203 Clinical Risk Management Policy

2.1. Clinical risk management, clinical governance and continuous quality improvement are complementary organisation-wide processes. This policy should be considered in conjunction with the Open Arms Governance Policy (100), Clinical Governance Policy (200), Continuous Quality Improvement Policy (102) and Organisational Risk Management Policy (203). These documents share a focus on identifying potential problems and implementing corrective actions, including the ability to protect people at risk, minimise errors, enhance efficiency and improve care and services.

2.2. This policy is aligned with the current national plan for preventing self-harm and suicidal behaviour (the Fifth National Mental Health and Suicide Prevention Plan 2017–2022). It is also aligned with the current national plan for preventing family and domestic violence (the National Plan to Reduce Violence against Women and their Children 2010–2022) and the DVA Family and Domestic Violence Strategy 2020–2025.

2.3. The Open Arms workforce is multidisciplinary, with a combination of clinical and non-clinical staff working together to provide an environment and processes to support the Open Arms vision: ‘Improved quality of life for veterans and their families’. Within this multidisciplinary approach, clinicians and peers collaborate to enable integration of both clinical and lived-experience peer perspectives and practices, to identify and respond to both service-level and individual-level risks. 

3.1. Clients have a right to receive mental health care in an environment that actively works to protect their safety, and Open Arms staff equally have the right to work in a safe environment.

3.2. Open Arms supports the active involvement of its workers in developing and enhancing systems and procedures to identify, mitigate and manage risk.

3.3. Risk is dynamic and can be affected by circumstances that can change over time. Therefore, risk assessment and management approaches need to include frequent review.

3.4. Open Arms leadership is committed to robust policy and processes that support the integration of continuous quality improvement and enhanced organisational responses to clinical risk. 

3.5. The Open Arms approach to individual clinical risk identification, assessment and management is recovery oriented, focusing on balancing duty of care with dignity of risk and supporting a client’s right to self-determination and personal growth with the need to ensure safety and delivery of care in the least restrictive manner. 

3.6. Open Arms supports and values the role of those with lived experience in contributing to risk management processes and procedures.

4.2. Open Arms employs a systemic approach to clinical risk management and has in place embedded structures, processes and tools to assist in identifying, analysing, evaluating and treating clinical risk at the organisational and individual levels. The Open Arms clinical risk management framework emphasises the importance of communication and consultation as well as regular monitoring and review.

4.3. This includes the use of a recovery-oriented framework for identifying, assessing and managing individual clinical risk, in addition to systemically identifying what can and does go wrong during care, understanding the factors that influence this, learning lessons from any clinical incident and ensuring action is taken to improve system responses based on lessons learned.

4.4. A clinical audit framework is in place to ensure that regular review points are built into the delivery of care, to monitor quality of service delivery at the individual, region and service levels. These audits are an integral part of the Open Arms Continuous Quality Improvement Policy (102) and enhance organisational capacity to identify, mitigate and respond to clinical risk.

4.5. Open Arms escalation responses recognise the value of integrated responses to risk management. The Open Arms Escalations Procedure (203-04) guides workers to provide a proactive outreach response to clients who have been identified as being at elevated risk to themselves, to others or from others, and clients who have been otherwise identified as requiring assertive support. 

4.6. In consultation with the Regional Director, Assistant Directors jointly oversee the quality of clinical risk management in the region and provide clinical oversight and management of case escalations within a stepped-care model of service provision. Each Assistant Director has primary responsibility for clinical oversight of the service stream that they line manage. However, the regional leadership team takes a flexible and collaborative approach to this on an as-needed basis, recognising that situations often arise where Assistant Directors must act interchangeably within service streams to support clinical staff and respond to service demand.

4.7. In each region, a risk consultancy group (comprising the Assistant Director Clinical Operations, Assistant Director Clinical Outreach and Groups, Duty Officer and Assistant Director Clinical Coordination) meets regularly to discuss assessment, intervention and management of significant risk concerns in all service streams, with a view to escalating matters to the Open Arms Director as required.

4.8. Open Arms builds and maintains relationships with external partners, including ex-service organisations , health professionals and health facilities, through our community engagement teams to ensure we are positioned to support wraparound services for clients who are vulnerable or at risk, and to enhance our approach to care coordination. 

4.9. Open Arms invests in professional development and supervision of workers to ensure our skills, knowledge and practice are evidence informed and consider risk in terms of how we support and connect with our clients. Consulting with internal and external supervisors and using defined escalation procedures where necessary further enhances our response to client risk and the way responsibility for risk across our organisation is shared.

4.10. Open Arms recognises that teamwork is the best defence against clinical risk. Everyone who works for Open Arms is an essential and equal member of the team and is valued and empowered to work to the best of their ability. Communication between team members about clinical risk management, and consultation with clinical managers, is explicitly encouraged and fostered within a culture of trust, mutual respect and open communication. 

