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Clinical risk assessment and management (Cram)in western australian mental health servicesPolicy and Standards
HP1
0607
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© Department of Health, 2008Produced by the Mental Health Division
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© Department of Health, State of Western Australia (2008)
Copyright to this material produced by the Western Australian (WA) Department of Health belongs to the State of Western Australia, under the provision of the Copyright Act 1968 (Commonwealth of Australia). Apart from any fair dealings for personal, academic, research or non-commercial use, no part may be reproduced without written permission of the Mental Health Division, WA Department of Health. The WA Department of Health is under no obligation to grant this permission. Please acknowledge the WA Department of Health when reproducing or quoting material from this source.
Disclaimer
All advice and information in this document is given in good faith and is based on sources believed to be reliable and accurate at the time of release. The State of Western Australia, the WA Department of Health and their respective officers, employees and agents do not accept legal liability or responsibility for the content of this advice or information or any consequences arising from its use.
Suggested reference:
Mental Health Division, WA Department of Health (2008). Clinical Risk Assessment and Management (CRAM) in Western Australian Mental Health Services: Policy and Standards. Perth, Western Australia: Department of Health.
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Policy and standards
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Executive director’s foreword
The Clinical Risk Assessment and Management Project was implemented under Key Initiative 5 (Workforce and Safety Initiatives) of the Mental Health Strategy 2004-2007 from a long-standing need to develop a consistent approach to clinical risks in mental health settings. A Project Reference Group of consumer and carer representatives, clinicians and service managers was formed to provide specialist input into the project.
The Project Reference Group spent many hours considering the current literature and evidence base, including guidelines and frameworks from other services, internationally, from other states, and from our own services. It
also spent many hours deliberating about what happens in the ‘real world’ of mental health practice and what could be realistically done to manage clinical risks.
from the outset, the Project Reference Group acknowledged that mental health services in Western Australia are committed to the best outcomes for consumers, carers and staff. It became clear though that services had different procedures for assessing risk and that they offered different types of training related to clinical risk management, for example aggression management courses.
One of the original aims of the project was to develop a clinical framework for risk assessment and management and to develop a training package. Whilst undoubtedly important, it became apparent that a clinical framework or risk assessment tool is not enough to ensure consistent evidence-based risk management practice across the state. The Project Reference Group defined a standardised approach for services to assess and manage clinical risks that could then be tailored to the specific service requirements of each service.
The result is a policy that details five steps to identify, assess and manage clinical risks in mental health settings. The policy outlines a standardised approach to clinical risk assessment and management throughout the Western Australian public mental health service. The aim is that through clinical governance processes, services can use the policy to develop new, or audit existing, procedures.
finally, I would like to thank the Project Reference Group for their hard work and commitment in producing the policy and standards.
Dr steve Patchett Executive director, Mental Health
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Table of Contents
Executive director’s foreword i
1. POLICY 1
Policy Statement 1
Scope 1
Objectives 1
Relevant documents 2Legislation and Codes 2Standards 2Policy and Guidelines 2Operational Circulars 2Source Documents 3
Policy Background 5The Clinical Risk Assessment and Management Project 5Remit of the Reference Group 5Policy Development 5
2. sTANDARDs FOR CLINICAL RIsK AssEssMENT AND MANAGEMENT 8
Risks: An outline 8
The Clinical Risk Management Process 9
Standards 11
3. IMPLEMENTATION 31
Staged Implementation 31
Auditing 31
Training and development 31
Policy Review 32
4. ACKNOWLEDGEMENTs 33
5. GLOssARY 35
6. REFERENCEs 38
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Policy and standards
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1. Policy
Policy statementOne of the outcomes of the National Mental Health Plan 2003-2008 has been the increased safety of consumers, carers and families, staff and the community. Western Australian mental health services are committed to the safety and well-being of consumers, carers and staff and will work to minimise the likelihood and impact of adverse clinical risks.
Mental health staff have the right to work in a safe environment, and consumers and their carers have a right to receive mental health care in an environment that actively works to protect their safety. However, mental health services are never risk-free and clinical risks like suicide and violence cannot be predicted with 100% accuracy. Instead, good clinical risk management is based on effective treatment that is focused on an individual’s history and current circumstances.
In order to minimise the possibility of harm to consumers, their carers and staff, services require:
A common, evidence-based understanding of the principles of clinical risk assessment and management to support a consistent approach and process.
The capacity to manage clinical risks that includes the appropriate allocation of staffing, access to training and the ability to manage and rectify the physical work environment.
This policy outlines the minimum requirements for safe practice in this area. At the outset, it should be acknowledged that services and staff often already demonstrate evidence-based, safe practice in this area. This policy therefore aims to highlight and support existing safe practice and provide a structure for accountability.
scope This policy applies to all clinicians and managers in the Western Australian public mental health services. It is a system-wide policy that supersedes all policies and guidelines related to clinical risk assessment and management previously produced by the Mental Health division.
All staff are required to take reasonable steps toward their own and their colleagues’ health and safety. This means that individual clinicians and managers will need to be familiar with the policy to ensure the safety and well-being of the workforce, as well as to ensure safe standards of practice. This policy should serve as the foundation for service-level procedures and protocols concerning clinical risk. It should also be used in the development of other policies pertaining to staff safety and security within the mental health services.
ObjectivesThe objectives of this policy are to:
1. Promote a safe environment for mental health consumers, carers and staff.
2. Establish the minimum standards for clinical risk assessment and management in the Western Australian public mental health services.
3. Assist both services and individual staff to understand and apply the principles of clinical risk assessment and management.
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Relevant DocumentsThis policy should be considered within the following legislation, standards, policies, guidelines and operational circulars.
Legislation and CodesOccupational Safety and Health Act 1984 (WA).
Occupational Safety and Health Regulations 1996 (WA).
Mental Health Act 1996 (WA).
Professional Codes of Conduct for mental health professions, including psychiatry, nursing, psychology, social work and occupational therapy.
standardsAustralian/New Zealand Standard – Risk Management (AS/NZS 4360:2004). Standards Australia International Ltd and Standards New Zealand.
Department of Health and Ageing (1996). National Standards for Mental Health Services. Canberra: Government of Australia.
department of Health and Ageing (2002). National Practice Standards for the Mental Health Workforce. Canberra: Government of Australia.
Policy and GuidelinesWA department of Health, (2004). Guidelines for Responding to Child Abuse, Neglect and the Impact of Family and Domestic Violence. Perth, Western Australia: department of Health.
WA department of Health, (2004). Prevention of Workplace Aggression and Violence: Policy and Guidelines. Perth, Western Australia: department of Health.
Office of Safety and Quality, WA Department of Health (2005). Clinical Risk Management Guidelines for the Western Australian Health System. (Information Series No. 8). Perth, Western Australia: department of Health.
Mental Health division, WA department of Health (2006). Guidelines: The management of disturbed/violent behaviour in inpatient psychiatric settings. Perth, Western Australia: department of Health.
