Conducting Investigations - Incident Reporting - Training

Conducting Investigations - Incident Reporting Training Session

This session will cover:

What is an incident and the workflow of an incident
Investigations:
Why we investigate
Who investigates
How we do investigations
NDIS reportable incident investigations

The session will take around 30 minutes to complete. At the end, you will be required to complete a short, comprehensive quiz.

What is an Incident?

Anglicare recognises incidents as events that provide unexpected, unplanned and unintended outcomes for the clients, employees and the organisation.

For Anglicare an incident might be:

Client incidents
Employee work health and safety incidents and hazards
Client or stakeholder complaints and compliments
Unplanned disruptions to service delivery.

Anglicare is required to report some incidents. We do this to fit in with legislation.

In Disability work particular incidents must be reported to the NDIS Quality and Safeguards Commission. Click here to remind yourself about NDIS reportable incidents.

Download Incident Definition

Reflection

Employees are encouraged to report all incidents including near misses; it is better to report something rather than not reporting because not reporting might put clients or employees at risk.

What type of things could be considered an incident?

Examples
- A client being hurt or hospitalised while we were working
- A near miss- where something happens or something is forgotten and it could have caused harm.
- Someone didn’t do their job
- Support was given outside of a client’s support plan
- Someone acted outside of their role
- Support was stopped or changed unexpectedly
- A client, family or someone makes a complaint
- An employee is hurt, harmed or hospitalised during work
- There was an event like fire, flood, or loss of power that affected client care.

Anglicare Incident Reporting (AIR) system

Having good incident management means Anglicare can respond well to client needs and expectations and provide a safer service.
To support the incident management process, Anglicare maintains AIR (Anglicare Incident Reporting system).
AIR is used to:

report
review
analyse
investigate
implement services changes
record incidents for Anglicare.

Incident Reporting Process
Anglicare’s incident management process has 4 steps.
1. Immediate response
2. Preliminary review/needs assessment
3. Incident analysis and investigation
4. Follow up and action
Click image to enlarge and read what happens at each step.

Investigations

Investigations are one part of Anglicare’s Incident Management system. All Incidents must be investigated. Investigation reports are recorded on AIR.

Why do we investigate incidents?

We do investigations to help prevent incidents in the future and to make sure we are continually improving the way we do things and the services we provide. They make sure we manage risk and get better outcomes for our clients.

Investigations are reviews. They should tell us what caused an incident; what happened and what the impact was; what we did and what we will do.
Who Investigates Incidents, Disability Services?
Usually, incidents are managed and investigated internally by the Service Manager/Team Leader.

When an incident report is submitted using AIR, the appropriate service manager or team leader will receive an email that a new report has been created. The General Manager and the Senior Quality and Safe Guards Advisor (disability services) will also receive an email.

If the incident is an NDIS Reportable Incident the Senior Quality and Safe Guards Advisor (disability services) will manage the investigation. They may ask the Service Manager/Team Leader to investigate or they may appoint another investigator.

This person could be:
- Someone from a different part ofAnglicare
- Someone from another registered NDIS provider
- An external party with the skills and experience to conduct the investigation.
Why are different people sometimes appointed to investigate?
It is important that for each incident the right person undertakes the investigation. We can also be asked by the NDIS to appoint an external investigator, depending on the type of incident.

An Investigator needs to:
- Be impartial and objective
- Not be part of the incident
- Have the required expertise to do the investigation
- Be trained and have experience in investigations
Reportable incidents are specific types of serious incidents that have, or are alleged to have occurred in connection with the provision of supports and services. These can have serious impacts. This may mean it is best for the investigator to be an external person so everyone can heard and all issues looked at fairly.

AIR Incident Management Workflow

Have a look below at the AIR Incident Management workflow.

Can you identify where you could be involved in this process? What might be required at each stage of the incident workflow?

View the Incident Management Process on Confluence

Doing an investigation - Team Leader and Service Managers

Every incident is different and may require you to do different things.
As an investigator you may need to check the facts, talk to staff and clients, gather evidence (photo’s, information, records), find the cause, make an assessment and look for things that need to be changed.

There are two levels of incident investigations:

1. Preliminary review/needs assessment
This is the first part of any incident investigation and it may happen over a few days.
At this stage you are finding out
- Was the initial response appropriate to the incident? (what happened and what did we do, was this the best thing or could we have done something else)
- Could the incident have been prevented? And how did you decide that?
- Are there any actions to take or follow up needed? (Do we need to do anything now, tomorrow or going forward)
- Is the incident reportable or does it require systems analysis?
  (A systems analysis means an in depth look at the service and supports we provide; how we provide supports, what are the different parts to that support and how do all the parts/supports work together)
2. Incident analysis and investigation

When it is decided that an incident requires a systems analysis or is reportable, then another more in-depth investigation is carried out. This is called the incident analysis and investigation.

