REPORTABLE INCIDENT POLICY (CONTRACTED ORGANISATIONS ONLY)

DOCUMENT CONTROL

Managed by: Director Commissioning	Approved by: Executive Director Commissioning	Version: 2.3
Next Review Date: 31/05/2024	Date Approved: 04/08/2023	Status: FINAL

REVISION RECORD

Date	Version	Revision Description
04/08/2023	2.3	Updated Reportable Incident definition to include: ‘A reportable incident is any suspected or actual, unintended or unexpected event…’. Removed ‘suspected’ from breaches of clinical, professional, or regulatory standards, and unlawful activity by a provider or a member of their staff. Included ‘data breach’.
26/07/2023	2.2	Updated Reportable Incident definition to include ‘Definition: A reportable incident is any unintended or unexpected event in relation to the contracted service that contains one or more of the following components…’
31/05/2023	2.1	Minor formatting changes and updated staff titles.
11/11/2022	2.0	Minor changes to wording throughout document to remove duplication and simplify the content. Key changes made: Change name form Reportable Incident Management Policy to Reportable Incident Policy (Contracted Organisations only). Section 2 – update of the Reportable Incident Definition to refine wording. Section 2 – input of Special Considerations sub-section and update of scenarios and information in this section. Section 4 – renaming of this section to Reporting and Managing Reportable Incidents. Update of content in Section 4. Update of content in Section 5. Changes made to governance of reportable incidents and reporting timeframes to GCPHN. Removal of work instructions and other administrative tasks – these are included in the updated Reportable Incident Work Instructions (Contracted Organisations only).
06/08/2021	1.2	Review to ensure alignment with current work practices. Simplification of language and consolidation of terminology and definitions of incidents, major, reportable and notifiable.
23/05/2021	1.1	Minor updates to wording in 5.2 Managing Incidents, and Closing incidents to assist as a public facing policy that can be moved to the website on a ‘Provider page’ should this progress (decision pending) Update to Section 8. Associated documents Link to the location of the reporting template added Addition of Reportable Incident Form Administration Work Instruction (to assist with internal administration and Folio assistance)

TABLE OF CONTENTS

REPORTABLE INCIDENT POLICY	4

1.	POLICY PURPOSE	4

2.	POLICY SCOPE	4

3.	POLICY PRINCIPLES	5

4.	REPORTING AND MANAGING REPORTABLE INCIDENTS	5

5.	REPORTABLE INCIDENT GOVERNANCE	6

5.1	DATA MANAGEMENT	6

6.	MONITORING, EVALUATION AND REVIEW	6

7.	ASSOCIATED DOCUMENTS	7

REPORTABLE INCIDENT POLICY

POLICY PURPOSE

The Reportable Incident Policy (Contracted Organisations only) outlines the approach and key actions required by Gold Coast Primary Health Network (GCPHN) and contracted organisations of health and human services to report incidents related to PHN activities, funded services, and programs.

This Policy outlines the requirements and process for reporting incidents to GCPHN and the actions, if any, that GCPHN will take because of those incidents. Where applicable, GCPHN will work with contracted organisations to respond, investigate, and manage incidents to maintain consumer safety, service quality and program integrity.

POLICY SCOPE

The Policy covers:

Reportable incidents that impact on the delivery of GCPHN contracted organisations who deliver health and human services, including services the contracted organisations may subcontract. Any GCPHN contracted organisation who sub-contracts other organisations to undertake services on their behalf will be responsible for ensuring the sub-contractor adheres to this policy.

Definition: A reportable incident is any suspected or actual, unintended or unexpected event in relation to the contracted service that contains one or more of the following components:

death, serious injury or illness to a person

harm to a person

allegation of professional misconduct

breaches of clinical, professional, or regulatory standards

data breaches

unlawful activity by a provider or a member of their staff

activity which is contrary to the specified or expected standard of service outlined in the Contract/Schedule; and/or

poses a risk to the reputation of GCPHN or Contractor, including Complaints that threaten to go to the media, a politician, or the Department of Health.

Special Considerations:

All incidents not falling into reportable incident definition are required to be notified and discussed by contracted organisations through the quarterly performance report and quarterly performance review meetings.

Incidents which occur within GCPHN (and do not directly relate to contracted organisations). These incidents fall within the scope of GCPHN’s Emergency and Reportable Incident Management Procedure.

