Incident Management Systems | Aged Care Quality and Safety Commission

What is an IMS?

Your IMS is a system that helps you to prevent incidents. It also helps you to identify, respond to and manage any incidents and near misses that occur during the course of delivering care and services to consumers. Your IMS includes policies and procedures that your workers use to prevent and manage incidents, the tools that they use to document information about incidents and find solutions, and the training and culture they rely on to continuously improve safety. Your IMS should support a cycle that empowers you to learn from incidents and how you manage them. Learning from the incident management process will allow you to continuously improve your service and outcomes for consumers.

There are 6 essential elements to an effective IMS:

What is an IMS?

Your service’s IMS is a system that helps you to prevent incidents. It also helps you to identify, respond to and manage any incidents and near misses that occur during the course of delivering care and services to consumers. The IMS includes policies and procedures that you will use to prevent and manage incidents, the tools that you will use to document information about incidents and find solutions, and the training and culture you rely on to continuously improve safety. The IMS supports a cycle that empowers you to learn from incidents and how you manage them. Learning from the incident management process will allow you to continuously improve your service and outcomes for consumers.

There are 6 essential elements to an effective IMS:

IMS cycle showing the 6 elements: Ensure leadership and a safety culture, respond to incident, record and report incident, analyse the incident, implement actions, and close the loop.

'Your role in the SIRS' provides detailed guidance on each of these elements in their respective pages.

1

Preparing for incident management – your safety culture

Phase 1 looks at embedding strong leadership and a safety culture.

2

When an incident happens – response, recording and reporting

Phase 2 involves responding, recording and reporting incidents into your IMS.

3

After the incident - continuous improvement

Phase 3 seeks answers to the problem(s) in order for the service to continuously improve.

Three phases of incident management

The IMS Cycle can be broken down into 3 phases- prepping for an incident, when an incident happens, and after the incident

This page will provide guidance for:

the policies, procedures, and training associated with your IMS
the roles of workers and consumers in your IMS.

Key actions

Make sure your IMS is developed in a consistent and accessible format
Make sure your IMS follows the 6 essential elements to effectively prevent and manage incidents
Make sure everybody in your service knows how to use your IMS

Key actions

Make sure you know how to access your IMS
Make sure you understand your role within the IMS
Make sure you have the necessary tools and skills to perform your role in the IMS

What incidents should be managed through your IMS?

All incidents must be recorded in your IMS and managed appropriately regardless of whether they have occurred, are alleged, or you suspect that they have occurred. This also includes where the consumer involved in the incident has a cognitive impairment, such as dementia.

An incident is something that caused harm to a consumer, or another person, or could reasonably be expected to have caused harm. This also includes omissions, where action should have been taken but was not.

A near miss is when an occurrence, event or omission happens that does not result in harm but had potential to do so. This could be an injury, illness or danger to the health of a consumer or another person. This can also be referred to as a close call.

Both incidents and near misses should be captured by your IMS.

What form should your IMS take?

Your IMS may look different to other providers as it must be tailored to meet your service’s needs. The IMS you choose will be based on your size, location and the type of services you provide. Some providers may use a quality management system or risk management system, while others might use Excel spreadsheets or a paper-based system.

IMS system types include: Paper-based systems, Spreadsheets and Quality or risk management systems. Consider the accessibility needs of your staff. (eg. Are there any staff members who rely on a screen reader?) Take measures to ensure the IMS is accessible for everyone to perform their role.

No matter what form your IMS takes, it must include effective systems for reporting, management and prevention, including:

What does an IMS look like?

There are many ways an IMS can be set up depending on the size and type of the aged care provider. If your service is small, it could be a paper-based system stored in folders, or a spreadsheet. Larger and more complex services may use dedicated quality or risk management software.

IMS system types include: Paper-based systems, Spreadsheets and Quality or risk management systems.

You must ensure that you are able to access your IMS as required by your role. Speak with your manager if you have any difficulties accessing the IMS.

- processes to support effective management and efficient recording

- tracking tool to inform continuous improvement

- trend analysis and management

- visibility of incident types and severity

- real time incident reporting.

Assessing your IMS

Effective incident management involves the ongoing assessment of your IMS. Your IMS should involve a robust assessment process where management regularly evaluates the IMS against the 6 essential elements. This process will be informed by your experience analysing and investigating real incidents. Your service should focus on continuous improvement throughout the incident management cycle to ensure you have gathered feedback to inform improvements.

Policies and procedures

The policies and procedures in your IMS should allow you to tailor your response to each incident depending on the incident type and seriousness.

