Implementing an Effective Incident Management System: Aged Care Quality and Safety

An incident management system allows aged care services to systematically identify, report, manage and respond to incidents that occur during the delivery of care. This includes reportable incidents under the SIRS such as unreasonable use of force, inappropriate sexual conduct, psychological or emotional abuse, unexpected death, stealing or financial coercion by a staff member, use of restrictive practices, and unexplained absences.

Having an effective incident management system is not only a legislative requirement under the Aged Care Quality Standards, but also critical for providers to continuously improve the quality and safety of the services provided to older people. It enables providers to learn from incidents and near misses to prevent similar incidents from occurring in the future.

Benefits of an aged care IMS

There are many benefits to implementing an effective incident management system in aged care services, including:

• Improved safety and wellbeing of consumers
• Early identification and mitigation of risks
• Opportunity for continuous improvement
• Increased accountability and transparency
• Compliance with legislative requirements
• Enhanced reputation and public trust

An incident management system empowers staff to speak up when they witness an incident occurring, enabling a timely response to address the immediate needs of those affected and prevent incidents from escalating. Over time, analysing trends in incident data can reveal systemic issues and drive continuous improvement in the quality of care.

Key features of an effective incident management system

While each aged care service will have a system tailored to its specific context, some key elements should be included in every incident management system:

1. Leadership commitment

Effective incident management requires strong leadership and governance. The governing body and senior management must foster an organisational culture that prioritises the health, safety and wellbeing of consumers, and supports staff to report incidents without fear of reprisal.

2. Comprehensive policies and procedures

Clear policies and procedures must be established outlining the roles and responsibilities of staff in identifying, reporting, managing and responding to incidents. This includes having processes for reporting to the Aged Care Quality and Safety Commission and notifying consumers and their representatives.

3. Staff education and training

All staff must be trained to recognise and report incidents, as well as understand their roles in managing incidents when they occur. Training should cover the different types of reportable incidents under SIRS, how to submit a report and the importance of reporting all incidents and near misses.

4. Accessible reporting mechanisms

There must be a variety of accessible and easy-to-use channels for staff, consumers and visitors to report incidents at any time. This may include phone and email hotlines, paper-based forms, and online reporting tools. Consumers should be given information on how they can report incidents upon entry to a service.

5. Consistent investigation and analysis

A systematic process must be followed for investigating and analysing incidents to identify contributing factors and root causes. All incidents and near misses should be documented, even if they are not classified as reportable incidents under SIRS. Investigation findings should be used to develop corrective actions to prevent similar incidents in the future.

6. Open disclosure and communication

Providers must practice open disclosure when incidents occur, including apologising to and supporting those affected. Consumers and their representatives should be kept informed and involved throughout the incident management process. Incidents and actions taken should also be communicated to staff to facilitate learning.

7. Continuous improvement and sharing of learnings

Incident data and trends should be regularly analysed to identify areas for improvement in the quality of care. Learnings should be shared within the organisation and across the broader aged care sector to collectively work towards enhancing the safety and wellbeing of older Australians.

Reportable incidents under the SIRS

The Serious Incident Response Scheme (SIRS) defines the types of incidents that aged care providers must report to the Aged Care Quality and Safety Commission. As of 1 April 2021, the following incidents are considered reportable incidents under SIRS in residential aged care:

• Unreasonable use of force
• Unlawful sexual contact or inappropriate sexual conduct
• Neglect
• Psychological or emotional abuse
• Unexpected death
• Stealing or financial coercion by a staff member
• Inappropriate use of restrictive practices
• Unexplained absence (missing consumers)

From 1 December 2022, the SIRS was extended to cover aged care services delivered in the home or community settings. Providers must report all incidents that occur in connection with the services they provide, including those that happen while delivering care and services, or that are related to the services provided.

Reportable incidents must be classified as either Priority 1 or Priority 2 based on the impact on the consumer and the immediate actions required:

• Priority 1 incidents must be reported within 24 hours
• Priority 2 incidents must be reported within 30 days

All unlawful sexual contact or inappropriate sexual conduct must be reported as a Priority 1 reportable incident as of 3 October 2022.

Fostering a culture of reporting

One of the major challenges in aged care is the underreporting of incidents due to fear of repercussions or lack of understanding about what should be reported. Research has found that only around 10% of incidents in residential aged care are reported.

To overcome this, providers must work to create a 'just culture' that strikes a balance between individual and organisational accountability. Staff should feel supported and empowered to speak up about incidents without fear of blame or punishment for human errors. At the same time, reckless behaviour should not be tolerated.

Incident management systems rely on staff proactively identifying and reporting incidents and near misses. A near miss or close call is an event that could have resulted in harm but did not. Capturing near misses provides valuable opportunities for learning and preventing incidents before they occur.

Through training and ongoing communication, providers should reinforce that reporting is a positive behaviour that contributes to continuous improvement and risk management. Involving staff in developing and refining incident management processes can help build trust and ownership.

The role of the Aged Care Quality and Safety Commission

The Aged Care Quality and Safety Commission (ACQSC) is the national regulator of aged care services in Australia. The ACQSC accredits, monitors and assesses providers against the Aged Care Quality Standards.

Under the SIRS, the ACQSC receives reportable incidents from providers and uses this information to identify trends and issues across the sector. The ACQSC can take regulatory action where providers are non-compliant with their responsibilities, including issuing compliance notices, imposing sanctions, and revoking accreditation.

The ACQSC provides a range of resources to support providers in effective incident management, including guidance material, educational videos, and online learning modules. Providers are encouraged to access these resources to ensure their incident management systems are best-practice and meet the expectations of the ACQSC.

Conclusion

Effective incident management is critical to delivering high-quality aged care services and safeguarding the health, safety and wellbeing of older Australians. By implementing a comprehensive incident management system, providers can better identify, manage and prevent incidents, while driving continuous improvement.

The Serious Incident Response Scheme (SIRS) has put incident management in the spotlight and increased the accountability of providers. With the Royal Commission into Aged Care Quality and Safety highlighting widespread issues, it has never been more important for providers to prioritise effective incident management.