The final step when managing incidents is closing the loop. Here you examine issues, barriers, how they have been addressed, the successes and adjustments made along the way. This also helps identify gaps, drive continuous improvement, and communicate findings to those affected.
You will complete an end-to-end review of the process on both a macro and micro level to look at how the process was followed during the incident and an overall review to examine any changes to the process. After an incident, your focus will be on the continuous improvement process, where you use your IMS incident data to conduct a high-level examination of across your service.
The final step when managing incidents is closing the loop. Here you examine issues, barriers, how they have been addressed, and the successes and adjustments made along the way. This also helps identify gaps, drive continuous improvement, and communicate findings to those affected.
Management will complete an end-to-end review of the process looking both at the process itself and how it was applied during an incident. You may be asked for feedback to help drive continuous improvement and further down the line to see if the changes have made a difference.
Before closing the loop, you must complete a holistic review of the incident management process.
You are also responsible for regularly assess, review, and monitor your IMS data to ensure your IMS is effective and reliable. This is critical as your IMS provides valuable insight into future risks and improvements necessary.
To close the loop management will review the process end to end, this can involve asking for your feedback as a staff member. Working with consumers in their home and offsite means that you are likely to have experiences and a point of view that is valuable to improving the process as you will see any changes made put into practice.
Share feedback with your service to help make changes that can improve the quality of care for consumers and others associated with aged care.
How do we improve?
The key aims of the incident management process are to learn from incidents and near misses, to know what can be done to prevent them from occurring again and build trust with workers and your system.
By analysing all the IMS data, it helps to:
identify and address systemic issues in the quality of care provided
identify repeated occurrences (including alleged/suspected occurrences) of similar incidents or near misses
analyse trends and identify patterns of incidents (e.g. behaviours)
provide feedback and educate staff about prevention and management of incidents
provide information to the Commission when requested.
Analysing incident trends and data
Your service’s IMS must allow the collection of data and other information relating to incidents. The process should:
- identify and address systemic issues in the quality of care provided
- identify repeat incidents— including alleged occurrences
- analyse trends and identify incident patterns
- allow for feedback and training on preventing and managing incidents
- provide information to the Commission when requested.
Incident data should be regularly reviewed and analysed to help inform improvements. Part of the broader risk management process in identifying risks the following should be considered:
- incident trends
- incident causes
- common or repeat incidents
- feedback from consumers, workers and others.
Evaluate the outcome
Once the incident has been defined, the cause determined, actions identified and implemented, the final step in the 5-step problem solving process is to evaluate the outcome.
You should ask yourself these questions:
Have we accomplished what we set out to achieve?
Has the introduced change improved practice and/or reduced future risks?
What work is required to ensure continual improvement is made across your service?
What was the impact and result for the consumer and impacted parties?
Learning from Incidents
The key aims of the incident management process are to learn from incidents and near misses, to know what can be done to prevent them from occurring again and build trust in your service’s system.
Information should be shared to help you and others avoid repeating incidents. Your management should share results of an incident investigation with you along with the board, the leadership team, those affected by the incident and the public.
Reflecting on the incident analysis
Your service’s IMS needs to be regularly checked to ensure that it is working as required. Regular review helps to find areas for further improvement. If you have feedback do not wait for your manager to request it, share changes you think might be needed as they appear.
Everyone has a role in improving the quality of incident analysis and actions.
Do you know how to recognise an incident?
Was it clear how to react when an incident occurred?
Is there any area you feel you were unsure about?
Were the actions taken able to reduce further harm?
Does management listen to yours and others feedback?
Were you able to learn from the incident investigation?
If there are areas of improvement you think management should know about, share your thoughts and concerns.
Your service should be practicing open disclosure. Part of the final step in incident management review checks that consumers and their family or representatives have been made aware of any incident that has occurred. It is a requirement under the quality standards and is an opportunity to involve consumers in the process of any changes made.
Ensure you maintain open communication channels and engage with key parties impacted by the incident. This includes providing relevant updates and discussing outcomes. You should ensure that any organisational changes made in response to an incident are well communicated to consumers and their representatives, workers and other third parties.