National safety priorities in mental health: a national plan for reducing harm

Priorities for strengthening the safety building blocks in mental health services

Page last updated: October 2005

Rationale

To ensure safe mental health service environments generally, strategies are needed that strengthen the information infrastructure and other building blocks underpinning the ability to provide safe mental health services that continuously improve quality.

Objectives

  • Mental health services use safety Key Performance Indicators for detecting and monitoring adverse events and in quality improvement processes such as benchmarking.
  • Mental health services use available adverse event data to develop local action plans to improve safety, as part of continuous quality improvement processes.
  • Mental health services use incident monitoring and management systems to improve the safety of mental health services for consumers, staff and others.
  • Mental health services actively engage in training and development opportunities that will increase their ability to analyse and respond to adverse events.
  • Mental health services engage in ongoing quality improvement processes, including in-depth external review against National Standards for Mental Health Services by accreditation agencies, and implementation of National Practice Standards for Mental Health Workforce.
  • Mental health services develop and maintain working relationships and protocols with relevant acute, emergency and primary care services, as well as other relevant services sectors.
  • Mental health services have formal structured mechanisms for mental health consumers and carers to provide feedback including complaints, and actively participate in service planning, policy, implementation, evaluation and quality improvement processes.

Strategies

  • Ensure mental health services have systems in place for risk management and risk analysis that are linked to organisational and clinical governance arrangements.
  • Promote, encourage and facilitate a transparent and a just culture within which mental health service providers can report safety incidents without fear of inappropriate blame.
  • Ensure mental health professionals are trained in risk management, including in the areas of suicide and violence, and also inpatient safety improvement methodologies.
  • Include a specific focus on strengthening the safety standard in any national review of the National Standards for Mental Health Services.
  • Promote, encourage, and facilitate recording of mental health related adverse events in incident management systems and the use of incident information in quality improvement processes.
  • Improve existing incident reporting and management systems to ensure that mental health specific adverse events are recorded and fed-back into safety improvement processes at the service level, provide meaningful aggregation of incidents data and have some capacity for benchmarking.
  • Identify what mental health information should be collected and reported nationally, in addition to the national sentinel event reporting of suicides that occur in an inpatient unit. This would require further work with jurisdictions and relevant expert groups in the existing health and mental health data environments to ensure national consistency in data definitions, classifications and reporting that can contribute to improvements in safety and quality of mental health care in hospital and community based services.
  • Develop, in collaboration with the National Mental Health Working Group's Information Strategy Committee, nationally agreed key performance indicators for safety.
  • Ensure that mental health services consider coronial findings and other relevant inquiries, and feed these into incident management and quality improvement processes.
  • Ensure that local services use all available data on incidents and adverse events (complaints data, reports from external scrutiny bodies such as Australian Council on Healthcare Standards clinical data, accreditation reports or reports from official/community visitors) to analyse and determine local priorities for safety and quality improvement.
  • Ensure that mental health services have in place arrangements for information sharing with criminal justice agencies, transport providers and primary health care professionals.
  • Ensure that if a mental health consumer is involved in a safety incident that this automatically prompts the review of the mental health consumer's care within a reasonable time period that is specified in relevant procedural documentation.
  • Ensure that mental health services have in place activities that reduce stigma experienced by people with mental health disorders, promote mental health and foster recovery oriented services.
  • Promote mental health consumer participation in their health care through the use of 10 tips for safer healthcare 8, in addition to other mental health service specific consumer and carer participation strategies.
  • Ensure all mental health consumers have in place an individual care plan on discharge from mental health inpatient care and that they receive a copy, and if agreed a copy is also provided to a carer.
  • Identify good practice for the involvement of carers in treatment including following discharge from inpatient mental health care, with a focus on relapse management and discharge documentation when developing individual care plans.
  • Promote a consistent and effective approach to complaints management through the use of the Better Practice Guidelines for Complaints Management for Health Care Services 9 and the accompanying Complaints Management Handbook for Health Care Services.
  • Promote use of national falls prevention guidelines 10 within mental health services.

Footnotes

8 Australian Council for Safety and Quality in Health Care (2003), 10 tips for safer health care, Commonwealth of Australia, 2003.
9 Australian Council for Safety and Quality in Health Care (2004), Better Practice Guidelines on Complaints Management for Health Care Services, Commonwealth of Australia, July 2004.
10 Australian Council for Safety and Quality in Health Care (2005), Preventing falls and harm from falls in older people. A resource suite for Australian hospitals and residential aged care facilities, Commonwealth of Australia.