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Incident Management Policy and Procedure

NDIS Policies and Procedures Manual – Core Module

Document Number: CM-POL-011

Document Control

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Legal Name: Holistic Healthcare Management Services
ABN: 20695058096
ACN: 695058096
Primary address/head office: 15 Agasse Way, Tapping WA 6065
Document Name: NDIS Policies and Procedures Manual – Core Module
Document Number: CM-POL-011
Approved by: Director
Date Approved: February 2026
Version No: 1.0
Comments: Initial Release of the Policies and Procedures Manual
Next Review Date: May 2026

Introduction and Purpose

Holistic Healthcare Management Services is committed to safeguarding the wellbeing of participants by implementing a comprehensive incident management system that ensures incidents are effectively acknowledged, responded to, managed, and learned from. This policy aligns with the National Disability Insurance Scheme (Incident Management and Reportable Incidents) Rules 2018 to promote safety, transparency, and continuous improvement in service delivery.

The purpose of this policy is to provide a framework for managing incidents in a way that protects participants, workers, and the organisation, while fostering a culture of accountability and learning.

This policy supports compliance with legal and regulatory requirements, reinforcing Holistic Healthcare Management Services’s dedication to participant safety and service excellence.

Scope

This policy applies to all areas of Holistic Healthcare Management Services’s operations, including:

  • Participant care and safety.
  • Service delivery processes and standards.
  • Work Health and Safety (WHS) compliance.
  • Governance and operational management.

It encompasses all workers, including employees, contractors, consultants, and volunteers, as well as third-party service providers involved in incident management.

The policy covers all incidents, including but not limited to:

  • Adverse events affecting participant safety or wellbeing.
  • Worker injuries or safety concerns.
  • Near-misses that have the potential to result in harm.
  • Reportable incidents as defined under the NDIS Incident Management and Reportable Incidents Rules.

Definition

Term Description
Incident Any event or circumstance that results in, or has the potential to result in, harm to participants, workers, or the organisation.
Reportable Incident Incidents that must be reported to the NDIS Quality and Safeguards Commission, including but not limited to serious injuries, abuse, neglect, and deaths of participants.
Incident Management System (IMS) A structured process for reporting, documenting, investigating, and responding to incidents, ensuring compliance with regulatory requirements.
Corrective Actions Steps taken to address the root causes of an incident and prevent recurrence.
Continuous Improvement The ongoing effort to enhance services and processes based on lessons learned from incidents.

Outcomes and Indicators

Term Description
Each participant is safeguarded by the provider’s incident management system, ensuring that incidents are acknowledged, respond to, well-managed and learned from.
  • An incident management system is maintained that is relevant and proportionate to the scope and complexity of supports delivered and the size and scale of the organisation. The system complies with the requirements under the National Disability Insurance Scheme (Incident Management and Reportable Incidents) Rules 2018.
  • Each participant is provided with information on incident management, including how incidents involving the participant have been managed.
  • Demonstrated continuous improvement in incident management by regular review of incident management policies and procedures, review of the causes, handling and outcomes of incidents, seeking of participant and worker views, and incorporation of feedback throughout the provider’s organisation.
  • All workers are aware of, trained in, and comply with the required procedures in relation to incident management.

Guiding Principles

  • Proactive Risk Management: Incident prevention is prioritised through proactive identification and mitigation of risks (Indicator 1).
  • Transparency and Accountability: Participants and stakeholders are kept informed about incident management processes and outcomes (Indicator 2).
  • Continuous Improvement: Regular reviews and feedback mechanisms inform updates to policies and practices, ensuring the organisation learns and evolves (Indicator 3).
  • Training and Awareness: Workers are equipped with the knowledge and skills necessary to effectively manage incidents (Indicator 4).
  • Participant-Centred Approach: All incident management activities prioritise participant safety, dignity, and wellbeing.

Types of Incidents

Incidents may involve various forms of abuse, misconduct, or risks. The following categories require immediate attention and appropriate reporting:

Abuse and Harm

Abuse may occur in different forms, each requiring specific responses:

  • Sexual Abuse: Unwanted sexual advances, assault, harassment, or grooming.
  • Child Abuse: Physical, emotional, or sexual harm to a child, including neglect.
  • Bullying and Harassment: Repeated behaviour that causes distress, fear, or intimidation.
  • Physical Abuse: Assault, hitting, restraining, or any action causing physical harm.
  • Emotional or Psychological Abuse: Coercion, threats, manipulation, or control affecting mental wellbeing.
  • Financial Abuse: Misuse or theft of a participant’s funds, coercion into financial transactions.