Operational CircularsWA department of Health (february 2005). OP 1914/05 Access to the Mental Health Clinical Information System (PSOLIS).
http://www.mhidp.health.wa.gov.au/one/uploads/resource/94/OP191505.pdf
WA Department of Health (April 2006). OP 2050/06 Patient Confidentiality and Divulging Patient Information to Third Parties.
http://www.health.wa.gov.au/circulars/circular.cfm?Circ_Id=12052
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WA department of Health (September 2006). OP 2102/06 Child Protection – Children and Community Services Act 2004.
http://www.health.wa.gov.au/circulars/pdfs/12105.pdf
WA department of Health (April 2006). OP 2055/06 Emergency Psychiatric Treatment and Issues of Consent: Mental Health Act 1996 (SS113-115 and Part 5, div 2).
http://www.chiefpsychiatrist.health.wa.gov.au/publications/docs/_Emergency_Psychiatr.pdf
WA department of Health (April 2006). OP 2058/06 Seclusion, Restraint and Time Out: Mental Health Act 1996.
http://www.chiefpsychiatrist.health.wa.gov.au/publications/docs/Seclusion,_restraint.pdf
WA department of Health (April 2006). OP 2061/06 Matters To Be Reported To The Chief Psychiatrist.
http://www.health.wa.gov.au/circulars/pdfs/12063.pdf
source DocumentsA number of national and state documents provide the context for the development of this policy, namely:
The National Safety Priorities for Mental Health (2005)
The National Practice Standards for the Mental Health Workforce (2002).
The policy is underpinned by the Clinical Risk Management Guidelines for the Western Australian Health System (Guidelines) (Office of Safety and Quality, 2005). The Office of Safety and Quality produced the Guidelines to assist department of Health staff in meeting their risk management responsibilities through consistent and systematic identification and management of clinical risk. As such, mental health clinicians are also subject to these guidelines. Services therefore should review this policy in light of the Guidelines.
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Clinical Risk Assessment and Management in Western Australian Mental Health Services
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Figure 1: Context of the Clinical Risk Assessment and Management Policy and Framework
National Mental Health Plan(2003–2008)
National Standards for the Mental Health Services
(1997)
National Safety Priorities in Mental Health
(2005)
National Practice Standards for the Mental Health Workforce
(2002)
Western Australian Mental Health Strategy 2004–2007
(Key Initiative 5: Workforce and Safety)
Clinical Risk Assessment and Management Policy for Western Australian
Mental Health Services (2006)
Area Mental Health Service Policies and Procedures for Clinical Risk Assessment and Management
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Policy Background
The Clinical Risk Assessment and Management ProjectIn 2002, the Metropolitan Mental Health Service (MMHS) Interim Clinical Advisory Group (ICAG) endorsed the Framework for Clinical Risk Assessment and Management of Harm. This document was an adaptation of a framework developed at the Institute of Psychiatry (IOP) and Maudsley in London (2001). Over the following years, some services in WA made use of and adapted this framework, including implementing screening tools. However, the overall approach to clinical risk management within the state was not consistent.
following the release of the National Practice Standards for the Mental Health Workforce (Standards) in September 2002, a statewide reference group was formed by the Western Australian Office of Mental Health (as the Mental Health Division was then known) to review how the Standards could best be implemented and evaluated. The membership included academic and clinical staff, and the work of the group was informed by emerging trends from the Office of the Chief Psychiatrist Clinical Governance reviews.
As a result of these developments, the Clinical Risk Assessment and Management Project was one of several projects under Key Initiative 5 (Workforce and Safety Initiatives) of the Mental Health Strategy 2004-2007 aimed at supporting implementation of the Standards. Other initiatives on workforce safety include the development of the Guidelines: The management of disturbed/violent behaviour in inpatient psychiatric settings (2006).
Remit of the Reference GroupThe Clinical Risk Assessment and Management Project Reference Group was established to provide consumer, carer and specialist clinical input. In developing the policy, the Project Reference Group confined its deliberations to the risk of harm to self or others.
The Project Reference Group’s priority was for consumers, carers and staff to feel secure and to work within safe surroundings. As such, the Project Reference Group acknowledged the conflicting and competing tensions between maintaining a consumer’s confidentiality and privacy and the importance of informing relevant others to ensure a reasonable standard of care. Added to this was the consideration of the public interest when there is an identified risk.
The Project Reference Group also carefully considered the complex issue of risk assessment, particularly the role of standardised instruments, forms and checklists. The Project Reference Group determined that while such tools are useful for supporting consistency in assessment, they do not, in themselves, constitute comprehensive risk assessment or the infallible prediction of risk. The Project Reference Group was mindful of the need to rate and communicate levels of risk against the need for a flexible, individualised approach. That is, there is a need to balance the use of checklists and standardised instruments against the clinician’s judgement. Clinicians are encouraged to consider all elements of assessment and methods to understand clinical risk.
Policy Development The development of this policy was informed by:
The Project Reference Group, consisting of consumer and carer representatives, clinicians and managers
The evidence and a review of the literature
The source documents outlined above
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Broader discussions and consultation with the clinical field and other key stakeholders, including:
Leaders in clinical governance and staff development
Office of the Chief Psychiatrist
Office of Safety and Quality
The results of a survey of clinicians’ training needs and competency in this area
A review of a number of state, national and international policies and guidelines on clinical risk, suicide and violence, namely:
American Psychiatric Association (2003). Practice Guideline for the Assessment and Treatment of Patients with Suicidal Behaviors. Arlington, USA: American Psychiatric Association.
Auditor General of Western Australia (2001). Life Matters: Management of Deliberate Self-Harm in Young People.
Auditor General of Western Australia (2005). Follow-up Performance Examination.
Barwon Health (2003). ACE Guidelines: Assessment Care & Evaluation (Version 3). Geelong, Victoria: Barwon Mental Health Service.
Clinical Risk Assessment & Management Training Project (2005). A Guide to Clinical Risk Assessment and Management for Violence, Suicide and Absence without Permission. Queensland: Queensland Government.
East London and the City Mental Health Trust (2002). Clinical Risk Assessment & Management Policy. London: NHS.
Glenside Campus Mental Health Service, Royal Adelaide Hospital (2002). Clinical Practice Manual - Risk Assessment Policy and Procedure (MHCLPR-0900). Adelaide: Government of South Australia.
Greater Glasgow Primary Care Trust Mental Health division (2005). Aggression Management Policy and Guidance. Greater Glasgow: National Health Service.
Health Services Research department (2002). Clinical Assessment of Risk Decision Support (CARDS). London: Institute of Psychiatry.
Kingsley, B. (2001). Elder Abuse: Protocol and policy guidelines to prevent the abuse of older people in community and residential care. Perth, Western Australia: The Centre for Research into Aged Care Services, Curtin University of Technology.
Mental Health Reference Group (2000). Risk Management. Scotland: Scottish Executive.
