Communique from the Co-Chairs of the Governance Advisory Panel - 8 November 2022

The Child Safe Governance Review Governance Advisory Panel (the Panel) met for the seventh time on Tuesday, 8 November 2022 via Microsoft Teams for a special meeting on incident management systems and open disclosure.

The meeting agenda focussed on:

• an overview of the National Safety and Quality Health Service Standards (NSQHS) Standards with particular reference to clinical governance, the Australian Charter of Healthcare Rights and incident management systems and open disclosure
• an insight into the experiences of frontline staff making good faith reports to the incident management system
• a presentation on LGH Hospital Acquired Complication data
• a presentation on the operation and governance of incident reporting, management and monitoring, including a demonstration of the SRLS.  The new child safety module was not presented due to the unavailability of a key official – this will be presented at the next GAP meeting.
• a presentation on the analysis of incidents, including open disclosure.

National Standards and Consumer Rights in Healthcare

Professor Deb Picone, Co-Chair of the Panel, spoke to members of the Panel regarding the National Safety and Quality Health Service (NSQHS Standards. The eight NSQHS Standards provide a nationally consistent statement about the level of care consumers can expect from health services.

Deb spoke in more detail on Clinical Governance Standards 1.11, incident management systems and open disclosure and spoke briefly about national rates of Hospital Acquired Complications (HAC) and compared those rates with the LGH rates.

The Panel was also provided with an overview of the Australian Charter of Healthcare Rights, which is consistent with NSQHS Standard 2 relating to healthcare rights and informed consent.

Experiences of frontline staff using the Incident Management system (the Safety, Reporting and Learning System (SRLS))

Dr Lucy Reed, Deputy Executive Director of Medical Services Hospitals North and Dr Emma-Jane McCrum, Acting Director Allied Health, provided the Panel with an insight into their experience with the reporting of incidents, as well as those of colleagues they have discussed this matter with, including other members of the Panel. Dr Reed and Dr McCrum are both members of the GAP.

Some of the positive insights noted for the panel were:

• training in the use of the SRLS is available to all staff (via the Tasmanian Health Education Online (THEO) E-learning system)
• access to the SRLS is available to all staff
• it is relatively easy to record a safety event in the SRLS system, and
• the SRLS dashboard is accessible and useful once you know how to use it.

Some of the perceived negatives noted to the Panel were:

• no standard training is available on responding to or investigating an incident
• the initial reporter is often not being kept in the loop or provided with feedback, including in instances where a Severity Assessment Code (SAC) rating has been changed
• investigations and conclusions can occur without engagement with the initial reporter
• incident reports ending up with a person who has a real or perceived conflict of interest in the matter
• the algorithm for determining SAC ratings isn’t understood by many staff, and
• the SRLS can sometimes be slow to operate.

A number of recommendations were proposed for consideration by the Panel.

These proposed recommendations will be considered and refined by the Panel for inclusion in the final report.

Hospital Acquired Complication Data (HAC) at the LGH

Jen Duncan, Acting Chief Executive Hospitals North, presented to the Panel regarding data on HACs at the LGH.

This data is discussed at monthly accountability meetings at the LGH, with issues identified escalated to Health Quality executive meetings.

It was noted by some LGH staff members on the Panel that this data hasn’t regularly been available to them.  This may be the result of communication blockages given that the data is reported quarterly at the LGH executive meetings.

It was noted that if clinicians had ready access to this data, it could help drive real improvements in patient safety and care outcomes.

Operation and Governance of Incident Reporting, Management and Monitoring, including Demonstrations of the SRLS System

Morag McPherson, Director of Improvement - North, presented to the Panel an overview of the operation and governance of incident reporting, management and monitoring at the LGH.

Data was provided around the numbers of safety events at the LGH over the last year, including numbers on daily and monthly events and the number of events that have been rejected, which it was noted is generally because they are duplicate reports or do not actually relate to a safety event.

The Panel was provided with an overview of the reports and dashboards available through the SRLS, an example of recommendations and their implementation, as well as the education and training that is provided to and available for staff on safety events management, safety culture, Root Cause Analysis (RCAs) and use of the SRLS.

Kath Cooper, Statewide Manager SRLS, provided panel members with a demonstration of the SRLS using a de-identified case study, noting in particular the audit history that is contained in a record that shows when a record has been accessed or modified.

After discussion, the Panel recommended that the design of a new safety reporting system should consider including functionality that allows the initial reporter of an incident to be notified by the system when an incident report is updated on review. There should also be a defined process in place for a reporter to query a change to a safety event record.

The Co-Chair of the Panel noted that the SRLS appears to be a functional system. However, communication and feedback around its functionality and the processes for review and update of incident reports needs to be stronger to avoid any perception that event ratings and report details are being changed surreptitiously.

A brief demonstration was also provided for Panel members on the operation of the new child safety module of the SRLS.  Governance of the child safety module will be discussed further at the next meeting of the Panel.

A number of recommendations have been proposed to the Panel and these will be considered and refined by panel members for inclusion in their final report.

Feedback on Analysis of Incidents, including Open Disclosure

Dr Jodi Glading, Deputy Chief Medical Officer, DoH, provided the Panel with a presentation on the review of patient safety events at a statewide level, including an overview of the Quality Governance Framework which establishes systems and processes for the delivery of safe, high quality health services in Tasmanian publicly funded health services.

Detail was provided on the senior staff involved in the safety event review process, along with the review and committee reporting process and structure.

Next Meeting

The next meeting of the Governance Advisory Panel is scheduled for 15 November 2022 and will be held onsite in Launceston.

This meeting will focus on further discussions around the implementation of the Child Safe Organisation Framework at the LGH, including mandatory child safety training.

The Panel will also discuss the matter of organisational and individual accountability for child safety and discuss all child safety recommendations that have so far come out of the GAP process.

Further to this, the Secretary of the Department, Kathrine Morgan-Wicks, will be attending the meeting for a discussion with the Panel.

View the Interim Recommendations of the Child Safe Governance Review – Governance Advisory Panel

Find out more about the Child Safe Governance Review