| Policy area | Incident Management |
| Applicable to | SK Dhaliwal Pty Ltd |
| Version | V1.0 |
| Date approved | 22 June 2025 |
| Approved by | Director |
| Next review date | 22 June 2026 |
| Authority | NDIS Act 2013 NDIS Practice Standards and Quality Indicators NDIS Code of Conduct NDIS (Incident Management and Reportable Incidents) Rules 2018 UN Convention on the Rights of Persons with Disabilities UN Convention on the Rights of the Child NDIS Code of Conduct Aged Care Act 1997 Aged Care Quality and Safety Standards Aged Care Code of Conduct Privacy Act 1988 |
PURPOSE
The purpose of this policy and procedure is to explain our organisation’s commitment and approach to incident management.
Refer to the Reportable Incident Management Procedure for detail on reportable incidents.
SCOPE
This policy and procedure applies to all our workers (employees, contractors and volunteers).
DEFINITIONS
| Term | Definition |
|---|---|
| Incident | An act, omission, event or circumstance connected with providing support or services to a client, which has, or may have caused harm to the client. It includes ‘near misses’ that are potentially harmful and it includes complications, accidents and side effects. |
| Incident Management System | An incident management system comprises the policies, procedures, forms, templates and processes that support the identification, management, resolution and documenting of incidents and near misses that are known, suspected or alleged to have occurred during the course of providing support or services to clients. |
| Open Disclosure | The practice of acknowledging the incident, expressing regret to the person impacted that standards or expectations have not been met, finding out what happened, how and why and seeking to learn from the experience and make improvements. Note: Expressing regret does not mean an admission of guilt. |
| Reportable Incident | A ‘subset’ of overall incidents. These are incidents which have mandatory reporting requirements to regulatory bodies such as the NDIS Commission, Aged Care Quality and Safety Commission and the Police. Refer to the Reportable Incident Management Procedure for details. |
CONTEXT
Our organisation recognises that an effective incident management system is an important part of ensuring the health, safety and wellbeing of clients. We are committed to implementing and maintaining an incident management system that:
- is proportionate to the size and scale of our organisation and the scope and complexity of supports provided;
- prioritises safe and quality care and support to clients;
- identifies, assesses, analyses, manages, monitors and documents risks clearly, consistently and accurately;
- upholds clients’ human rights — including their right to privacy, confidentiality, dignity and respect;
- promotes clients’ right to choice, control and self-determination;
- encourages and supports client independence and capacity-building, where possible;
- provides cultural and language-accessible modes and methods for clients to report incidents;
- fosters a collaborative and resolution-based culture of open disclosure in relation to incidents; and
- identifies incident-related trends, issues and areas for improvement.
POLICY STATEMENT
1. Fostering a Safety Culture
- We will maintain processes to provide person-centred, safe and quality care and support to clients.
- We will make sure clients are aware of their right to report an incident and support them to do this if requested or required.
- We will ensure the client feels culturally safe and seek their input on creating safeguards that best meet their cultural and communication needs and preferences.
2. Risk Management
- We will maintain processes to ensure accountabilities, delegations of authority and incident reporting lines are clearly identified, documented and communicated across the organisation.
- We will conduct client risk assessments at intake, during reviews and during support provision.
3. Response Actions
- We will take required action(s) to address immediate client risks, issues or concerns.
- We will comply with both internal and external incident reporting requirements in the required timeframes and formats.
- We will contact the client’s family/support network to provide additional support to the client, if requested.
- We will acknowledge the incident verbally and/or in writing to the client and explain the response actions that are being/will be taken.
4. Communication and Collaboration
- We will communicate and collaborate with the client and other relevant stakeholders throughout the incident process.
- We will conduct all discussions with the client and/or family/alternate decision-maker/advocate with sensitivity, courtesy and respect.
- We will encourage the involvement of the client and/or their family/alternate decision-maker/advocate in identifying ways to reduce or prevent incidents from occurring and/or recurring.
5. Continuous Improvement and Quality Management
- We will seek to learn from incidents and near misses and continually improve our service delivery processes.