Ministry of Health and Health funding Authority (1998). Guidelines for Clinical Risk Assessment and Management in Mental Health Services. Wellington, New Zealand: Ministry of Health.
National Institute for Clinical Excellence (2004). Self-harm: The short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care. Clinical Guideline 16. London: NICE.
National Institute for Mental Health (2003). Preventing Suicide – A Toolkit for Mental Health Services. Leeds, United Kingdom: NIMH.
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New South Wales department of Health (2004). Suicide Risk Assessment & Management Protocols. North Sydney: NSW department of Health.
New South Wales department of Health (2005). Policy Directive: (Policy Guidelines for) Management of Patients with Possible Suicidal Behaviour (Pd2005_121). Sydney: NSW Health.
Royal Australian and New Zealand College of Psychiatrists (2000). Guidelines for the Management of Deliberate Self Harm in Young People. Australasian College for Emergency Medicine.
Service development Unit (2003). Guidelines for Clinical Risk Assessment and Management. Warrnambool, Victoria: Service development Unit, South West Healthcare Psychiatric Services division (Unpublished).
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2. Standards for Clinical Risk Assessment and Management
Risks: An Outline Risk in mental health has been defined as the likelihood of an event happening with potentially harmful or beneficial outcomes for self and others (Morgan, 2000).
Mental health services are particularly concerned about risks that are highly likely in terms of probability and that have severe consequences, such as imminent suicide attempts or violence. Examples of clinical risks in mental health include:
Risks to self: Self-harm and suicide, including repetitive self-injury
Self-neglect
Absconding and wandering (which may also be a risk to others)
Health including: drug and alcohol abuse Medical conditions, e.g. alcohol withdrawal, unstable
diabetes mellitus, delirium, organic brain injury, epilepsy
Quality of life, including dignity, reputation, social and financial status.
Risks to Others: Harassment
Stalking or predatory intent
Violence and aggression, including sexual assault or abuse
Property damage, including arson
Public nuisance
Reckless behaviour that endangers others e.g. drink driving.
Risks by Others: Physical, sexual or emotional harm or abuse by others
Social or financial abuse or neglect by others.
(Adapted from Ministry of Health, 1998; Top End Mental Health, 2004).
Risks may also be posed to consumers by systems and treatment, such as the side-effects of medication, ineffective care, institutionalisation and social stigma. Whilst these types of clinical risks are often not immediately obvious, they should be carefully considered in management planning (Ministry of Health, 1998).
The frequency and prevalence of certain clinical risks that clinicians encounter will also depend on the setting and age group seen. for instance, the risk of abuse or neglect by others may be higher in children, and the risk of self-neglect higher in older adults. However, age alone does not preclude the presence of certain clinical risks. Adolescents may still be at risk of self-neglect, and adults living independently can still be at risk of exploitation.
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The Clinical Risk Management ProcessIn line with both the Australian/New Zealand Standard AS/NZS 4360:2004 Risk Management and the Clinical Risk Management Guidelines for the Western Australian Health System, this policy follows a five-step process and contextualises this processes for mental health settings.
step 1: Establish the context. Identify and understand the service’s operating environment and strategic context.
step 2: Identify the risks. Identify internal and external clinical risks that may pose a threat to the health system, organisation, business unit, and team and/or patient.
step 3: Analyse the risks. Undertake a systematic analysis to understand the nature of risk and to identify tasks for further action.
step 4: Evaluate and prioritise the risks. Evaluate the risks and compare against acceptability criteria to develop a prioritised list of risks for further action.
step 5: Treat the risks. Identify the range of options to treat risks, assess the options, prepare risk treatment plans and implement them using available resources.
Two factors underpin these five steps, namely:
Communication and Consultation
Monitoring and Review.
Both are vital to effective clinical risk management and need to be implemented simultaneously at each level of the clinical risk management process.
Services seeking further information about this process should refer to both the Australian Standard and the department of Health’s Guidelines.
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Clinical Risk Assessment and Management in Western Australian Mental Health Services
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Figure 2: Overview of the Clinical Risk Management Process (Office of Safety and Quality, 2005).
Com
mun
icat
e an
d Co
nsul
t
Mon
itor
and
Rev
iew
Step One: Establish the Context
Step Two: Identity the Risks
Step Three: Analyse the Risks
Step four: Evaluate the Risks
Step five: Treat the Risks
Risk Assessment Risk Assessment
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Policy and standards
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standards Within each of the above steps of the clinical risk management process are core principles and standards for assessing and managing clinical risk within mental health settings. These standards are aligned to the National Mental Health Standards (NMHS), and are:
Figure 3: standards for Clinical Risk Assessment and Management
NMHs Clinical Risk Assessment and Management standard
1. Establish the Context 11.3.1 11.3.15 11.3.16 11.4.E.1 11.4.E.3 11.4.E.6 11.4.E.14
1.1 Clinical risk assessment and management in mental health services must be legal, ethical and evidence-based.
1.2 The practice of clinical risk assessment and management is person-centred and promotes the dignity of risk.
1.3 Clinical risk assessment and management is a shared, systemic responsibility, underpinned by a ‘no-blame’ culture.
1.4 Clinical risk assessment and management is regarded as a core competency for practice.
2. Identify the Risks 2.1 Clinical risks are identified and their nature documented.
3. Analyse the Risks (Assessment)
11.2.12 11.3.1 11.3.2 11.3.3 11.3.5 11.3.6
11.4.E.4
3.1 Consumers accepted for assessment by mental health services undergo a clinical risk assessment to evaluate harm to self or others. The assessment is timely, biopsychosocial and according to clinical best practice that is based on structured clinical judgement.
4. Evaluate the Risks 4.1 On the basis of the information gathered during the assessment, clinical risk is evaluated.
5. Treat the Risks (Management)
11.4.3 11.4.10 11.4.11
11.4.A.12 11.4.d.6 11.4.E.2 11.4.E.5 11.5.4 11.5.6 11.6.5
5.1 In managing risk, the immediate safety of consumers, carers and staff is prioritised.
5.2 A Clinical Assessment and Management (CRAM) plan is generated and incorporated within the overall management plan.
5.3 Consumers actively participate in CRAM Planning at the first appropriate opportunity.
5.4 families and carers actively participate in CRAM Planning within the limits of confidentiality.
5.5 The clinical risk is managed in the least restrictive manner possible, appropriate to the type and level of risk.
5.6 Risk management utilises appropriate pathways and specialised models of care for the consumer as far as possible.
6. Communicate and Consult
11.3.8 6.1 The CRAM Plan is communicated to those parties involved in managing the risk.
6.2 Recording and documentation of the CRAM Plan is standardised and clearly identifiable in the clinical notes and on Psychiatric Services On-line Information System (PSOLIS).