Some programs and funding agreements may place specific requirements on GCPHN regarding incident reporting. These requirements will be reflected in the Services Schedule for the relevant contracted services and supersede this policy.

The Policy does not replace the requirement for contracted organisations to develop their own policies and procedures to manage and respond to incidents, to be accountable for their actions and to manage the quality of their own services. In this manner the Policy also does not replace the contracted organisations’ responsibility for meeting workplace health and safety legislative requirements and its obligations under the Australian Privacy Act (1998) (Privacy Laws).

Contracted organisations’ performance and management issues will not directly fall within the scope of this Policy, although they may be identified because of an incident. Where an incident results in the identification of serious misconduct, breaches of contractual requirements or other serious issues, GCPHN’s quality assurance, contract management and oversight mechanisms will be used to respond to and act on these issues.

POLICY PRINCIPLES

The following principles underpin the design of the Reportable Incident Policy (Contracted Organisations only), and guide all actions undertaken:

Person-centred – management and reporting of incidents is respectful of and responsive to individual needs, preferences and values while supporting the person’s safety and wellbeing.

Outcome-focused – incidents should be managed and reported to ensure an understanding of impact the incident had on the outcomes for the person/s involved.

Clear, simple and consistent – the reportable incident management policy is easily understood and accessible to all GCPHN stakeholders.

Accountable – contracted organisations have primary accountability for managing the response to incidents. Each party involved in the management of incidents understands their role and responsibilities and will be accountable for decisions or actions taken in relation to an incident.

Continually improving – the incident reporting policy facilitates the ongoing identification of issues and implementation of changes that result in better outcomes.

Fit for purpose – the reportable incident management policy is capable of meeting the objectives of the system and adaptable to meet the needs of different service types.

Proportionate – the nature of any investigation, review or other actions following an incident will be proportionate to the harm caused and the risk of future harm.

REPORTING AND MANAGING REPORTABLE INCIDENTS

Contracted organisations must:

Manage incidents as they arise, including reporting the incident and any resulting action taken, or proposed action, to GCPHN and any other relevant bodies.

Notify GCPHN immediately (within 1 working day) in the case of death, serious injury or illness of a staff member or service user.

Notify the GCPHN of any other Reportable Incident within three (3) business days.

Use the GCPHN Reportable Incident Form located in the Reportable Incident Work Instructions (Contracted Organisations only).

Undertake a review process and communicate to GCPHN a summary of learnings and actions within 10 business days.

Report the incident on the standard quarterly performance reports as per the normal processes.

GCPHN staff must:

Follow Reportable Incident Work Instructions (Contracted Organisations only).

REPORTABLE INCIDENT GOVERNANCE

Relevant Commissioning Team Project Officer is responsible for liaising between GCPHN and the contracted organisation and recording relevant details in the designated secure GCPHN system as per work instruction.

Program Coordinator and Director of Commissioning are responsible for review of the incident and monitoring of agreed management actions.

Director of Commissioning is responsible for recommending closure of a reportable incident once all agreed and required management actions have been completed.

Director of Commissioning is responsible for reporting of reportable incidents to GCPHN Governance and Risk Committee.

GCPHN CEO and Executive Director – Commissioning to be informed of any reportable incident that is notified to GCPHN.

GCPHN can recommend for reportable incident reporting to be included in the GCPHN Executive Report that goes to GCPHN Board on a six (6) monthly basis.

GCPHN Governance and Risk Committee (G&R) can appoint an external expert to advise on a contracted organisation’s approach to clinical governance and responses to incidents.

Disputes between GCPHN and contracted organisations regarding Reportable Incident obligations should be first resolved by Director of Commissioning. If an agreement cannot be reached, parties should make use of standard escalation and dispute resolution procedures.

DATA MANAGEMENT

Incident reporting will be kept at the highest level of confidentiality including:

Only be visible to selected users, the Person Responsible and any approvers.

Not appear on any List Screens.

Not appear in any report (regardless of who generates it).

MONITORING, EVALUATION AND REVIEW

This Policy will be reviewed annually.

ASSOCIATED DOCUMENTS

Please see Quality Management - Designing and Contracting - All Documents (sharepoint.com) for:

Reportable Incident Form (Contracted Organisations Only)

Reportable Incident Policy (Contracted Organisations Only)