- We will review and analyse incident data to identify systemic issues and take follow up action(s) as required (e.g. changes to policy and procedures, worker rostering, supervision and training, technology and communications).
- We will report outcomes of incident investigations to both the client and other stakeholders (including relevant workers) and ensure this is documented in our quality management system as part of the continuous improvement process.
6. Reviewing and Monitoring Processes
- We will conduct audits to review and monitor our incident management process and make any required adjustments.
- We will maintain an Incident Register and a Continuous Improvement Register with details, actions and outcomes of incidents and suggested improvements.
7. Information and Record-keeping
- We will ensure information and records are accurate and up to date.
- We will ensure the client has provided us with all required written consents.
- We will store the information securely to ensure privacy, dignity and confidentiality and make sure it is accessible to the client and only other stakeholders authorised to access it.
8. Worker Training and Supervision
- We will maintain a skilled and trained workforce, which has the skills and knowledge to report and escalate incidents and near misses in required timeframes and formats.
- We will maintain processes to adequately monitor and supervise workers.
PROCEDURES
Following are the key steps in the incident management process. Refer to Schedule 1 at the end of this document for a graphical representation of the process steps.
1. Identify Incident
- Identify that an incident or near miss with potential to cause harm to the client has occurred.
- Take action(s) to ensure the immediate health and safety needs of the client. This may include contacting one or more of the following: emergency services (ring Triple Zero); the client’s GP (in business hours and when not urgent); over-the-phone pharmacy/medical advice (out of business hours). For example, 13 HEALTH or 1300 MH CALL); client’s family/alternate decision-make/advocate; and/or line manager or other internal responsible officer.
- Notify manager and complete an Incident Report with details of the incident.
2. Investigation
- Determine if the incident constitutes a reportable incident with mandatory reporting requirements. If it does, follow the Reportable Incident Management Procedure.
- Review the details of the incident, including the people involved, location, circumstances and outcome (injury, sickness, death, ‘near miss’).
- Complete an Incident Investigation Form or an Accident Investigation Form with information on primary and underlying causes of the incident, immediate actions required, recommended preventative actions.
- Leave any other specific investigation for the relevant authorities (Police, WHS, NDIS Commission, Aged Care Quality and Safety Commission).
3. Client Support
- Ensure the client feels safe, supported and respected.
- Ensure the client is aware of their right to engage an advocate and support them to do this if requested.
- Assess the environment to ensure client safety and to prevent recurrence.
- Communicate with the client and/or family/alternate decision-maker/advocate throughout the process and keep them up to date with actions and outcomes.
4. Analyse Incident
- Establish the cause(s) and effect(s) of the incident and any operational issues that may have contributed and the nature of the investigation.
- Encourage feedback from the client and/or their family/alternate decision-maker/advocate in identifying ways to reduce or prevent the incident from recurring.
5. Corrective Actions, Documentation and Continuous Improvement
- Develop a corrective action plan and discuss with relevant stakeholders.
- Complete corrective actions as required within identified completion dates. This may include revising policies, procedures, forms, checklists, adjusting worker rosters, developing worker training, increasing supervision etc).
- Document details of the incident, action(s) and outcomes in the Incident Management – Final Report, Incident Register and the Continuous Improvement Register.
- Update other documentation as required (support plan, behaviour support plan, complex health plan, comprehensive health assessment).
- Communicate changes and outcomes to relevant personnel.
- Conduct internal audits to check integrity of process and completion of corrective actions.
SUPPORTING DOCUMENTS
- Incident Investigation Form — Final Report
- Incident Investigation Form
- Incident Register
- Staff Incident Reference Card
RESPONSIBILITIES
- maintaining this policy, its related procedures and associated documents;
- ensuring the policy and procedure is effectively implemented across the service;
- monitoring workers compliance with the requirements of this policy and procedure; and
- ensuring training and information is provided to workers to carry out this policy and procedure.
All workers are responsible for complying with the requirements of this policy and procedure.
COMPLIANCE
Deliberate breaches of this policy and procedure will be dealt with under our misconduct provisions, as stated in the Code of Conduct Agreement.