7. Monitor and Review 11.3.14 11.3.17 11.3.18 11.6.4
7.1 The clinical risk is re-assessed and the CRAM Plan is monitored, evaluated and reviewed.
7.2 Services utilise existing systems (e.g. Advanced Incident Management System (AIMS), Occupation Safety and Health (OSH)) that record incidents and near misses to inform the CRAM process.
7.3 Sentinel incidents and adverse events are considered a system responsibility, not an individual failure, and should be viewed as opportunities for improvement.
7.4 following an adverse event, sentinel or critical incident involving serious assault or abuse, injury or death, the restoration and maximisation of the well-being and mental health of all involved is a service priority.
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The following table outlines each of these standards against the Clinical Risk Management Process, along with:
The criteria for meeting each standard
The conditions and circumstances required to meet the criteria (including additional or pre-requisite processes and resources)
Particular factors that may challenge, or prevent, the criteria from being met
Recommended evaluation or audit methods.
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Policy and standards
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NM
Hs
stan
dard
Crit
eria
Cond
itio
ns t
o Fu
lfilli
ng t
he C
rite
ria
Chal
leng
es t
o Fu
lfilli
ng
the
Crit
eria
Eval
uati
on o
r A
udit
M
etho
d
1. Establish the Context
11.3.1, 11.3.15, 11.3.16, 11.4.E.1, 11.4.E.3, 11.4.E.6, 11.4.E.14
1.1
Clin
ical
ris
k as
sess
men
t an
d m
anag
emen
t in
m
enta
l hea
lth
serv
ices
mus
t be
le
gal,
eth
ical
and
ev
iden
ce-b
ased
.
Asse
ssm
ent
and
man
agem
ent
is
unde
rtak
en w
ithi
n th
e pa
ram
eter
s of
OSH
, th
e M
enta
l Hea
lth
Act,
the
N
atio
nal M
enta
l Hea
lth
Stan
dard
s, t
his
polic
y,
prof
essi
onal
cod
es o
f co
nduc
t an
d et
hics
and
ot
her
rele
vant
law
s.
Staf
f ha
ve a
cces
s to
OSH
tra
inin
g an
d po
licie
s, M
enta
l Hea
lth
Act
trai
ning
an
d co
pies
of
thei
r pr
ofes
sion
al c
odes
of
con
duct
.
The
phys
ical
env
iron
men
t is
saf
e an
d in
acc
orda
nce
wit
h re
leva
nt
legi
slat
ion,
gui
delin
es a
nd p
olic
ies.
Nil.
Iden
tific
atio
n of
m
anda
tory
tra
inin
g re
quir
emen
ts.
Perc
enta
ge o
f st
aff
trai
ned
in t
hese
are
as.
OSH
aud
it.
1.2
The
pra
ctic
e of
clin
ical
ris
k as
sess
men
t an
d m
anag
emen
t is
pe
rson
-cen
tred
and
pr
omot
es t
he d
igni
ty
of r
isk.
Asse
ssm
ent
and
man
agem
ent
of c
linic
al
risk
occ
urs
wit
hin
a ho
listi
c un
ders
tand
ing
of
the
pers
on t
hat:
• Is
cul
tura
lly
appr
opri
ate
to t
he
loca
l are
a an
d to
the
co
nsum
er a
nd c
arer
s
• Is
sen
siti
ve t
o is
sues
of
gend
er a
nd s
exua
lity
• Is
bas
ed o
n an
un
ders
tand
ing
of
the
cons
umer
’s
indi
vidu
al h
isto
ry a
nd
circ
umst
ance
s
• Ta
kes
into
acc
ount
th
eir
view
s an
d ne
eds,
ev
en w
here
the
ir
men
tal s
tate
s or
age
pr
eclu
des
cons
ent
to
trea
tmen
t.
Staf
f ca
n ac
cess
tra
inin
g in
are
as
rela
ted
to c
linic
al r
isk
asse
ssm
ent
and
man
agem
ent,
par
ticu
larl
y w
hen
wor
king
wit
h fa
ctor
s kn
own
to e
leva
te
risk
suc
h as
cul
tura
l fac
tors
, se
xual
ity
conc
erns
and
abu
se o
r tr
aum
a.
Serv
ices
are
str
uctu
red
alon
g po
pula
tion
dem
ogra
phic
s to
ens
ure
adeq
uate
ser
vice
pro
visi
on in
rel
atio
n to
mat
ters
of
equi
ty a
nd d
iver
sity
.
Avai
labi
lity
of in
terp
rete
r se
rvic
es.
fact
ors
and
reso
urce
s th
at p
reve
nt s
ervi
ces
bein
g es
tabl
ishe
d or
hav
ing
the
nece
ssar
y ca
paci
ty,
such
as
geog
raph
ic
loca
tion
, st
affin
g an
d in
fras
truc
ture
.
Iden
tific
atio
n of
m
anda
tory
tra
inin
g re
quir
emen
ts.
Perc
enta
ge o
f st
aff
trai
ned
in t
hese
are
as.
Popu
lati
on d
emog
raph
ics.
No Lon
ger A
pplica
ble - R
escin
ded 7
Octo
ber 2
020
Clinical Risk Assessment and Management in Western Australian Mental Health Services
14
NM
Hs
stan
dard
Crit
eria
Cond
itio
ns t
o Fu
lfilli
ng t
he C
rite
ria
Chal
leng
es t
o Fu
lfilli
ng
the
Crit
eria
Eval
uati
on o
r A
udit
M
etho
d1. Establish the Context
Cons
umer
s an
d ca
rers
are
as
sist
ed t
o un
ders
tand
th
e se
rvic
e’s
expe
ctat
ions
of
tre
atm
ent
and
beha
viou
r, in
clud
ing
the
proc
ess
of c
onta
inin
g ri
sk
in t
he e
vent
of
harm
to
self
or
othe
rs.
Info
rmat
ion
abou
t th
e se
rvic
e’s
expe
ctat
ions
and
pol
icie
s ar
e cl
earl
y vi
sibl
e, e
.g.
anti
-vio
lenc
e st
atem
ents
.
Cons
umer
s an
d ca
rers
are
pro
vide
d w
ith
info
rmat
ion
abou
t th
e se
ttin
g (i
nclu
ding
rig
hts
and
resp
onsi
bilit
ies
of c
onsu
mer
s, c
arer
s an
d st
aff)
an
d ar
e as
sist
ed t
o un
ders
tand
thi
s in
form
atio
n.
Trea
tmen
t pl
anni
ng in
clud
es A
dvan
ce
Stat
emen
ts –
Men
tal H
ealt
h.
Leve
l of
acui
ty o
f ill
ness
an
d un
ders
tand
ing
of
verb
al a
nd w
ritt
en
info
rmat
ion
prov
ided
.
Info
rmat
ion
is v
isib
le.
Cons
umer
and
car
er
surv
eys
and
audi
ts.
file
aud
it.
1.3
Clin
ical
ris
k as
sess
men
t an
d m
anag
emen
t is
a
shar
ed,
syst
emic
re
spon
sibi
lity,
un
derp
inne
d by
a
just
cul
ture
.
