Chief Psychiatrist's annual report 2008-09 - Department of Health

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30 Chief Psychiatrist’s annual report 2008–09 During the reporting period the Chief Psychiatrist and advisers convened or attended a number of case conferences concerning clients with complex needs. Such requests have become more frequent over recent years as services look centrally for assistance and direction in responding to individuals with exceptional needs and risk issues. In particular there has been an increase in requests for input with high-risk adolescents and individuals with mental illness and intellectual disability. Case conferences may be held at the treating service or utilise teleconferencing. In addition to the Chief Psychiatrist and senior clinicians from the treating services, such meetings often involve those from other areas of Departmental responsibility such as disability services or child protection, and the non-government sector. 5.3 Homicides and critical incidents The Chief Psychiatrist is notified of critical incidents such as alleged homicides where the victim or the perpetrator is a client of mental health services or believed to have a mental illness, serious assaults, or a forensic patient absconding. The Chief Psychiatrist will gather relevant information and provide briefings as required to keep the Minister for Mental Health and Secretary informed. Most critical incidents of this kind will also be investigated by other agencies such as the Coroner or Victoria Police. The Chief Psychiatrist arranges for the relevant service to provide a detailed report regarding the care and treatment provided to those involved in a critical incident, and the response of the service following the incident.
Chief Psychiatrist’s annual report 2008–09 31 6 Improving service quality The Office of the Chief Psychiatrist undertakes a range of ongoing and time-limited activities to monitor and promote continuous improvement in clinical standards across the mental health service system, in addition to responding to identified concerns or problems. Improved service quality leads to improved consumer outcomes. 6.1 Quality Assurance Committee The Chief Psychiatrist chairs the Quality Assurance Committee (QAC), which was established under section 106AC of the Mental Health Act and proclaimed a consultative council under the Health Act 1958. The function of the QAC is to assist the Chief Psychiatrist in overseeing and monitoring standards of treatment and care in Victorian public mental health services. The QAC meets quarterly and membership consists of senior psychiatrists and mental health clinicians from across the clinical mental health service system. Members are appointed as authorised officers under the Mental Health Act for their work with the QAC and are subject to the confidentiality provisions relating to authorised officers and consultative councils. Membership of the QAC in 2008–09 is provided in the appendix. Further information about the QAC is available at www.health.vic.gov.au/chiefpsychiatrist/qac.htm The following key activities were undertaken by the QAC in 2008–09: • The QAC reviewed sentinel events referred from the department’s Sentinel Event Program. 13 Sentinel events referred to the Chief Psychiatrist are de-identified (by patient and by service) and include suicide (and near-miss suicide) in an inpatient unit (general hospital or specialist mental health unit) and any other catastrophic event relating to a mental health consumer in an inpatient service. The Chief Psychiatrist provides advice on any service system and quality issues arising from these reviews to the Sentinel Event Program which, in turn, provides feedback to the relevant services. During the reporting period 15 sentinel events were reviewed by QAC. • The QAC provided joint oversight together with the Victorian Quality Council of the Creating Safety: Addressing Restraint and Seclusion Practices project and its activities during the reporting period (see 6.1.1) • The QAC reviewed data reports about statutory functions and thematic summaries from coronial reports 14 . • The ECT subcommittee of the Quality Assurance Committee continued to meet in 2008–09. The sub-committee monitors ECT practice, oversees ECT training and in January 2009 produced the revised Electroconvulsive therapy manual. Licensing, legal requirements and clinical guidelines. In 2009–10 the QAC is expected to auspice a new round of clinical reviews of public mental health services. 6.1.1 Creating Safety: Addressing Restraint and Seclusion Practices The Creating Safety project was launched in 2007–08 as a partnership initiative of the Chief Psychiatrist, the Quality Assurance Committee and the Victorian Quality Council. The project aimed to strengthen and support safety in acute mental health services using an evidence-based 13 Further information on the Sentinel Event Program can be found at www.health.vic.gov.au/clinrisk/sentinel/ser.htm 14 These summaries an be accessed online at www.health.vic.gov.au/chiefpsychiatrist/corep
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Chief Psychiatrist's annual report 2008-09 - Department of Health

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