Click here to access the National Policy for the Management of Healthcare Incidents, Working Draft

Purpose

The purpose of Workstream 1: Policy is to develop a national policy for the coordinated management of incidents across the country that:

* considers all the requirements of best practice in incident management
* satisfies legal and legislative requirements
* is practical and able to be implemented by health and disability service providers.

Current Status

The policy was issued by the Ministry of Health to the sector in September 2008 as a “working draft”. This allowed all DHBs to undertake the training on incident management and Root Cause Analysis (RCA) and the many other components of incident management, so as to better understand the policy requirements before finalisation. The process and timeframe for finalising the policy will be determined by the Ministry of Health.

Key messages

The key messages for the NZ Incident Management System are:

•    Responsibility for action - identifying and reporting those things that go wrong in healthcare is everyone’s responsibility
•    Openness about failures – errors are reported and acknowledged without fear of inappropriate blame; the reporting of errors and incidents is encouraged
•    Open disclosure of adverse events – patients and their families/whanau are told what went wrong and why and offered an expression of regret that an incident occurred
•    Systems focus not individuals – the review of incidents is focused on the systems of care and not the individual’s contribution to the incident; human resources review processes are separate from the systems review
•    Emphasis on learning – the system is oriented towards learning from mistakes and employs improvement methods for this purpose
•    Obligation to act – the obligation to take action to remedy problems is clearly accepted and the allocation of this responsibility is unambiguous and explicit
•    Accountability – the limits of individual accountability are clear; individuals understand when they may be held accountable for their actions; health services will be held accountable for reporting and improvement action
•    A “just” culture – individuals are treated fairly
•    Appropriate prioritisation of action – action to address problems is prioritised and resources directed to those areas where the greatest improvements are possible
•    Teamwork – is recognised as the best defence of system failures and is explicitly encouraged and fostered within a culture of trust and mutual respect
•    National consistency – maintaining a consistent approach to incident management in all health and disability services is paramount.
•    National action – national level reporting and learning processes are financially, intellectually and technically well-resourced and effective.

Background on the development of the policy

Workstream 1: Policy

The purpose of Workstream 1 was to develop a national policy for the coordinated management of incidents across the country that:

•    considered all the requirements of best practice in incident management
•    satisfied legal and legislative requirements
•    was practical and able to be implemented by health and disability service providers.

Developing the policy

The national policy on incident management was required to be broad enough to be relevant to the range of New Zealand health and disability service providers, and yet specific and descriptive enough to support a nationally consistent, methodological approach. Many aspects and viewpoints were considered. To achieve national implementation, the policy needed to be easy to use, effective, realistic and based on learning from international experiences with similar systems.

Consultation

The NZIMS has, as its primary objective, the reduction of harm to patients. In ensuring that a wide range of views was obtained in the development of the national incident management policy, it was essential that consumers and appropriate family/whanau members had an opportunity to be involved. To manage this process effectively, several layers of consultation were undertaken. The consultation on the national incident management policy attracted a great deal of interest from all parts of the Health and Disability Sector. Approximately seventy submissions were received, mostly from managers and clinicians and DHBs. Comments were received from government agencies/committees/Maori purchasing-planning partners, disability service providers, private healthcare facilities and consumers. A report summarising the consultation feedback was developed. Both the report and appendix is available via the links below.

Report on Feedback

•    Policy Feedback Report
•    Appendix 2

National Policy Group

A small, high level group was established to identify the requirements of the major stakeholder organisations for consideration in the development of the policy. This group met on April 14th 2008 and included:

•    the Deputy Director-General, Sector Capability and Innovation, Ministry of Health
•    the Health and Disability Commissioner
•    the Project Lead CEO (represented by the Director of Board Governance, Waikato DHB)
•    the CEO of the Accident Compensation Corporation
•    the Chief Advisor to the Minister on Quality
•    the Acting Chief Coroner
•    a member of Quality Improvement Committee
•    a national Chief Medical Officer representative
•    a national Director of Nursing (and Midwifery) representative
•    the Project Director.

Review of existing DHB policies

Policies related to incident management and serious and sentinel event reporting were received by the project team from all District Health Boards. These were reviewed to provide an overview of current national activity with regard to incident management and highlighted many inconsistencies across the DHBs.  Analysis of the policies revealed multiple methods for defining, reporting, prioritising and investigating incidents and for determining required action by whom and when. (See Background Page for further detail.)

Defining incidents

Numerous methods exist to define incidents in healthcare. These include:

•    written descriptions of different terms
•    numerical definitions of different types of incidents (risk assessment matrix)
•    lists of specific events to be reported should they occur.

In March 2008, a decision was made at a combined forum for DHB Quality and Risk Managers, Directors of Nursing/Midwifery, Chief Medical Advisors and Ministry of Health Quality Representatives to use numerical definitions to determine the severity of an incident using a ‘severity assessment matrix’.  The NZ Incident Management System therefore adopted this method, which also identifies the appropriate action to be taken for each incident.

For more information, click here for the:

•    Incident Definitions Discussion Paper
•    NZ Severity Assessment Code
•    Guide to Using the Severity Assessment Code

Legislative reporting requirements

Several key pieces of legislation impact on the reporting requirements of the national incident management policy and needed to be considered. For example, the Health and Disability Services (Safety) Act 2001, the Coroner’s Act 2006 and the Health and Safety in Employment Act 1992 legislate a requirement for certain incidents in healthcare to be reported to the Ministry of Health, the police or to the Department of Labour, in addition to any reporting that must occur within the organisation.

For more information on the impact of New Zealand legislation on the NZ Incident Management System, click here to access the Report on Legislative Reporting Requirements.