Men
tal h
ealt
h se
rvic
es
prom
ote
a m
ulti
-di
scip
linar
y te
am-b
ased
ap
proa
ch t
o de
cisi
on-
mak
ing
abou
t cl
inic
al r
isk
and
staf
f ar
e en
cour
aged
to
lear
n fr
om s
itua
tion
s.
Team
s us
e an
d fo
ster
pee
r an
d su
perv
isor
con
sult
atio
n in
de
cisi
on-m
akin
g ab
out
clin
ical
ris
k m
anag
emen
t, s
uch
as d
iscu
ssio
n of
ri
sk m
anag
emen
t fo
rmul
atio
ns a
nd
plan
s at
inta
ke a
nd r
evie
w.
Man
ager
s, t
eam
lead
ers
and/
or
clin
ical
sup
ervi
sors
hav
e an
‘op
en
door
’ po
licy,
and
are
dir
ectl
y an
d/or
in
dire
ctly
acc
essi
ble
to s
taff
at
shor
t no
tice
.
Staf
f ha
ve a
cces
s to
clin
ical
su
perv
isio
n, p
eer
disc
ussi
on a
nd/
or m
ento
ring
aro
und
clin
ical
ris
k m
anag
emen
t de
cisi
ons
as a
lter
nati
ve
sour
ces
of s
uppo
rt.
Vari
ous
prof
essi
ons
are
not
avai
labl
e or
ac
cess
ible
wit
hin
the
team
.
Reso
urce
s, t
rain
ing
or p
olic
ies
are
not
reas
onab
ly a
vaila
ble
or g
eogr
aphi
cally
ac
cess
ible
.
Perc
enta
ge o
f st
aff
acce
ssin
g su
perv
isio
n.
file
aud
it.
Cons
umer
par
tici
pati
on.
Snap
shot
of
staf
f pa
rtic
ipat
ing
in c
linic
al
inta
ke a
nd r
evie
w.
Serv
ice
polic
y.
Clin
ical
dut
y/on
-cal
l sy
stem
s.
Serv
ices
pro
vide
su
perv
isio
n in
acc
orda
nce
wit
h lo
cal p
olic
y an
d/or
th
e Cl
inic
al S
uper
visi
on
Fram
ewor
k.
No Lon
ger A
pplica
ble - R
escin
ded 7
Octo
ber 2
020
Policy and standards
15
NM
Hs
stan
dard
Crit
eria
Cond
itio
ns t
o Fu
lfilli
ng t
he C
rite
ria
Chal
leng
es t
o Fu
lfilli
ng
the
Crit
eria
Eval
uati
on o
r A
udit
M
etho
d
1. Establish the Context
1.4
Clin
ical
ris
k as
sess
men
t an
d m
anag
emen
t is
re
gard
ed a
s a
core
co
mpe
tenc
y fo
r pr
acti
ce.
Serv
ices
pro
vide
st
anda
rdis
ed t
rain
ing
and
annu
al u
pdat
es in
clin
ical
ri
sk a
sses
smen
t an
d m
anag
emen
t.
Trai
ning
mat
eria
ls a
re s
tand
ardi
sed
and
lear
ning
obj
ecti
ves
set
in
acco
rdan
ce w
ith
the
abov
e st
anda
rds
for
care
.
Serv
ices
act
ivel
y su
ppor
t st
aff
to a
cces
s th
e tr
aini
ng;
fund
ing
is q
uara
ntin
ed a
nd r
esou
rces
are
av
aila
ble
to t
rain
and
bac
kfill
staf
f.
Annu
al u
pdat
es m
ay b
e pr
ovid
ed in
a
vari
ety
of f
orm
ats
such
as
in-s
itu
disc
ussi
on,
shor
t re
fres
her
cour
ses
or
onlin
e vi
gnet
tes.
Serv
ices
sup
port
sta
ff t
o ac
cess
tr
aini
ng r
elat
ed t
o cl
inic
al r
isk
fact
ors,
par
ticu
larl
y cu
ltur
al
com
pete
ncy,
sex
ualit
y an
d ge
nder
di
vers
ity,
bro
ad s
uici
de p
reve
ntio
n tr
aini
ng a
nd a
ggre
ssio
n m
anag
emen
t tr
aini
ng t
hat
focu
ses
on d
e-es
cala
tion
.
Reso
urce
s, t
rain
ing
or p
olic
ies
are
not
reas
onab
ly a
vaila
ble
or g
eogr
aphi
cally
ac
cess
ible
.
Trai
ning
mat
eria
ls.
Trai
ning
eva
luat
ion.
Perc
enta
ge s
taff
tra
ined
.
Perf
orm
ance
de
velo
pmen
t do
cum
enta
tion
.
Staf
f de
velo
pmen
t da
taba
ses.
Iden
tific
atio
n of
m
anda
tory
tra
inin
g re
quir
emen
ts.
Serv
ices
com
mun
icat
e st
aff
role
s re
gard
ing
clin
ical
ris
k as
sess
men
t an
d m
anag
emen
t.
Info
rmat
ion
abou
t st
aff
role
s an
d re
spon
sibi
litie
s is
com
mun
icat
ed
thro
ugh
Job
des
crip
tion
for
ms
(Jd
fs)
and
indu
ctio
n pr
oces
ses.
Effic
ienc
y of
sta
ff
plan
ning
and
rev
iew
pr
oces
ses.
Revi
ew o
f Jo
b d
escr
ipti
on
form
s.
Serv
ice
polic
y, e
spec
ially
re
gard
ing
orie
ntat
ion.
No Lon
ger A
pplica
ble - R
escin
ded 7
Octo
ber 2
020
Clinical Risk Assessment and Management in Western Australian Mental Health Services
16
NM
Hs
stan
dard
Crit
eria
Cond
itio
ns t
o Fu
lfilli
ng t
he C
rite
ria
Chal
leng
es t
o Fu
lfilli
ng
the
Crit
eria
Eval
uati
on o
r A
udit
M
etho
d2. Identify the Risks
2.1
Clin
ical
ris
ks a
re
iden
tifie
d an
d th
eir
natu
re d
ocum
ente
d.
Clin
ical
ris
k ty
pes,
co
ncep
ts a
nd d
efini
tion
s ar
e un
ders
tood
by
staf
f.
Staf
f ha
ve a
cces
s to
tra
inin
g in
cl
inic
al r
isk
iden
tific
atio
n ap
prop
riat
e to
the
ir s
etti
ng.
Staf
f ca
n ac
cess
res
ourc
es a
nd t
ools
th
at s
uppo
rt t
he p
olic
y an
d/or
tr
aini
ng,
such
as
rela
ted
guid
elin
es.
Nil.
Perc
enta
ge s
taff
tra
ined
.
