Gisborne Hospital Report - Health and Disability Commissioner

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Gisborne Hospital 1999 – 2000 Incident Reporting and Complaints Procedure 7. RECOMMENDATIONS Continuous quality improvement 7.1 A cross-functional team (with clear terms of reference) should be established to evaluate and further develop the current incident reporting system, with a particular emphasis on developing a framework that guides: what to report; which incidents will be reviewed; and by whom. 7.2 The purpose of the Incident and Complaint Management Policy should be extended to include a statement that reflects the value of complaints and incidents as learning opportunities for the organisation and as a component of continuous improvement. 7.3 An internal investigation of a complaint or review of a reported incident should lead to internal disciplinary processes or mandatory training only where there is evidence of repeated poor performance that breaches professional standards of conduct or constitutes a major departure from the standard of care and skill reasonably to be expected in the circumstances. 7.4 Definitions of reportable incidents should be reviewed and consideration given to clearly differentiating “incidents”, “near misses” and “adverse events”. 7.5 The layout and content of the incident report form should be reviewed and consideration given to further information that it may be valuable to capture, such as the location where the incident occurred, the outcome, contributing factors, and whether the incident was preventable. 7.6 Numbers should be printed on the incident forms to enable tracking, and hard copies should be kept in the reporting department. 7.7 Consideration should be given to categorising incidents (eg clinical/nonclinical; major/minor; actual/potential) to enable investigation, reporting, quality improvement and monitoring to be effectively targeted. 7.8 The text of the Incident and Complaint Management Policy should be reviewed and requirements relating to incidents and complaints should be more clearly differentiated from each other. 7.9 A standardised approach to incident investigation should be adopted across Tairawhiti District Health to enhance consistency of investigations, reduce staff anxiety and provide the basis for educating staff who have this responsibility. Culture 7.10 Consideration should be given to confidential (but not anonymous) reporting of “adverse events” or “near misses” until the culture of fear changes. 63
Gisborne Hospital 1999 – 2000 Incident Reporting and Complaints Procedure 7.11 Feedback should be sought and utilised from users of the system. Staff satisfaction with the incident reporting system should be formally monitored at designated timeframes. 7.12 A system-centered approach should be initiated, rather than a personcentered/blaming approach. 7.13 Support people should be welcome at incident review discussions. Education 7.14 The education of staff on the incident reporting system (at orientation and thereafter on a regular basis) should be reviewed so that staff are clear about the philosophy behind incident reporting. 7.15 All staff groups should receive sufficient education to gain a clear understanding of the incident reporting system and their responsibilities within it. 7.16 A standardised education programme for all staff groups should be implemented as an urgent priority at Tairawhiti District Health. Incident review process 7.17 The process for incident review should be clearly defined. 7.18 Staff delegated incident review responsibility should receive appropriate education for the role. Reporting and monitoring 7.19 Monitoring should be introduced with a focus on ensuring that serious failures are not recurring. 7.20 All evaluation methods listed in the Incident and Complaint Management Policy should be implemented: ie, monthly reports to the Quality and Risk Management Committee and Core Quality Group, and quarterly reports to the Audit Committee. 7.21 “Near misses” should be reported and analysed to identify common factors and causes. 7.22 Accountabilities for monitoring incident trends should be clarified and clear processes established to ensure accountability. (The Quality and Risk Management Committee is currently responsible for the regular monitoring and improvement of the incident reporting system. The Committee’s responsibility for monitoring the outcomes from the system is less clear.) 7.23 The Clinical Board should establish a timetable (eg, three monthly) for analysing reported incidents across Tairawhiti District Health with a view to discerning trends. 64
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GISBORNE HOSPITAL 1999 - 2000 A rep
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Table of Contents Page Executive Su
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1. BACKGROUND EXECUTIVE SUMMARY 1.1
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3. THE ENVIRONMENT 3.1 My investiga
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pathologist, staff shortages and pr
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Gisborne Hospital 1999 - 2000 Intro
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RECOMMENDATIONS Quality Assurance S
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Gisborne Hospital 1999 - 2000 Recom
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APPENDIX NZNO LETTER TO MINISTER OF
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11. The anaesthetist had a practice
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THE ANONYMOUS LETTER The anonymous
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GLOSSARY ABBREVIATIONS A&E A,T&R AQ
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Gisborne Hospital Report - Health and Disability Commissioner

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