CLINICAL INCIDENT MANAGEMENT FRAMEWORK

Transcription

1 CLINICAL INCIDENT MANAGEMENT FRAMEWORK MY HEALTH RECORD SYSTEM PRASHAN MALALASEKERA NEVILLE BOARD 26 July 2016

2 My Health Record System My Health Record provides a repository of an individual s key health information, drawn from existing information from across a range of healthcare settings. It is not a replacement of existing clinical systems - it is an additional tool available to supplement information available to clinicians at the point of care. Launched in July approximately 3.9 million Australians now have a record established Uptake has been slow but has started to grow significantly in recent months Increased use of the system has the potential to improve the safety of healthcare provision to consumers

3 My Health Record System Along with the benefits come the challenges: From a clinical safety perspective, potential issues include Consumer ability to block access and/or remove from view documents System largely a repository of information generated by other sources hence reliance on quality and accuracy of external systems Information may not update in real time

4 EVIDENCE & CONSULTATION PROCESS MAPPING REVIEW AND FINALISATION Development of the Framework Review of literature and existing incident management system processes Consultation with primary care, jurisdictions, Health IT safety experts, vendors and System Operator Process mapping with key stakeholders and experts of proposed incident management stages, including: identification of communication pathways and officers responsible, integration with existing processes use of scenario testing to validate assumptions Review and comments by Commission s Clinical Safety Oversight Committee, System Operator and NEHTA Formal handover of CIMF to the System Operator

5 Purpose of the Framework The Framework provides: Processes for incident identification A governance structure for incident management and investigation Processes for clinical incident management Definitions of incident severity Timeframes for reporting and investigation Processes to develop recommendations A requirement for feedback

6 Clinical Incident Management Framework Features: Ability to integrate with with existing clinical incident processes at state/territory level Four incident categories developed at the outset, with the ability to add/remove as the system evolves and usage increases A more robust reporting mechanism for users to notify incidents/near misses A severity of incident classification that addresses individual and system issues A safety alert system to disseminate information to participants on issues identified through monitoring or as a result of an incident investigation

7 SEVERITY SOI 1 Critical SOI 2 High SOI 3 Medium SOI 4 Low ACTUAL OR POTENTIAL HARM TO AN INDIVIDUAL death and national sentinel events specifically caused by health care major harm specifically caused by health care may include permanent disability or disfigurement moderate harm specifically caused by health care admission to acute facility surgical intervention required medical intervention required minor or zero harm specifically caused by health care review and evaluation additional investigations referral to another clinician consumers with no harm SOI 1 Critical SOI 2 High SOI 3 Medium SOI 4 Low HARM OR POTENTIAL HARM AS A RESULT OF SYSTEM ISSUES Low detectability of error(s) Credible clinical scenario Less credible Lower detectability Credible clinical scenario High detectability Implausible clinical scenario High detectability

8 WORKFLOW

9 Clinical Incident Management Framework Challenges and next steps Challenges Improving the ability to easily report issues to the System Operator Potential for a large volume of non My Health Record issues being reported over time particularly from primary care Next Steps Commission is currently providing a clinical incident management unit (CIMU) for the System Operator, putting in place elements of the framework Commission to work with the Australian Digital Health Agency (as System Operator) to undertake further implementation work for more complex aspects of the framework (e.g. streamlined incident reporting)

10 Questions? Thank you Australian Commission on Safety and Quality in Health Care