This document provides checklists for developing an incident management policy and procedures that meet regulatory requirements. The policy should define what constitutes an incident and approach to management. Procedures should address responding to incidents, identifying and recording incidents, reporting requirements, and investigating incidents to prevent recurrence and improve supports. The overall goal is to have a systematic process for handling incidents that prioritizes participant safety, meets legal obligations, and leads to continuous quality improvement.
This document provides checklists for developing an incident management policy and procedures that meet regulatory requirements. The policy should define what constitutes an incident and approach to management. Procedures should address responding to incidents, identifying and recording incidents, reporting requirements, and investigating incidents to prevent recurrence and improve supports. The overall goal is to have a systematic process for handling incidents that prioritizes participant safety, meets legal obligations, and leads to continuous quality improvement.
This document provides checklists for developing an incident management policy and procedures that meet regulatory requirements. The policy should define what constitutes an incident and approach to management. Procedures should address responding to incidents, identifying and recording incidents, reporting requirements, and investigating incidents to prevent recurrence and improve supports. The overall goal is to have a systematic process for handling incidents that prioritizes participant safety, meets legal obligations, and leads to continuous quality improvement.
This document provides checklists for developing an incident management policy and procedures that meet regulatory requirements. The policy should define what constitutes an incident and approach to management. Procedures should address responding to incidents, identifying and recording incidents, reporting requirements, and investigating incidents to prevent recurrence and improve supports. The overall goal is to have a systematic process for handling incidents that prioritizes participant safety, meets legal obligations, and leads to continuous quality improvement.
This resource is a checklist which contains recommended elements of
an effective policy and procedures that meets meets NDIS Commission requirements. Use it to identify where your own policy/procedure could be improved or as a guide to the development of a policy/procedure. Remember to use it to guide what you need in a way that suits the size of your service and the types of supports it provides. Risk Incidents and Complaints Management
Incident Management Policy
and Procedure Checklist
Incident Management Policy Checklist
Define incidents and incident management You identify incidents that must be recorded and managed as events or incidents occur that have or could have caused harm to a person using your supports or loss or damage to property They include acts by a participant that happen in connection with providing supports that have causes serious harm, or a risk of serious harm to another person They also include a near miss, which did not cause harm but had the potential to do so Identify a hazard as a situation that has the potential to harm a person (cause death, illness or injury) environment or damage property Harm includes death, injury, illness (physical and psychological) or disease that may be suffered by a person as a consequence of exposure to a hazard Accidents are events or situations that actually resulted in harm to an individual or damage to equipment or property. This policy includes accidents as incidents Risk as something that could potentially lead to an incident or accident A Notifiable Incident is an extremely serious incident arising out of service delivery that relates to any person-employee, participant, contractor or member of the public and has mandatory reporting requirements under Work Health and Safety (WHS) legislation (see Incidents resources) They include ‘reportable incidents’, required to be made to the NDIS Commission, that have (or are alleged to have) occurred in connection with providing support to a participant Identify incidents which must be reported to the NDIS Commission in relation to a participant, to include events that occurred in connection with providing supports to a participant and resulted in or could have resulted in harm to the person with disability, or arise from acts by a person with disability that cause or risk causing serious harm to another person. Risk Incidents and Complaints Management
The NDIS Commission determine ‘reportable incidents’ as:
• Death of a participant • Serious injury of a participant • Abuse or neglect of a participant • Unlawful sexual or physical contact with, or assault of, a participant by a worker or another NDIS participant • Sexual misconduct committed against, or in the presence of, a participant, including grooming of the participant for sexual activity • Unauthorised use of a restrictive practices. The incident management system identifies how your organisation manages and resolves these types of incidents. Approach to Incident Management It is everyone’s responsibility to ensure the safety and wellbeing of participants Fosters a culture of continuous improvement with a proactive approach to managing incidents Rely on your risk management system to eliminate or minimise identified risks Inform participants about your incident management practices and how you provide supports in a safe environment All staff are trained in the required procedures relating to incident management When an incident occurs you have a process that promptly and appropriately identifies and responds to, records, reports it (if required) and investigates (if required) the incident to ensure they are prevented from occurring in future Commitment to keeping incident records to show accountability and transparency for decisions you make The process includes providing information to participants about how incidents that involved them have been managed. Determine lessons to be learnt and changes to be made There is a systematic way of recording and monitoring incidents received. (e.g. you use a form to collect required information relating to an incident which assists to investigate and prompt further actions and an incident register to monitor incident management) The service reviews the operation of the incidents management system regularly to ensure it is delivering effective outcomes and to look for improvements in the process. Risk Incidents and Complaints Management