Clin
ical
ris
k is
iden
tifie
d an
d re
spon
ded
to t
hrou
gh
beha
viou
ral,
ver
bal o
r ph
ysic
al p
rese
ntat
ion,
co
llabo
rati
ve in
form
atio
n an
d ot
her
indi
cato
rs o
f cl
inic
al r
isk
wit
h se
nsit
ive
enqu
iry
and
ques
tion
ing.
Clin
ical
ris
k fa
ctor
s an
d pr
otec
tive
fa
ctor
s ar
e un
ders
tood
by
staf
f,
appr
opri
ate
to t
he s
etti
ng.
Nil.
file
aud
it.
Cons
umer
and
ca
rer
feed
back
and
in
volv
emen
t.
3. Analyse the Risks (Assessment)
11.2.12, 11.3.1, 11.3.2, 11.3.3, 11.3.5, 11.3.6, 11.4.E.4
3.1
Con
sum
ers
asse
ssed
by
men
tal h
ealt
h se
rvic
es u
nder
go
a cl
inic
al r
isk
asse
ssm
ent
to
eval
uate
har
m t
o se
lf
or o
ther
s.
Th
e as
sess
men
t is
tim
ely,
bi
opsy
chos
ocia
l and
ac
cord
ing
to c
linic
al
best
-pra
ctic
e, b
ased
on
str
uctu
red
clin
ical
ju
dgem
ent.
Clin
icia
ns u
nder
taki
ng
risk
ass
essm
ents
se
ek a
nd r
espo
nd t
o in
form
atio
n fr
om:
• T
he c
onsu
mer
• C
arer
s an
d/or
par
ents
• o
ther
rec
ords
(pa
st
men
tal h
ealt
h re
cord
s fr
om o
ther
hos
pita
ls,
dist
rict
s, o
r so
cial
se
rvic
es d
epar
tmen
ts
and
a hi
stor
y of
cri
min
al
offe
nces
[w
here
ap
plic
able
], r
efer
ral
lett
ers,
incl
udin
g PS
OLI
S)
• O
ther
pro
fess
iona
ls.
Sour
ces
are
avai
labl
e an
d re
ason
ably
ac
cess
ible
, e.
g. f
rom
ano
ther
hea
lth
serv
ice
or h
ospi
tal i
n Au
stra
lia.
Whe
re in
form
atio
n is
mis
sing
or
sour
ces
inac
cess
ible
, th
is is
not
ed
in t
he a
sses
smen
t.
Info
rmat
ion
cann
ot b
e re
ason
ably
acc
esse
d, e
.g.
reco
rds
from
ano
ther
co
untr
y.
Clin
ical
ris
k as
sess
men
ts
are
ofte
n no
t ea
sily
lo
cata
ble
in fi
les.
Cons
umer
s m
ay b
e un
able
or
unw
illin
g to
pa
rtic
ipat
e.
file
aud
it.
Cons
umer
and
ca
rer
feed
back
and
in
volv
emen
t.
No Lon
ger A
pplica
ble - R
escin
ded 7
Octo
ber 2
020
Policy and standards
17
NM
Hs
stan
dard
Crit
eria
Cond
itio
ns t
o Fu
lfilli
ng t
he C
rite
ria
Chal
leng
es t
o Fu
lfilli
ng
the
Crit
eria
Eval
uati
on o
r A
udit
M
etho
d
3. Analyse the Risks (Assessment)
Asse
ssm
ents
incl
ude
asse
ssin
g th
e sa
fety
of
othe
rs,
e.g.
vul
nera
ble
fam
ily a
nd s
taff
.
Adeq
uate
info
rmat
ion
is a
vaila
ble
to
mak
e th
e as
sess
men
t w
ith
rega
rd t
o vu
lner
able
fam
ily m
embe
rs a
nd s
taff
.
fam
ily c
an b
e co
ntac
ted
and
are
will
ing
to b
e in
terv
iew
ed w
ith
appr
opri
ate
cons
ent.
fact
ors
evid
ent
duri
ng
init
ial i
nfor
mat
ion
mak
e it
uns
afe
for
the
asse
ssm
ent
to p
roce
ed,
e.g.
pr
esen
ce o
f w
eapo
ns,
unsa
fe in
terv
iew
ing
envi
ronm
ent.
file
aud
it.
feed
back
fro
m a
ll st
akeh
olde
rs.
Asse
ssm
ents
of
susp
ecte
d ch
ild a
buse
or
neg
lect
fol
low
dep
artm
ent
of
Hea
lth
polic
y.
Nil.
file
aud
it.
Init
ial a
sses
smen
ts o
f ur
gent
ref
erra
ls s
houl
d oc
cur
wit
hin
best
-pr
acti
ce s
tand
ards
and
/or
com
men
ce w
ithi
n on
e ho
ur o
f in
itia
l co
ntac
t an
d no
n-ur
gent
in
itia
l ass
essm
ents
are
co
mm
ence
d w
ithi
n 24
ho
urs
of in
itia
l con
tact
.
Best
-pra
ctic
e is
defi
ned
for
sett
ings
, e.
g. E
mer
genc
y d
epar
tmen
ts.
Reso
urce
s, t
rain
ing
or p
olic
ies
are
not
reas
onab
ly a
vaila
ble
or g
eogr
aphi
cally
ac
cess
ible
.
Aust
rala
sian
Col
lege
of
Emer
genc
y M
edic
ine
(ACE
M)
Tria
ge
Benc
hmar
ks.
Serv
ice
polic
y an
d re
ferr
al p
athw
ays.
Asse
ssm
ents
are
un
dert
aken
:•
Whe
n a
cons
umer
is
adm
itte
d or
ass
esse
d fo
r th
e fir
st t
ime
• W
hen
a co
nsum
er
is d
isch
arge
d or
tr
ansf
erre
d•
At
clin
ical
tea
m
revi
ews
(eve
ry 3
m
onth
s) in
WA
men
tal
heal
th s
ervi
ces
• W
hen
ther
e ha
s be
en
a si
gnifi
cant
cha
nge
in t
he p
erso
n’s
stat
us,
e.g.
ser
ious
inci
dent
, co
ncer
n ab
out
curr
ent
inju
ries
, ch
ange
in
cir
cum
stan
ce o
r si
gnifi
cant
life
eve
nts
such
as
loss
.
Staf
f un
ders
tand
how
to
asse
ss c
linic
al
risk
.N
il.fi
le a
udit
.
No Lon
ger A
pplica
ble - R
escin
ded 7
Octo
ber 2
020
Clinical Risk Assessment and Management in Western Australian Mental Health Services
18
NM
Hs
stan
dard
Crit
eria
Cond
itio
ns t
o Fu
lfilli
ng t
he C
rite
ria
Chal
leng
es t
o Fu
lfilli
ng
the
Crit
eria
Eval
uati
on o
r A
udit
M
etho
d3. Analyse the Risks (Assessment)
Whe
re t
here
are
con
cern
s
abo
ut c
linic
al r
isk
in t
he
pre
sent
ing
hist
ory
or
ref
erri
ng in
form
atio
n,
and
the
con
sum
er a
nd/o
r
car
ers
refu
se a
ser
vice
’s
invo
lvem
ent,
alt
erna
tive
s
teps
to
man
age
the
risk
a
re t
aken
, e
.g.
refe
rral
b
ack
to r
efer
rer
and/
or
GP,
lett
er t
o co
nsum
er
and
/or
care
r w
ith
supp
ort
info
rmat
ion
and
cont
act
n
umbe
rs,
ongo
ing
supp
ort
t
o ca
rers
.