Having a second level to the investigation process means we can gather greater detail. This assists Anglicare to work on how to improve. This level of investigation is especially important when we must give details of cause and our action to the NDIS Safeguards Commission for Reportable Incidents and when we are required to report to other external organisations.

Read the NDIS Commission report: Then and Now – A new incidents reporting and complaints system in Tasmania.

Read the NDIS Commission report: Practice guide – Expectations of workers providing services in incident management and reporting incidents.

This level of the investigation process can be carried out by the Service manager or Team leader but can be conducted by someone else.

When investigating an incident you will need to consider the following things...

Are the details of the incident recorded correctly?
What was the cause? What contributed to the cause?
Who was impacted? What was the impact?
Did we respond appropriately?
How was the incident managed?
Did we take care of the client?
Could the incident have been prevented?
Have we talked with a family member or advocate?
Were services or staffing affected?
What has been done to prevent or minimise more incidents like this?
Do any other people or organisations need to be told?
Is the issue resolved?

Recording Investigation Details on AIR

Manager/Team Leader receives an email notification of a new report on AIR.
Open AIR by selecting the ID number.
Sometimes a worker may choose the wrong manager, you can reassign the task by selecting the assign button or Change Business Area under the workflow menu.
If the wrong form has been filled in, or you decide this report is not an incident, select Form Submitted in Error.
To commence the investigation/review, open the Record investigation process tab.
Complete the form.
1. All notes/details relating to the initial investigation are to be recorded in Preliminary review/needs assessment box.
2. If the incident needs a systemic review, or is reportable, a more in-depth investigation is completed. Notes for this are recorded in the Incident analysis and investigation box. *Please note that the comments section is for brief internal messages between people involved in the investigation not for details of the investigation.
To save the form, select the Investigation Process button (bottom right of screen).
Investigations may take a few days. You can add to the investigation notes by clicking on Add to Investigation.
After filling out the investigation form, a new menu item will appear, Implement actions and service changes. You need to determine any follow up actions or changes and record these here.
To close the incident, select Finalise Investigation, this button will display in the top menu after other forms are filled in.

Please download the attached pdf for a step by step look at filling out an investigation report on AIR. Click here to view the AIR User Guide on Confluence.

Download PDF Version

Incident Investigation Exercise

What Happened

AIR has alerted you that a new incident report has been recorded. Client supports have not been provided as per support plan.

I arrived at my shift at 4pm, went to check on clients and say hello. Client A did not greet me in their usual way, so I stopped to talk to him. Client A has limited communication skill but is able to indicate need and answer questions with gestures and sounds. Client indicated that his pad need changing.

When I and another staff member went to change Client A we discovered the pad was very wet, “soaked”, including his clothes.

Continued...

Client A’s support plan requires regular pad checks for his comfort and skin integrity, these are completed in the morning, before an afternoon rest, after an afternoon rest and after dinner. The client can be asked at other times if he would like a change. It is apparent that this had not been attended to or checked since the morning supports had been given.

With the client’s permission, I checked the skin, there was no redness or anything unusual to report. I cleaned the area and applied a barrier cream. I changed the client’s pad.

Exercise 1

The investigation has been assigned to you as the Service Manager/Team Leader by the Senior Quality and Safeguards Advisor – Disability Services, he deems this to be a Reportable Incident under possible neglect.

How would you proceed with the investigation?

Write down the steps you would take, what information you would clarify, who you would speak to, what you might ask those involved or others, and anything else you would do.

Write down your next steps

Further information

Statements were collected from staff present for the morning and middle of the day, 4 staff, and from the second person involved at the time. Details were clarified with the reporter.

Client A lives with an acquired brain injury. Requires supports with all aspects of daily living. Ongoing client impact appears minimal, client does not appear distressed or concerned at time of investigation. Skin integrity post incident is good.

The statements gathered confirmed that the client had received usual morning supports of personal care and pad changed. Pad had not been changed again by staff.

Continued...

The statements revealed that the client’s routine had not been usual for that day. Client A usually had a nap in the afternoon after lunch and pad checks are attended to before and after this. Instead of a nap client A had been out from 12.30pm and had returned at 3.30pm.

Documentation was checked. Documentation showed that Client A had received usual meals and ate as usual and drank well during the day.

Client A’s support plan documents that Client A can communicate the need for a change or to go to the toilet. Documentation confirmed that pad check had not occurred.

