Audit says Vic doesn't have an effective statewide incident management system

Friday, 03 September, 2021

Audit says Vic doesn't have an effective statewide incident management system

Victoria has made some progress in improving its clinical governance, but doesn't have a fully functioning statewide incident management system, according to the latest Victorian Auditor-General's Office (VAGO) audit.

In 2016, the Victorian Government commissioned the Targeting zero report, following a cluster of baby deaths at Djerriwarrh Health Services. The report found that the then Department of Health and Human Services (DHHS) was not effectively leading and overseeing quality and safety across the health system and recommended VAGO to follow up on the Department's progress in improving clinical governance.

In February this year, DHHS was split into the Department of Health (DH) and the Department of Families, Fairness and Housing.

The recent VAGO audit looked at how DH — including Safer Care Victoria (SCV) and the Victorian Agency for Health Information (VAHI) — managed quality and safety risks across the health system and examined how it produces and uses information to identify and reduce risks.

The Auditor-General's Office found that the Department had made some clinical government improvements and its risk management approach no longer masked poor quality and safety performance at public health services.

SCV also worked with health services to improve sentinel event reporting, but the Department's ability to reasonably assure Victorians of the health system’s quality and safety was still found to be limited due to the following reasons:

  • It cannot ensure that health services are operating within safe scopes of clinical practice.
  • It cannot regularly and easily detect trends and risks across the system.
  • Victoria still does not have a fully functioning statewide incident management system.
  • VAHI, DH's specialist analytics and reporting unit, is working to improve its reporting but can still do much more to consistently provide timely, meaningful and actionable insights that highlight risks and improvement opportunities.

The Auditor-General’s office has made 18 recommendations with an aim to improve the Department’s systems and process for managing and detecting quality and safety risks across the health system. The Department has accepted all recommendations.

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