4. Evaluate the Risks
4.1
On
the
basi
s of
th
e in
form
atio
n ga
ther
ed d
urin
g th
e as
sess
men
t, c
linic
al
risk
is e
valu
ated
.
Risk
is r
ated
aga
inst
ac
cept
ed c
rite
ria.
The
crit
eria
ref
er t
o th
e lik
elih
ood
and
cons
eque
nces
of
the
risk
, an
d m
ay in
clud
e es
tim
ates
of
imm
edia
cy
or im
min
ence
.
Staf
f un
ders
tand
the
cri
teri
a an
d ca
n us
e th
e cr
iter
ia c
onsi
sten
tly.
Nil.
Serv
ice
polic
y an
d ex
plan
atio
ns o
f cr
iter
ia.
Risk
is f
orm
ulat
ed a
s th
e ba
sis
for
the
man
agem
ent
plan
.
Risk
for
mul
atio
n su
mm
aris
es a
nd
docu
men
ts t
he t
ypes
of
risk
s an
d to
w
hom
, w
hat
esca
late
s or
dec
reas
es
the
risk
, ho
w im
min
ent,
ser
ious
and
vo
lati
le t
he r
isk
is,
wha
t st
rate
gies
can
re
duce
the
ris
k an
d ho
w e
ffec
tive
the
m
anag
emen
t pl
an w
ill b
e.
Nil.
file
aud
it.
Cons
umer
car
er
invo
lvem
ent
is o
bvio
us
and
evid
ent.
Risk
for
mul
atio
n an
d/or
man
agem
ent
plan
con
nect
ed t
o th
e as
sess
men
t is
in
the
file
note
s. In
par
ticu
lar,
the
use
of
a ‘t
ick-
box’
che
cklis
t or
iden
tific
atio
n fo
rm is
acc
ompa
nied
by
prom
pts
or
a pr
ofor
ma
for
risk
for
mul
atio
n an
d m
anag
emen
t pl
an.
Nil.
file
aud
it.
No Lon
ger A
pplica
ble - R
escin
ded 7
Octo
ber 2
020
Policy and standards
19
NM
Hs
stan
dard
Crit
eria
Cond
itio
ns t
o Fu
lfilli
ng t
he C
rite
ria
Chal
leng
es t
o Fu
lfilli
ng
the
Crit
eria
Eval
uati
on o
r A
udit
M
etho
d
5. Treat the Risks (Management)
11.4.3, 11.4.10, 11.4.11, 11.4.A.12, 11.4.d.6, 11.4.E.2, 11.4.E.5, 11.5.4, 11.5.6, 11.6.5
5.1
In m
anag
ing
risk
, th
e im
med
iate
sa
fety
of
cons
umer
s,
care
rs a
nd s
taff
is
prio
riti
sed.
In t
he in
stan
ce o
f im
min
ent
harm
, al
l se
rvic
es e
nsur
e th
at
emer
genc
y pr
oced
ures
an
d re
spon
se c
odes
are
fo
llow
ed.
flow
char
ts a
nd g
uide
lines
exi
st f
or
acce
ssin
g em
erge
ncy
serv
ices
.
firs
t ai
d ki
ts a
re a
vaila
ble.
Staf
f un
ders
tand
how
to
acce
ss
emer
genc
y se
rvic
es.
Staf
f ar
e tr
aine
d ac
cord
ing
to s
ervi
ce
requ
irem
ents
in b
asic
life
sup
port
.
Nil.
Serv
ice
polic
y.
Perc
enta
ge s
taff
tra
ined
.
Risk
esc
alat
ion:
a) E
xtre
me
and
high
cl
inic
al r
isk
is s
ubje
ct
to t
eam
inpu
t, r
evie
w
and
cons
ulta
tion
.
Cons
ulta
tion
wit
h se
nior
clin
icia
ns/
med
ical
sta
ff a
bout
inst
ance
s of
ex
trem
e or
hig
h cl
inic
al r
isk
occu
rs
imm
edia
tely
.
Inst
ance
s of
ext
rem
e or
hig
h cl
inic
al
risk
are
pri
orit
ised
for
tea
m r
evie
w.
Reso
urce
s, t
rain
ing
or p
olic
ies
are
not
reas
onab
ly a
vaila
ble
or g
eogr
aphi
cally
ac
cess
ible
.
file
aud
it.
b) M
oder
ate
risk
is
man
aged
acc
ordi
ng
to a
sses
smen
t/
form
ulat
ion
of r
isk
and
avai
labi
lity
of c
linic
al
risk
man
agem
ent
cont
rols
.
Cont
rols
are
ava
ilabl
e to
the
clin
icia
n an
d se
rvic
e, s
uch
as b
eds,
car
er
supp
ort
and
rem
oval
of
mea
ns o
r op
port
unit
y to
har
m o
r be
har
med
.
Whe
re c
ontr
ols
may
not
be
avai
labl
e,
or w
here
clin
icia
ns c
anno
t m
anag
e a
com
pone
nt o
f th
e CR
AM P
lan,
cl
inic
ians
to
cons
ult
wit
h, a
nd m
ay
esca
late
man
agem
ent
to,
seni
or s
taff
.
Adeq
uate
con
trol
s su
ch
as b
eds
or c
arer
sup
port
ar
e no
t av
aila
ble.
The
unav
aila
bilit
y of
co
ntro
ls s
houl
d be
co
nsid
ered
and
not
ed
in t
he a
sses
smen
t an
d fo
rmul
atio
n of
ris
k.
file
aud
it.
c) L
ow r
isk
is s
ubje
ct t
o re
gula
r re
view
ad-
hoc,
as
per
the
Mon
itor
ing
and
Revi
ew S
tand
ard
(7.1
).
Staf
f un
ders
tand
the
dyn
amic
nat
ure
of c
linic
al r
isk
and
are
able
to
mon
itor
ac
cord
ingl
y.
Cons
umer
is u
ntra
ceab
le
or n
ew in
form
atio
n ab
out
them
is u
nava
ilabl
e.
No Lon
ger A
pplica
ble - R
escin
ded 7
Octo
ber 2
020
Clinical Risk Assessment and Management in Western Australian Mental Health Services
20
NM
Hs
stan
dard
Crit
eria
Cond
itio
ns t
o Fu
lfilli
ng t
he C
rite
ria
Chal
leng
es t
o Fu
lfilli
ng
the
Crit
eria
Eval
uati
on o
r A
udit
M
etho
d5. Treat the Risks (Management)
Cons
umer
s ar
e pr
ovid
ed
wit
h a
safe
, su
perv
ised
en
viro
nmen
t.