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Incident Management Procedure Checklist
Help people affected by an incident After an incident occurs, you provide immediate support and assistance to participants affected by the incident as the highest priority, and re-establish a safe environment You have a process to determine how participants affected by an incident will be supported, how this is best delivered, including facilitating access to advocates You contact the appropriate emergency contact or family member/carer/guardian as soon as practicable You check with participants about how to resolve the issue, and what could have been done to prevent it occurring You keep the participant informed of progress on the incident You seek feedback on how well the incident response was managed and what if any corrective action needs to be undertaken to prevent further incidents or minimise any impact. Responding to incidents Incident identification, recording and reporting Staff understand what to record and the timeframe in which to record that captures all factors contributing to the incident, immediate actions and identified /planned follow- up actions and any reports made externally e.g. police or NDIS Commission. (See an example in Incidents resources) Your record of incidents includes a description of the incident, the impact on or harm caused to any person affected by the incident, and whether or not it is reportable All 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 examined to reduce the likelihood of a similar event occurring again All staff contractors, students and volunteers have a responsibility to ensure details of any incident are recorded and reported via your established line of reporting The line of incident reporting describes the following: • When police or emergency services should be notified • A requirement to notify the participant’s family, carers, guardian, and • Who must be notified internally when an incident occurs (e.g. immediate supervisor) A designated role collates and records all incidents reports, such as into an Incident register. This includes providing support to the affected person/s, the identification of whether the NDIS Commission requires the incident to be reported to them, or elsewhere. Risk Incidents and Complaints Management
Reportable incidents (to the NDIS Commission)
You have a way to determine what incidents must be reported to the NDIS Commission (see link Incidents resources) you use the NDIS Commission Portal ‘My Reportable Incidents’ page to notify and manage all reportable incidents and you keep the Commission informed of any investigation or actions arising from the incident You have identified the roles of Authorised Reportable Incidents Notifier and Authorised Reportable Incidents Approver, who both have responsibilities for meeting your Commission reporting obligations. The Approver may – but doesn’t have to – be the same person who is required by the Rules to be identified as the person who reports incidents to the Commission (now known as the ‘Specified Personnel’) Your system ensures the required timeframes for reporting are followed: • for reportable incidents other than unauthorised use of a restrictive practice: within 24 hours of your key personnel becoming aware of the incident • for unauthorised use of a restrictive practice: within five days of your key personnel becoming aware of the incident • unless the incident also involved other reportable aspects: 24 hours. Responding to incidents You have a process to: • Ensure that a response plan is developed when incidents occur • Identify when corrective action should be taken in response to an incident, and • Identify when an investigation is required The response process includes the following factors: • Description of the incident • Collect the data, information surrounding the incident • Look at possible causes • Determine through problem solving the cause of the incident • Take steps to address the cause of the incident • Record how a decision was reached and the rationale for the decision and action taken You have a plan to deal with incidents when they arise that includes: • Any actions to be taken immediately after the incident to ensure the health, safety and wellbeing of the participant involved in the incident • The assessment and mitigation (reduction) of any immediate risks to other people with disability that could be impacted by the incident, and • Where the incident is or maybe a reportable incident, further action that must be taken. Risk Incidents and Complaints Management