Your service's policies and procedures should include:

Procedure	Description
Roles and responsibilities	Roles and responsibilities of workers in identifying, managing, resolving and preventing incidents and near misses. Roles and responsibilities of workers for notifying the Commission of reportable incidents. The role of each worker in complying with the IMS. Training requirements for each worker in the use of, and compliance with, the IMS. Roles and responsibilities of all others delivering care and services, including subcontractors.
How incidents are identified, recorded and reported	Definitions of incidents and near misses. Correct method of recording information. Appropriate points of contact and required timeframes for recording and reporting incidents.
When others should be notified of incidents	When and how to notify consumer representatives, or other emergency contacts. When police or emergency services should be notified. When and how other entities should be notified, including: Aged Care Quality and Safety Commission Australian Health Practitioner Regulation Agency (AHPRA) or state and territory health departments NDIS Quality and Safeguards Commission, where incidents relate to NDIS participants.
How you will provide support and assistance to people affected by an incident	How you will involve affected people and/or their representatives in the management and resolution of an incident. The use of open disclosure processes when things go wrong. How to provide consumers and their representatives with information about consumer advocates.
Reviewing, analysing and investigating incidents	A process for analysing all incidents to determine: whether the incident could have been prevented how well the incident was managed and resolved whether other entities need to be notified of an incident. The circumstances and processes for undertaking an internal investigation into an incident.
What action might be required	A description outlining when changes must be made in response to an incident, including (but not limited to): if the incident may have been prevented, or the severity of the impact lessened, by some action taken by you or a worker if there is an ongoing risk to consumers, visitors, workers or others if a change may prevent or minimise the risk of a similar incident happening again. The different types and nature of changes that may be needed, including (but not limited to): changes to organisational/clinical governance individual and/or service-wide worker training educating consumers and/or visitors changes to the service environment or equipment changes to the care and services provided to consumers.

Policies and procedures

The policies and procedures in your IMS should allow you to tailor your response to each incident depending on the incident type and seriousness.

Your service's policies and procedures should include:

Procedure	Description
Roles and responsibilities	Roles and responsibilities of workers in identifying, managing, resolving and preventing incidents and near misses. Outline the type of risks that are in connection with care and must be managed by workers, contrasted with risks that are not connected with care. The roles and responsibilities of workers for notifying the Commission of reportable incidents The role of each worker in using and complying with the IMS. Training requirements for each worker in the use of, and compliance with, the IMS. The roles and responsibilities of all others delivering care and services, including subcontractors.
How incidents are identified, recorded and reported	Definitions of incidents and near misses. Correct method of recording information. Appropriate points of contact and required timeframes for recording and reporting incidents.
When others should be notified of incidents	When and how to notify consumer representatives or other emergency contacts. When police or emergency services should be notified. When and how other entities should be notified, including: Aged Care Quality and Safety Commission Australian Health Practitioner Regulation Agency (AHPRA) or state and territory health departments NDIS Quality and Safeguards Commission, where incidents relate to NDIS participants.
How you will provide support and assistance to people affected by an incident	How you will involve affected people and/or their representatives in the management and resolution of an incident. The use of open disclosure processes when things go wrong. How to provide consumers and their representatives with information about consumer advocates.
Reviewing, analysing and investigating incidents	A process for analysing all incidents to determine: whether the incident could have been prevented how well the incident was managed and resolved whether other entities need to be notified of an incident. The circumstances and processes for undertaking an internal investigation into an incident.
What action might be required	A description outlining when changes must be made in response to an incident, including (but not limited to): if the incident may have been prevented, or the severity of the impact lessened, by some action taken by you or a worker if there is an ongoing risk to consumers, visitors, workers or others if a change may prevent or minimise the risk of a recurrence. The different types and nature of changes that may be needed, including (but not limited to): changes to organisational/clinical governance individual and/or service-wide worker training educating consumers changes to the service environment or equipment changes to the care and services provided to consumers.

Your service’s IMS policies should reflect that all home service environments will have unique risk factors to consider. Workers will encounter different risks between service environments and prevention strategies will need to adapt accordingly. Your IMS should provide a framework to support workers' decision-making when managing the unique risk factors of each service environment.

Work tool

Use the Finding policies and procedures (IMS) work tool to keep track of your service’s policies and procedures on incident management.

Use the Effective IMS checklist for a detailed account of the Incident Management System requirements.

Work tool

Use the Finding policies and procedures (IMS) tool to keep track of your service’s policies and procedures on incident management. Knowing where to find this information will help you to respond quickly when an incident happens in your service.

Training and education for IMS

All workers have a role in incident management and prevention. You should provide training and education to empower workers to uphold your IMS policies and processes. As your IMS continuously improves, training and education should be updated accordingly to ensure workers stay up to date with any changes to the IMS.

All workers, not just clinical workers and personal care workers should understand your IMS. Workers that are not involved in direct care delivery may be the first to become aware of an incident occurring and have a role to play.

