1. Clinical Risk Management Department of Human Services l Aim - transparency, no-blame, improve hospital systems and patient outcomes l CRM Strategy - framework for systematic review of adverse events l Funding - to support systems development l Reports - mandatory sentinel event list; hospital-selected subjects for medical record screening l Other requirements - complaints management; incident reporting systems in all hospitals l Future activities - CRM education and training

2. Clinical Risk Management l Governance - Board Quality Committee l Accountability - Chief Executive and General Managers l Leadership - Medical Directors/senior clinicians l Resourcing - CRM Coordinator l Structure - DHS requirements, existing campus & Bayside committees l Systems - track, review, follow-up, reports l Subjects - high risk, high volume l Values - transparency, open disclosure, systems error focus Bayside Health

3. Clinical Risk Management Bayside Health Strengths l Driven and supported at the top l Committed senior clinicians in key roles l Some financial support from DHS l Quality unit and health information services staff Weaknesses l Early stages, some confusion l Paper-based systems l Challenge to access baseline data

4. Clinical Risk Management Systems and processes l Tracking - medical records flags & screens, electronic reports, AIMS, audits l Review - root cause analysis involving clinicians, case studies l Follow-up - in clinical area, in committees, top level systems oversight l Reports - internally up and down, externally to Department and community Bayside Health

5. Clinical Risk Management Bayside Health Progress l ICD10 codes study; establishing medical record screening/report l Electronic reports for cardiac/respiratory arrest, pressure sores, unplanned admission to ICU l Site mortality reports and follow-up l Detailed falls analysis, follow-up, training, promotion l Several medication error projects - warfarin, “like-drugs”, imprest cupboards l Pressure sore research and audits

6. Clinical Risk Management Bayside Health Achievements l Mainly process implementation l Some success with medication errors Next Steps l Clear expectations l Quantified targets & outcomes l More effort re baseline measures l Financial and other resource commitment

7. Clinical Risk Management Case Study Lessons/Practical Tips 1. Look after the Person Involved 2. Look after the Family intense work at time of incident commit to long term follow up 3. Look after Staff involved debrief and longer term support statements/depositions 4. Look after Stakeholders Media/Ministers Office/DHS/Board Broader internal communication 5. Formal Processes and Referrals Coroner/Insurers/Lawyers Internal Committees