The New Zealand Incident Management Project

How did the project come about?

A report prepared for the Minister of Health in November 2006, entitled Scoping the Priorities for Quality in the Health and Disability Sector, helped determine six quality priority areas and provided programme outlines on how each of these could be achieved. One of the six priorities identified was the development of a national approach to the management of healthcare incidents. At the first meeting of the (Ministerial) Quality Improvement Committee, the Minister gave the committee the report, stating that the report established their first work plan.  Projects based on four of these priority areas were established and comprised a national quality improvement campaign that was sponsored by the Quality Improvement Committee (QIC) and overseen by District Health Board New Zealand (DHBNZ).

In February 2008, Waikato District Health Board (WDHB) was identified as the lead DHB to develop and implement this national approach to incident management. WDHB contracted Communio to partner with them to undertake this project, which ran during from March 2008 to October 2009.

Incident management in the sector at the start of the project

When the NZIMS project commenced in March 2008, there was considerable variation in the management of healthcare incidents in the NZ health and disability sector.

•    There was a lack of understanding of the need for a consistent national approach to incident management and the need to manage all incidents in all health and disability services in a consistent way.
•    No DHB had a single policy that dealt with the whole process of incident management in that DHB. When asked to provide the project team with their incident management policies, 46 policies were provided from 21 DHBs. These did not include policies for open disclosure of adverse events.
•    The policies received described many different ways of defining and reporting incidents, for determining required action and the roles and responsibilities of staff at various levels of the organisation.  
•    There was a long standing requirement to report serious and sentinel events to the Ministry. Most DHBs were unaware of any timeframes for achieving this and reported variously, if they reported at all.
•    Definitions of serious and sentinel events required an element of subjective interpretation due to their descriptive nature.
•    Methods for investigating serious and sentinel events varied and there were no mechanisms for managing near-miss incidents or those that resulted in minimal to no harm but with the potential for significant harm.
•    There was no requirement to act on the results of investigations to ensure that improvements were made and future incidents were prevented.
•    There was no requirement to report the results of investigations to a central national point where lessons could be identified and disseminated to all health and disability services.
•    The information collected about incidents was inconsistent and management processes varied across all services.
•    Limited, if any, national learning occurred.

The NZ Incident Management System Project needed to address these and many other variables in order to be successful.

Project Goal

The project goal was to achieve a nationally consistent approach to incident management across all health and disability services in New Zealand, in order to:

1.    reduce harm caused to patients, their families and to clinicians
2.    develop a culture and environment within which incidents could be identified, reported, investigated and acted upon to prevent recurrence and fear and defensiveness would be reduced
3.    implement (eventually) an information system that would support the culture and assist providers in the above process.

In so doing, it was expected that the project would result in:

•    identification of as many incidents in the health and disability sector as possible
•    prioritisation of incidents using a common tool
•    notification of all incidents to the right person (people) for action
•    review and investigation of incidents to identify causes and to develop mitigation strategies
•    classification of incidents using a common hierarchy and taxonomy
•    action, both local and national, to prevent recurrence
•    truthful and open disclosure of adverse events
•    support for patients, families and staff involved in incidents and adverse events
•    the establishment of a sustainable, consistent, ongoing programme for the management of all incidents across the entire health and disability sector.

Key focus areas

The three key project areas were:
1.    Policy: The development of a national policy for the coordinated management of incidents across the country.
2.    Education and Training: The provision of education and training in all District Health Boards to implement the policy and train staff in incident management.
3.    Information System: The identification of the business and technical requirements for a nationally coordinated incident information system (IIS).

Healthcare is one of the most complex activities that humans engage in and there are inherent risks associated with the delivery of that care for patients, clinicians and for organisations that provide the care. Most harm to patients results from errors made by healthcare providers. This is because healthcare providers are human and therefore prone to error, and because the systems of care do not support providers in their efforts to manage the “human condition” and to provide safer care. Errors occur at all levels of an organisation. It is the result of errors that is important. Seemingly minor mistakes in one circumstance will have minor consequences but in different circumstances will have major consequences, resulting in an adverse incident for a patient. The overall number of errors or adverse incidents is far less important than the action that is taken to prevent their recurrence.

Other high risk industries, such as the nuclear power and the aviation industries, have responded by implementing safety improvement systems, and so too is the health industry. The purpose of such systems is to identify, investigate, analyse and act upon incidents as or before they occur to minimise the chance of the occurrence and reoccurrence of untoward outcomes of healthcare. There are many components of a clinical governance and quality improvement system. An incident management system is but one of those components. It is essential that health and disability services develop an effective local incident management system which is aligned with the national policy, and recognise that this is not the only focus of clinical governance and quality improvement activity.