Domestic and Family Violence

Incidents involving domestic or family violence, particularly affecting participants in supported living, independent care, or home environments, must be addressed immediately.

Neglect and Exploitation

  • Neglect: Failing to provide essential care, medical support, or personal safety.
  • Exploitation: Taking advantage of a participant’s vulnerability for personal gain.

Reportable Incidents (NDIS Commission)

As per NDIS requirements, serious incidents must be reported within the prescribed timeframes:

  • Within 24 hours: If an incident involves death, serious injury, sexual misconduct, abuse, or unauthorised restrictive practices.
  • Within 5 days: If the incident is serious but does not require immediate intervention (e.g., financial exploitation, non-critical neglect).

Reportable incidents include:

  • Death of an NDIS participant.
  • Serious injury requiring medical intervention.
  • Abuse or neglect of an NDIS participant.
  • Unlawful sexual or physical contact, assault, or violence.
  • Sexual misconduct, including grooming, harassment, or exploitation.
  • Unauthorised restrictive practices.

Policy

Holistic Healthcare Management Services is dedicated to implementing and maintaining an incident management system that is tailored to the size, scope, and complexity of the supports delivered. The system will:

  • Clearly define the processes for identifying, reporting, documenting, investigating, resolving, and reviewing incidents. These processes will be communicated to all workers and stakeholders to ensure consistent application across the organisation.
  • Comply with all relevant legislative and regulatory requirements, including the National Disability Insurance Scheme (Incident Management and Reportable Incidents) Rules 2018, ensuring that participants’ safety and rights are prioritised at every stage (Indicator 1).
  • Promote a culture of transparency and accountability, where incidents are viewed as opportunities for learning and improvement.

The organisation commits to:

  • Providing participants with clear information about incident management processes (Indicator 2): Participants will be provided with accessible and understandable information about how incidents are managed, including the steps involved in acknowledging, responding to, and resolving incidents. Clear communication will ensure participants understand their rights and the organisation’s obligations.
  • Regularly reviewing incident management policies, procedures, and outcomes (Indicator 3): Policies and procedures will be reviewed at least annually or after significant incidents to ensure they remain effective and reflective of best practices. Participant and worker feedback will be actively sought and integrated into updates to strengthen the system.
  • Ensuring all workers are trained in and adhere to incident management procedures (Indicator 4): Comprehensive training will be provided to all workers, covering incident reporting, documentation, investigation, and resolution. Training will also address workers’ responsibilities in creating a safe and supportive environment for participants.

Incident Management Process

Holistic Healthcare Management Services’s incident management process is represented below:

Incident Reporting: All incidents must be reported immediately to the appropriate internal personnel, ensuring swift intervention. Staff, participants, or stakeholders can report incidents through verbal, written, or online reporting channels.

Incident Documentation: Every reported incident is formally documented using an Incident Report Form, including details of the event, involved parties, and immediate actions taken. Reports must be completed within 24 hours and securely stored for compliance and review.

Investigation and Analysis: A thorough and impartial investigation is conducted to assess the cause, contributing factors, and impact of the incident. Evidence is gathered, including witness statements, participant accounts, and supporting documentation, ensuring procedural fairness.

Incident Resolution: Corrective actions are implemented to prevent recurrence, including risk mitigation strategies, staff training, and process improvements. Where required, disciplinary actions, safeguarding interventions, or external referrals are made.

Participant Communication: Participants and their support networks are informed of the incident outcome in a transparent and sensitive manner. Where appropriate, support services, advocacy, or counselling are offered to ensure participant wellbeing.

Continuous Improvement: Incident trends and root causes are analysed to identify systemic issues and process gaps. Policies, training programs, and risk management strategies are regularly updated to enhance safety and service quality.

Procedure

Incident Acknowledgment and Immediate Action

Acknowledging and addressing incidents promptly is critical to ensuring participant safety and organisational accountability.

  • Acknowledgment of Incidents: All incidents must be acknowledged within 24 hours of occurrence or notification. Workers responsible for incident acknowledgment must provide immediate reassurance to participants and affected individuals, ensuring that their concerns are taken seriously. Participants will be informed of the initial steps taken, including who will manage the incident and expected timelines for resolution. This communication will be conducted in a manner suited to the participant’s communication preferences to foster trust and transparency.
  • Immediate Action Taken: Depending on the nature and severity of the incident, immediate actions may include administering first aid or arranging medical care for affected participants, securing the environment to eliminate further risks (such as isolating hazards or evacuating affected areas), and engaging emergency services or regulatory bodies if required by the severity of the incident. These actions will be documented in the incident report, detailing the steps taken to prioritise safety and mitigate potential harm.

Investigation and Escalation

The investigation process ensures accountability and the prevention of similar incidents in the future.

