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CRM Policy and Funding Guidelines 2004-05
Page Contents: CRM Policy and Funding Guidelines 2004-05 | Specific CRM reporting requirements
Funding will continue to be provided to support hospitals and health services in consolidating their clinical risk management programs.
The key components of the Clinical Risk Management (CRM) program are:
- the integration of systems for identifying and reporting adverse events, potential adverse events and near misses. Such systems include, but are not limited to, Limited Adverse Occurrence Screening (LAOS) and clinical incident reporting
- integration with other elements of the clinical governance framework that relate to patient safety, for example infection control, complaints and consumer participation, clinical indicators and clinical auditing
- responding to the Coroner’s findings and recommendations in relation to deaths occurring in hospitals through an analysis of the findings undertaken by health services and, if appropriate, dissemination of lessons learnt across all health services
- developing and implementing a pilot project to support the Australian Council for Safety and Quality in Health Care’s Open Disclosure Standard which will assist health services in their communication with patients and their families following an adverse event or a near miss.
- a review of all aspects of the sentinel event program is planned in consultation with the health sector. Upon completion the sentinel event program will be enhanced and will reflect a stronger focus on the dissemination of lessons learned from root cause analyses to support a preventative strategic approach to system improvement. Further education will also be provided on undertaking a thorough root cause analysis (RCA) and the development of a Risk Reduction Action Plan (RRAP).
Reporting requirements for the sentinel event program including notification of sentinel events are required within 3 working days of the event occurring. The RCA and RRAP must be reported within 60 working days from the notification of the event. A review of the RCA and RRAP framework is currently underway. Advice to the sector will be provided regarding its development.
- The department in conjunction with the Australian Council for Safety & Quality in Healthcare (ACSQHC) and the Victorian Quality Council, is implementing the Council’s recently released ‘Open Disclosure Standard: A National Standard for Open Communication in Public and Private Hospitals, following an Adverse Event in Health Care. To support the implementation process, a national pilot project will be conducted with a small number of selected sites representing Victoria in the national rollout of the standard. These sites will provide leadership to a statewide rollout of the standard.
- Supporting CRM is the Clinical Risk Management Reference Group which comprises of a range of experts from the health sector who provide advice to the department on aspects of the CRM program, in particular reviewing sentinel events and coroner’s reports and working with a range of councils and committees to provide recommendations for dissemination to all health services.
Funding will continue during 2004-05 to provide rural divisions of general practice financial support for the rural LAOS program. This program is an integral part of small rural hospitals’ clinical risk management program and as such, recommendations that arise from the local Division of GP’s reference panels’ review of clinical practice through medical records review, are required to be addressed through the health services’ CRM program.
Indicators are being developed for the rural LAOS program, which will require the lead agencies of Divisions of General Practice to report on the number and the outcomes of recommendations provided to each hospital in 2004-05 in their catchment.
Specific CRM reporting requirements
- Root cause analyses with a risk reduction action plan for sentinel events
- Coronial recommendations with action and outcome plans
- Quarterly LAOS indicators for small rural hospitals
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