4.11. Open Arms implements case review meetings to support best practice and evidence-informed treatments. Case reviews provide a mechanism for multidisciplinary teams to work collaboratively to optimise health outcomes for clients. They offer an enhanced opportunity to identify and manage risk, particularly for vulnerable or at-risk clients. Reviews are also conducted on outreach program counsellor clinical records as part of broader quality assurance processes.

4.12. In managing direct clinical risk to individuals, Open Arms uses the SafeSide Framework for Recovery-Oriented Suicide Prevention. This enables Open Arms workers to consider individual factors within a broader context of clinical risk management. 

5.1. Open Arms workers are required to adhere to a standard of reasonable care while performing any action that could foreseeably result in harm to others. Duty of care also encompasses the need to take positive action to ensure that the provision of Open Arms services is in line with the National Standards for Mental Health Services (NSMHS) 2010. See the NSMHS Accreditation Instruction for information on this process.

5.2. Open Arms clinical and non-clinical staff collectively and individually have an obligation to ensure the safety and wellbeing of clients, employees and the public. 

5.3. Open Arms maintains transparent communication with clients regarding duty of care responsibilities through practices and processes stipulated in the Open Arms Client Information, Rights and Records Policy (101). This includes the use of Open Arms consent forms that explicitly communicate instances where confidentiality may be breached. See the Privacy and Confidentiality Procedure (101-02) for further information.

6.1. Open Arms recognises that a client’s right to self-determination is a vital part of successful treatment and recovery. The principles of recovery emphasise choice and self-determination within legal and ethical limits and duty of care. 

6.2. Open Arms workers manage the tensions between various, and often complex, factors involved in making decisions on how they will respond to client risk. These factors include maximising client choice, supporting positive risk-taking, working in accordance with legal and ethical requirements, and promoting safety. Striking a balance requires us to understand the complex and sometimes discriminatory nature of the goal of reducing harmful risks. 

6.3. Open Arms achieves a balance between duty of care and dignity of risk through strong clinical governance, maintaining good clinical records, and determining a measure of reasonable risk through management review and consultation processes that support informed decision-making.

7.1. When clinical incidents are identified, Open Arms adopts an open disclosure approach within a restorative just culture framework (see the Clinical Incident Review Procedure (102-05)). Open disclosure involves an open discussion with a client and/or family member about an incident that resulted in harm while they, or their family member, were receiving Open Arms support. 

7.2. The elements of open disclosure are: 

• an apology or expression of regret
• a factual explanation of what happened
• an opportunity for the client or family member to relate their experience
• an explanation of the next steps being taken to manage the incident and prevent recurrence. 

7.3. The Open Arms approach to open disclosure is aligned with the Australian Commission on Safety and Quality in Health Care Australian Open Disclosure Framework (2013). 

8.1. The National Manager:

• promotes a focus on clinical risk management within Open Arms
• ensures effective clinical risk management systems are operating across all Open Arms sites and services
• reviews and consider recommendations following clinical risk incidents involving Open Arms clients.

8.2. The Assistant National Manager:

• prioritises clinical risk management activities in the regions and ensures escalation procedures are being followed
• ensures effective clinical risk management processes are operating across all Open Arms sites and services
• ensures professional development and supervision arrangements related to clinical risk management are in place for all relevant regional staff
• ensures oversight and reporting mechanisms are in place in response to clinical risk management at a regional level. 

8.3. The Assistant National Manager National Operations (roles now within the Mental Health and Wellbeing Services Division) :

• maintains clinical risk management as a priority within National Operations
• ensures all relevant Open Arms staff complete training and skills development related to clinical risk management
• ensures Open Arms policy and procedures related to clinical risk management are reviewed regularly
• monitors and evaluates the effectiveness of training related to clinical risk management.

8.4. Open Arms leadership teams:

• ensure all workers undertake training and maintain skills related to assessing and responding to clinical risk
• establish clear expectations and embed mechanisms to ensure appropriate levels of oversight of cases where clinical risk exists
• support staff to attend professional development activities related to clinical risk management
• ensure staff are aware of support options such as external supervision, operational supervision, and employee assistance programs
• ensure recommendations following incidents are communicated and implemented
• provide clinical oversight and supervision of cases involving clinical risk.

8.5. Open Arms clinicians:

• ensure clinical risk is routinely assessed and managed in accordance with Open Arms policy and procedures
• collaborate with Open Arms community and peer workers in identifying and responding to clinical risk
• actively support and contribute to the review of clinical incidents. 

8.6. Open Arms community and peer workers:

• respond to risk in an appropriate and timely manner by seeking clinical consultation
• participate in the implementation of risk management and safety plans as developed with, or approved by, the Assistant Director Clinical Coordination
• actively support and contribute to the review of clinical incidents.