Training should support workers to understand:

who is responsible for different aspects of incident management
how to recognise incidents and near misses
how to assess, record, investigate & respond to incidents depending on their role
how to support impacted individuals
how to use the IMS to drive continuous improvement
when and how to report an incident externally, such as to the Commission, the police or other entities.

What you need to know

Incident management is everyone’s responsibility. All workers must understand their role in the IMS, not just clinical and personal care workers. Workers not involved in direct care delivery may be the first to become aware of an incident and have a role to play. You should be open to undertaking training and education relating to your service’s IMS.

You should understand:

your specific responsibilities for incident management
how to recognise incidents and near misses
how to assess, record, investigate & respond to incidents as required in your role
how to support impacted individuals
how to use the IMS to drive continuous improvement
when and how to report an incident externally, such as to the Commission, the police or other entities.

You should understand:

your specific responsibilities for incident management
how to recognise incidents and near misses
how to determine whether risks and incidents are connected with care
how to assess, record, investigate & respond to incidents as required in your role
how to support impacted individuals
how to use the IMS to drive continuous improvement
when and how to report an incident externally, such as to the Commission, the police or other entities.

Work tool

You can use the Worker readiness work tool to understand how engaged your workers are with your IMS, and how well they understand it.

This checklist is designed to be used as a survey with different workers in a variety of roles from across your organisation.

Engaging with consumers

You and your workers should actively engage with consumers, their families and representatives about your IMS. This highlights your service’s approach to risk management and continuous improvement. It will also contribute to consumer confidence and wellbeing.

Consumers and their families or representatives have an important role to play in the IMS. They may witness incidents or identify risks that were otherwise overlooked. Encourage consumers to speak up about risks and incidents to help contribute to your service’s safety culture. Meaningful engagement with consumers who are confident in reporting risks and incidents will give workers a better chance of identifying them for prevention and management.

You should support consumers to effectively report risks and incidents, share information, and get involved with solutions.

Engaging with consumers

You should actively engage with consumers, their families and representatives about your IMS. This highlights your service’s approach to risk management and continuous improvement. It will also contribute to consumer confidence and wellbeing.

Consumers and their families or representatives have an important role to play in the IMS. They may witness incidents or identify risks that were otherwise overlooked. Encourage consumers to speak up about risks and incidents to help contribute to your provider’s safety culture. Meaningful engagement with consumers who are confident in reporting risks and incidents will give workers a better chance of identifying them for prevention and management.

You should support consumers to effectively report risks and incidents, share information, and get involved with solutions.

Engaging with consumers

You and your workers should actively engage with consumers, their families and representatives about your IMS. This highlights your service’s approach to risk management and continuous improvement. It will also contribute to consumer confidence and wellbeing.

Consumers and their families or representatives have an important role to play in the IMS. They may witness incidents or identify risks that were otherwise overlooked. Encourage consumers to speak up about risks and incidents to help contribute to your service's safety culture.

This is especially important in home services, where as an approved provider, you may have limited control over the service environment. There may be risk factors that develop outside of direct service hours and go unobserved by staff. Meaningful engagement with consumers who are confident in reporting risks and incidents will give staff a better chance of identifying them for prevention and management.

You should support consumers to effectively report risks and incidents, share information, and get involved with solutions.

Engaging with consumers

You should actively engage with consumers, their families and representatives about your IMS. This highlights your service’s approach to risk management and continuous improvement. It will also contribute to consumer confidence and wellbeing.

Consumers and their families or representatives have an important role to play in the IMS. They may witness incidents or identify risks that were otherwise overlooked. Encourage consumers to speak up about risks and incidents to help contribute to your service's safety culture.

This is especially important in home and community settings, where your service may have limited control over the service environment. There may be risk factors that develop outside of direct service hours and go unobserved by yourself or other workers. Meaningful engagement with consumers who are confident in reporting risks and incidents will give workers a better chance of identifying them for prevention and management.

You should support consumers to effectively report risks and incidents, share information, and get involved with solutions.

Contact us

If you have a question about the SIRS, you can call us on 1800 081 549.

This phone line is open 9 am to 5 pm (AEST) Monday to Friday and 8 am to 6 pm (AEST) Saturday to Sunday.

You can also email us at sirs@agedcarequality.gov.au.

Facilitated workshops

The Commission provides facilitated workshops to sector participants. All current workshops are available on the Commission’s Workshop page.

Online learning

The Commission’s Aged Care Learning Information Solution, Alis provides free online education for employees of Commonwealth-funded aged care providers, including modules about incident management systems.

You can access Alis at learning.agedcarequality.gov.au.

Disclaimer

The information contained on this page is intended to provide you with general guidance; however, it is your responsibility to be aware of your legislative requirements.