Exercise 2

From all the information gathered write an investigation report. Your report should include:

Description of incident and lead up
Assessment on the cause of the incident
Assessment of impact and effect on the participant
Description of the support provided to the participant during and after the incident.
Could the incident have been prevented?
Action Plan – what will happen going forward, who is responsible for action?

Write an investigation report

Here is an Example Investigation Report

Example Report

Client A lives in a supported residential setting. Client A lives with an acquired brain injury and requires supports with all aspects of daily living. Client A has limited communication, communicating needs with gestures and sounds.

(Support Worker) began shift at the property, at 4pm. (Support worker) spoke with client A who indicated that he needed a pad change. During the process of attending to the pad change, with another worker, they found that Client A’s pad and clothes were wet, indicating that usual pad changes had not occurred.

Client A usually has an afternoon nap, but on this day did not have one. Client A had been on a short outing that afternoon. All other routines were normal for Client A that day, and personal care had been completed in the morning. Fluid intake was a usual amount for client. Diet was usual for client.

Support, once the pad was changed, was appropriate. Client A was assisted with washing and changing and the afternoon/evening routines were as usual for the client.

After receiving statements from the workers on shift that morning, it has been determined that Client A received supports on the day. However, Client A did not have a usual afternoon nap and this disturbed the usual routine of checking pads before and after this event. Staff were following care plan directions and the outing meant pads were not checked at the usual times. Pad changes are linked to the afternoon nap and not linked to prompting or asking client.

Client A’s support plan documents that Client A can communicate when he needs to go to the toilet or if he needs changing.

The impact and effect were that Client A was wet for a lengthy period of time. There is an issue of dignity and it is likely Client A was uncomfortable for this time. There is also an issue of skin integrity, which was not affected.

The incident could have been prevented with regular checks and verbal prompting not tied to an event, the afternoon nap, and also through some changes to the way the support plan is worded.

Action: Some changes to the support plan and a new toileting routine has been developed and implemented. This includes regular prompts and changing of pads. The new routine has been communicated to staff.

(Also remember to attach supporting documentation.)

NDIS Reportable Incident Definition

Let’s look briefly again at NDIS Reportable Incidents.

Please watch this video as the NDIS explain Reportable Incidents.

Reportable Incidents

Anglicare is required under legislation, funding and organisational standards to report specific incidents. To read more about these requirements, please click here.

In disability services, where an incident is identified as a Reportable Incident the Senior Quality and Safeguards Advisor – Disability Services reports the incident to the NDIS Commissioner.

An independent investigator may be appointed to investigate the incident.

What is the Service Managers/ Team Leaders responsibility for a Reportable Incident?

You may be asked to continue with the investigation or another person may be assigned this role. You must alert the Senior Quality and Safeguards Advisor as soon as possible after you become aware of the incident.

It is very important to know and to report the incident within Reportable Incident reporting time frames. Most incidents must be reported within 24hours. Download a list of NDIS reportable timeframes here.

What to report	Reporting Timeframe
Death of a person with disability	24 hours
Serious injury of a person with disability	24 hours
Abuse or neglect of a person with disability	24 hours
Unlawful sexual or physical contact with, or assault of, a person with disability	24 hours
Sexual misconduct committed against, or in the presence of, a person with disability, including grooming of the person for sexual activity	24 hours
The use of a restrictive practice in relation to a person with disability if the use is not in accordance with a required state or territory authorisation and/or not in accordance with a behaviour support plan	5 business days

You will also be required to support clients and staff involved in the incident.

Take a moment to familiarise yourself with the NDIS incident management process below.

Finishing Off, Closing the Loop

Why is good incident management important?

At Anglicare we want to provide the best support that meets the needs and expectations of our clients. Continually improving the quality of our services and managing risks are really important for this. It’s good to be aware of when and where we can improve, as this provides good outcomes for the client.

One way we do this at Anglicare, is by seeking feedback from clients, employees, families and others. We ask people to help us plan and deliver support. We ask people to review what we did and tell us how we did. We also encourage people to raise issues when they first happen and not wait to tell us when the issue is big. Anglicare welcomes this feedback. We want to learn from the feedback.

Managing incidents well, is another way we continually improve and provide quality services. We want to learn from the incidents that happen and, where we can, prevent more incidents and harm.

Investigating an incident is an important part of the management of an incident. They help us find where improvement can be made. At the end of an investigation it is important to provide feedback to the staff involved. Let them know the outcome and communicate any changes to supports.

Providing training will also help to improve staff skills and outcomes for clients.

Reflection

Think of an incident that you know about from work.

Can you identify any positive outcomes, changes or improvements that were made?

For example, a change in procedure or environment, increase in services, better or new equipment.