, which result in less serious impact to the participant. These types of incidents include:

  • Behaviour- including: dangerous, disruptive, sexual, self-harm, property damage
  • Illness
  • Injury
  • Medical condition (known) deterioration
  • Physical assault- participant to participant
  • Medication error- including: incorrect, missed, refused by client, other

 

These incidents are reported in the participant’s individual file is Supportability.

Journal record- scroll to bottom- incident list- add new incident- select site- complete report.

Analysis & Review

CSM, Operations Manager

  • Review incidents, incident data and any follow up reviews and investigations for potential system issues and opportunities for improvement- escalate as required
  • Where incidents are escalated, investigated and control actions developed ensure all relevant improvements tracked and monitored
  • Monitor, track and report on incident information and data