  • Investigation: All incidents, regardless of severity, will be subject to an impartial investigation to determine root causes and contributing factors. Investigations will involve collecting and reviewing physical evidence (e.g., photos, equipment), conducting interviews with participants, workers, and witnesses to gather firsthand accounts, and consulting subject matter experts or external advisors for specialised insights. Findings will be compiled in a detailed report, including recommendations for corrective actions and preventive measures.
  • Escalation: Serious incidents, including those classified as reportable under the NDIS Incident Management and Reportable Incidents Rules 2018, will be escalated to senior management immediately. Escalated incidents will also be reported to relevant regulatory bodies, such as the NDIS Quality and Safeguards Commission, within the required timeframes. Management will convene to assess escalated incidents and approve necessary corrective actions, ensuring alignment with organisational and legal requirements.

Follow-Up and Participant Support

Supporting participants after incidents is essential for fostering trust and mitigating long-term effects.

  • Follow-Up Support: Participants affected by incidents will receive personalised follow-up support, which may include access to counselling services or psychological support to address emotional impacts, provision of advocacy services to ensure their voice is heard throughout the incident resolution process, and regular updates on the status and outcome of the incident investigation.
  • Communication of Resolutions: Resolutions will be communicated clearly and empathetically, ensuring participants understand the actions taken and the steps to prevent recurrence. Workers responsible for this communication will tailor their approach to the participant’s needs, using accessible language and preferred communication methods.

Roles and Responsibilities

Ref No Roles Responsibilities
1 Board and Senior Management
  • Oversight and Governance: The board and senior management are responsible for overseeing the effectiveness of the incident management system and ensuring it aligns with regulatory requirements and organisational objectives.
  • Resource Allocation: Adequate resources, including personnel, training programs, and technological tools, will be allocated to maintain a robust incident management system.
  • Review and Approvals: High-risk incidents and systemic issues will be reviewed by senior management, who will approve corrective actions and strategic improvements.
2 Workers
  • Incident Reporting: Workers are responsible for reporting incidents promptly and accurately, ensuring initial actions prioritise participant safety and wellbeing.
  • Support Provision: Workers will provide immediate and ongoing support to participants affected by incidents, fostering an environment of care and trust.
  • Policy Adherence: Workers must adhere to all incident management procedures, including training requirements, reporting protocols, and corrective action implementation.
3 Incident Coordinator
  • Documentation and Coordination: The incident coordinator will ensure all incidents are documented comprehensively and entered into the incident register.
  • Investigation Management: Coordinators will oversee the investigation process, ensuring timeliness, objectivity, and compliance with policies.
  • Communication Liaison: Act as the primary contact for participants, workers, and regulatory bodies throughout the incident management process, ensuring clarity and transparency.

Record Keeping

  • Incident Register: A centralised incident register will be maintained to capture all incidents, investigations, and outcomes comprehensively. The register will include details such as the incident date, time, description, affected individuals, immediate actions taken, and resolution status. Regular reviews of the register will be conducted to identify trends, systemic issues, and areas for improvement. Access to the register will be restricted to authorised personnel to ensure confidentiality and compliance with privacy laws.
  • Investigation Records: Detailed investigation records will document all steps taken during the incident review process. These records will include witness statements, evidence collected, analysis of root causes, and recommendations for corrective actions. Investigation records will be securely stored in compliance with organisational policies and Australian data protection legislation, ensuring availability for audits or regulatory reviews.
  • Training Records: Training records will be maintained to demonstrate compliance with incident management policies and ensure worker competency. Records will include details of training sessions, including attendance logs, competency assessments, and refresher training schedules. Training programs will be regularly updated to incorporate lessons learned from incidents and evolving best practices.
  • Continuous Improvement Records: Documentation of all reviews, updates, and quality improvement initiatives related to incident management will be maintained. Continuous improvement records will detail changes made to policies, procedures, and training programs in response to incident trends and feedback. These records will serve as evidence of the organisation’s commitment to enhancing safety and quality.

Related Documents

  • Incident Report Form
  • Incident Register
  • Incident Investigation Form
  • Complaint Report Form
  • Feedback and Complaints Register
  • Risk Register
  • Staff Handbook
  • Participant Handbook
  • Staff Training Plan

References

  • National Disability Insurance Scheme (Incident Management and Reportable Incidents) Rules 2018
  • Privacy Act 1988 (Cth)
  • ISO 31000:2018 Risk Management

Policy Review

This policy will be reviewed annually to ensure alignment with best practices, legislative requirements, and feedback from participants, staff, and advocates. Updates will be made as needed to enhance its effectiveness and relevance.