Investigate You have a process in place to identify when a formal internal investigation of an incident is required, and the nature of the investigation. This includes to explore in more detail why an incident occurred and steps to prevent it reoccurring You have identified factors that may initiate an investigation include when police are involved, (Note, an internal investigation should not commence until the police have completed their enquiries) a mandatory report is required (including reportable incident), a notifiable report or an incident which could lead to potential litigation. Internal investigation maybe used to establish the cause of a particular incident, its effect and any operational issues that may have contributed to the incident occurring You state the principles of person-centred practice and procedural fairness in the conduct of all investigations. (The NDIS Commission have Guidelines on Procedural Fairness (see Incidents resources) You consider whether to either conduct a serious investigation either internally (with staff who have the skill and expertise) or out-source to an external investigator. Take corrective action if required Required corrective action will need to be taken in the following circumstances: • Where an incident may have been prevented (or the severity lessened) by some action (or inaction) by your service or a worker • Where there is an ongoing risk to participants, or • Where action by your service may prevent or minimise the risk of a future reoccurrence Corrective action may include further staff training, practice improvements, policy and procedure enhancement, changes to service delivery environments or changes to services provided At the conclusion of an incident resolution, you determine what further action should take place. This could include: • Providing ongoing support to impacted participants and/or ensuring the ongoing wellbeing and safety of impacted people with disability • Identifying and implementing improvements • Notifying the NDIS Commission and or other bodies, as appropriate • Undertaking further investigations • Identifying and taking corrective action to prevent a reoccurrence of an incident • Deciding no further action is required. Keep records You ensure that your system records and tracks evidence of incidents and actions taken in response to these incidents You make sure all information relating to incidents is securely stored and access is managed Risk Incidents and Complaints Management
The Incident register stores all incidents and details of their management and outcome or conclusion of each incident You ensure you maintain records and related evidence about incidents You make effective use of information and communication technologies and systems that collect data and track the progress of incident responses Records of incidents are kept for seven years from the date the incident report is created. Reporting to other agencies Your record system includes examining whether an incident is also required to be reported to other external agencies e.g. police, child safety authorities. Lessons learnt At the finalisation of your incident management, the procedure assesses the following: • Whether the incident could have been prevented • How well the incident was managed and resolved • What if any, remedial action needs to be undertaken to prevent further similar incidents from occurring, or minimize their impact, and • Whether other persons or bodies need to be notified. You seek the views of the participant/s impacted by the incident and staff, and any feedback at the conclusion of each incident response on the effectiveness of the management of every event in order to improve how incidents are managed You use information that comes from all incidents you manage to improve your service and avoid future incidents You have mechanisms to cross-reference incidents that are also the subject of a complaint, and/or work health and safety investigations You have a system of ongoing review of your Incident Policy and Procedure to ensure information that you learn from incident management is contributing to continuous quality improvement. Letting participants know… On commencement with your service, you provide information to participants on how incidents will be managed in an accessible format (e.g. Participant information pack/ Service Agreement). See how we manage incidents for participants in Incidents Resources Identify to participants (possibly in your service agreement) the circumstances in which you are obliged to share information about participants with the NDIS Commission, such as those involving reportable incidents. Train staff All staff are trained in their responsibility for maintaining an awareness of potential risks in their area of responsibility Risk Incidents and Complaints Management
Staff training occurs in relation to how to identify and manage risks, staff incident management responsibilities and how to follow in practice the incident and risk management procedures You ensure all staff have the necessary skills in identifying, reporting, managing and resolving incidents and in preventing incidents from reoccurring Staff are encouraged to speak up if they are unsure about identification of an incident Incidents are part of regular discussion within the service such as in staff meetings, to encourage a positive culture of reporting. Allocating responsibility Your incidents management system acknowledges all staff are also responsible for reporting any potential or actual risk Identifies which positions will be responsible for reporting, recording, conducting internal investigations and undertaking remedial(corrective) action related to incidents Nominates people with the appropriate skills to become Reportable Incident Authorised Notifiers within the service. (The NDIS Commission suggests the ‘Authorised Reportable Incidents Notifier’ is a supporting team member who can assist the ‘Authorised Reportable Incidents Approver’ to collate and report the required information. They must be familiar with the NDIS Commission’s Portal functionality on Managing your Reportable Incidents) Amends all staff job roles and position descriptions as required to reflect NDIS Commission required practices in relation to their role with incident management Ensures staff responsibilities to incident management are included in their job description and monitored during routine performance reviews Has a policy for worker disclosure e.g. Whistle Blower Protection Policy. (see example in Incident resources) If a policy already exists, update it for the new quality and safeguarding system.
