Incidents, Open Disclosure & Complaints

Clinical Policy

The Hader Clinic (THC) recognises that incidents may occur while providing services to patients and is committed to responding to incidents through an organisational wide, effective management and investigation process. This process as part of an integrated safety and quality system is underpinned by the THC Clinical Governance Framework. THC staff are obliged to appropriate full disclosure that ensures an open and honest service delivery.

Creation Date: 22/02/2021

Document Number: PL05431 V1

Owner: Wayne Hewetson

Contributors(s): Tarryn Argus, Jackson Oppy

References: 1. Australian Commission on Safety and Quality in Healthcare, NSQHS Standards2. Australian Commission on Safety and Quality in Healthcare, Open Disclosure Standard 2008

Review Schedule: One Year

Risk Rating: Low

Effective Date: 22/02/2021

Review Date: 22/02/2022

Departments: Geelong

Standards: Standard 1 Governance, Leadership Culture, Standard 2 CG & QI supporting partnering with consumers, Standard 6 CG & QI to support effective communication

Key Search Words: Incidents, Open Disclosure and Complaints Policy, issue

1. Policy Statement
1.1 GOVERNANCE
 The Hader Clinic will manage incidents and complaints inline with the Australian open disclosure
framework developed by the Australian Commission on Safety and Quality in Health Care

1.2 REPORTING
 The Hader Clinic Patient Safety Committee has overarching responsibility for incident, open
disclosure and complaints management across the organisation and reports to The Hader Clinic
Management Committee

1.3 INCIDENT MANAGEMENT
 Incidents will be recorded on One Vault and investigated in accordance with the National Safety
and Quality Health Service Standards and The Hader Clinic Incident and Complaints Procedure
including:
1.3.1 how and when incidents and near misses should be recorded
1.3.2 who is responsible for investigating and responding to the incident
1.3.3 timeframes for completing the investigation and implementing any required changes or
improvements.
1.3.4 training in identifying and managing incidents and near misses at induction and regularly
thereafter
1.3.5 designated responsibility for coordinating the analysis of clinical and non-clinical incidents and
near misses and reporting findings to the workforce
1.3.6 providing feedback to the workforce regarding incident data and lessons learned, information
gained and quality improvements implemented as a result of incident analysis
1.3.7 using incident analysis to improve staff education, update policy, procedures and patient
information, inform strategic and operational planning and implementing quality
improvement activities

1.4 OPEN DISCLOSURE
 The Australian open disclosure framework developed by the Australian Commission on Safety and
Quality in Health Care outlines the key principles of open disclosure. It provides a nationally
consistent basis for communication following a healthcare incident or adverse event. The
framework specifies:
1.4.1 Open and timely communication - a patient is to be provided with information about what
happened in an open and honest manner at all times, which may involve the provision of
ongoing information.
1.4.2 Acknowledgment - health services are to acknowledge when an adverse event has occurred
as soon as practicable, and to initiate the open disclosure process.
1.4.3 Apology or expression of regret - a patient is to receive an apology or expression of regret for any harm that resulted from an adverse event as early as possible.
1.4.4 Recognition of reasonable expectations - a patient may reasonably expect to be fully informed
of the facts surrounding an adverse event and its consequences, treated with empathy,
respect and consideration and provided with support in a manner appropriate to the patient’s
needs.
1.4.5 Staff support - health services are to create an environment in which all staff are able and
encouraged to recognise and report adverse events, and are supported through the open
disclosure process.
1.4.6 Integrated risk management and systems improvement - investigation of adverse events and
outcomes are to be conducted through processes that integrate a focus on risk management
and on improving systems of care and reviewing their effectiveness.
1.4.7 Good governance - a system of accountability must be in place (through the health service’s
chief executive officer or governing body) to implement clinical risk and quality improvement
processes that prevent the recurrence of adverse events, and to ensure changes are reviewed
for their effectiveness.
1.4.8 Confidentiality - health services are to develop policies and procedures with full consideration
of consumer and staff privacy and confidentiality, and in compliance with relevant law,
including Commonwealth and state or territory privacy and health records legislation.

1.5 COMPLAINTS
Complaints will be recorded and investigated in accordance with the National Safety and Quality
Health Service Standards and The Hader Clinic Incident and Complaints Procedure including:
1.5.1 how and when complaints should be recorded
1.5.2 who is responsible for investigating and responding to the complaint
1.5.3 what the timeframes are for completing the investigation and implementing any required
changes or improvements
1.5.4 how to report and to whom to report complaints
1.5.5 training of staff in dealing with patient complaints including how to diffuse the immediate
situation and who to involve to resolve the complaint as quickly as possible
1.5.6 the inclusion of complaints as part of team meetings to discuss solutions and reduce the risk
of repetition
1.5.7 the utilisation of complaints data collected over time to drive quality improvement.
1.5.8 designated responsibility for coordinating the analysis of complaints and reporting findings
1.5.9 providing feedback to the workforce regarding complaints data and lessons learned,
information gained and quality improvement implemented as a result of complaints analysis

2. Policy Scope
2.1 All staff at The Hader Clinic


3. Definitions
3.1 Open Disclosure
 Open disclosure is the open communication that takes place between health practitioners and
patient after an adverse event. At a minimum, an open disclosure process must include: an apology
or expression of regret a factual explanation of what occurred, including actual consequences an
opportunity for the affected patient to relate their experience the steps taken to manage the event
and prevent its recurrence.3.2 Incident

 An event or circumstance that resulted, or could have resulted, in unintended and/or unnecessary
harm to a person and/or a
complaint, loss or damage
National Safety and Quality and Health Service Standards

4. Policy Rationale
4.1 The intent of this policy is to manage incidents and complaints in accordance with national best
practice including Standard 1 of the National Safety and Quality Health Service Standards and the
ACSQHC Open Disclosure Standard

5. Standards
5.1 National Safety and Quality Health Service Standards
5.2 National Open Disclosure Framework

6. Responsibilities
‍6.1 Leadership | Executive
 Leadership | Executive have the responsibility to provide leadership and resources to enable
incidents, open disclosure and complaints to be managed in accordance with best practice.
6.2 Managers
 Managers are responsible for supporting this policy and supporting procedures within their area of
accountability.
6.3 Clinicians
 Clinicians are responsible for adhering to this policy and supporting procedures and conducting
open disclosure in accordance with the National Open Disclosure Framework.
6.4 Administration Staff
 Administration staff are responsible for adhering to this policy and supporting procedures.

7. Organisational Related Policy or Procedure
7.1 Clinical Governance Framework
Partnering with Consumers Policy
Risk Management Policy
APP Privacy Policy
Healthcare Records and Informed Consent Policy


8. Legislation
8.1 Health Practitioner Regulation National Law (Victoria) Act 2009
Health Records Act 2001
Health Records Regulations 2012
Health Services (Private Hospitals and Day Procedure Centres) Regulations 2013
Health Services (Conciliation and Review) Act 1987
Health Complaints Act 2016
Privacy Act 1988


9. Other Relevant Information / Documentation
9.1 NA

10. Other and Further Advice
10.1 N/A

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