Care
env
iron
men
ts a
nd s
taffi
ng le
vels
re
flec
t th
e de
gree
of
man
agem
ent
requ
ired
to
cont
ain
the
risk
.
Care
rs/f
amily
and
oth
er s
ocia
l su
ppor
ts a
re w
illin
g an
d ab
le t
o pr
ovid
e a
supe
rvis
ed e
nvir
onm
ent
whe
re a
ppro
pria
te.
Beds
and
sta
ff a
re n
ot
avai
labl
e; in
crea
sed
fam
ily s
uper
visi
on a
nd
supp
ort
is r
equi
red.
file
aud
it.
Staf
f ar
e ab
le t
o de
-es
cala
te o
r co
ntai
n vi
olen
t in
cide
nts.
Staf
f at
tend
de-
esca
lati
on t
rain
ing
that
incl
udes
rec
ogni
tion
of
earl
y w
arni
ng s
igns
of
ange
r/ag
gres
sion
, an
tece
dent
s an
d ri
sk f
acto
rs.
fact
ors
mak
e th
e si
tuat
ion
unsa
fe f
or
clin
icia
ns t
o pr
ocee
d w
ith
man
agin
g th
e ri
sk,
e.g.
pre
senc
e of
w
eapo
ns,
unsa
fe p
hysi
cal
envi
ronm
ent,
lack
of
back
-up
staf
f.
Perc
enta
ge s
taff
tra
ined
.
Adva
nce
Stat
emen
ts
– M
enta
l Hea
lth
are
take
n in
to a
ccou
nt w
hen
man
agin
g im
med
iate
or
imm
inen
t ri
sk.
Staf
f an
d co
nsum
ers
are
able
and
ha
ve t
he o
ppor
tuni
ty t
o de
velo
p Ad
vanc
e St
atem
ents
– M
enta
l Hea
lth.
Nil.
file
aud
it.
The
use
of r
estr
aint
and
se
clus
ion
are
redu
ced,
an
d w
here
pos
sibl
e,
elim
inat
ed.
Secl
usio
n is
onl
y us
ed f
or t
he
prot
ecti
on a
nd w
ell-
bein
g of
the
co
nsum
er a
nd/o
r ot
hers
and
for
the
le
ast
amou
nt o
f ti
me
poss
ible
.
Phys
ical
inte
rven
tion
/res
trai
nt is
onl
y co
nsid
ered
onc
e al
l de-
esca
lati
on
tech
niqu
es h
ave
faile
d.
Nil.
Offi
ce o
f th
e Ch
ief
Psyc
hiat
rist
, Co
unci
l of
Offi
cial
Vis
itor
s an
d M
enta
l Hea
lth
Revi
ew
Boar
d re
port
ing.
No Lon
ger A
pplica
ble - R
escin
ded 7
Octo
ber 2
020
Policy and standards
21
NM
Hs
stan
dard
Crit
eria
Cond
itio
ns t
o Fu
lfilli
ng t
he C
rite
ria
Chal
leng
es t
o Fu
lfilli
ng
the
Crit
eria
Eval
uati
on o
r A
udit
M
etho
d
5. Treat the Risks (Management)
The
circ
umst
ance
s an
d m
anag
emen
t of
inst
ance
s of
res
trai
nt a
nd s
eclu
sion
ar
e re
view
ed b
y th
e se
rvic
e an
d,
whe
re p
ossi
ble,
the
tea
m.
Rest
rain
t an
d se
clus
ion
are
in a
ccor
danc
e w
ith
Gui
deli
nes:
The
man
agem
ent
of d
istu
rbed
/vio
lent
beh
avio
ur i
n in
pati
ent
psyc
hiat
ric
sett
ings
(20
06).
Cons
umer
s an
d ca
rers
und
erst
and
that
se
clus
ion
and
rest
rain
t m
ay b
e us
ed
to p
rote
ct t
heir
wel
l-be
ing
and
that
of
oth
ers.
follo
win
g an
inst
ance
of
rest
rain
t or
se
clus
ion,
con
sum
ers
and
invo
lved
ot
hers
are
deb
rief
ed a
nd h
ave
an
oppo
rtun
ity
for
feed
back
; th
eir
Adva
nce
Stat
emen
ts –
Men
tal H
ealt
h ar
e re
view
ed.
5.2
A C
RAM
Pla
n is
ge
nera
ted
and
inco
rpor
ated
w
ithi
n th
e ov
eral
l m
anag
emen
t pl
an.
The
CRAM
Pla
n is
fo
rmul
ated
fro
m t
he r
isk
info
rmat
ion
obta
ined
in
the
asse
ssm
ent.
Cons
umer
s as
sess
ed b
y m
enta
l hea
lth
serv
ices
und
ergo
a c
linic
al r
isk
asse
ssm
ent
to e
valu
ate
harm
to
self
or
oth
ers.
Nil.
file
aud
it.
The
CRAM
Pla
n is
cle
arly
id
enti
fiabl
e w
ithi
n th
e m
anag
emen
t pl
an.
The
CRAM
Pla
n m
ust
dem
onst
rate
a
biop
sych
osoc
ial a
sses
smen
t th
at
deta
ils t
hose
sta
tic
(his
tori
cal)
and
dy
nam
ic (
clin
ical
) fa
ctor
s af
fect
ing
clin
ical
ris
k, in
clud
ing
• R
isk
and
prot
ecti
ve f
acto
rs,
trig
gers
an
d ea
rly
war
ning
sig
ns
• M
enta
l sta
te.
Nil.
file
aud
it.
No Lon
ger A
pplica
ble - R
escin
ded 7
Octo
ber 2
020
Clinical Risk Assessment and Management in Western Australian Mental Health Services
22
NM
Hs
stan
dard
Crit
eria
Cond
itio
ns t
o Fu
lfilli
ng t
he C
rite
ria
Chal
leng
es t
o Fu
lfilli
ng
the
Crit
eria
Eval
uati
on o
r A
udit
M
etho
d5. Treat the Risks (Management)
5.3
Con
sum
ers
acti
vely
pa
rtic
ipat
e in
CRA
M
Plan
ning
at
the
first
app
ropr
iate
op
port
unit
y.
Adva
nce
Stat
emen
ts
– M
enta
l Hea
lth
are
dete
rmin
ed w
ith
the
cons
umer
to
asce
rtai
n th
e m
ost
appr
opri
ate
step
s fo
r sa
fety
.
Adva
nce
Stat
emen
ts –
Men
tal H
ealt
h ar
e de
velo
ped
duri
ng p
erio
ds w
hen
the
clin
ical
ris
k is
mod
erat
e to
low
; ph
ysic
al s
afet
y is
not
an
imm
edia
te
prio
rity
and
the
con
sum
er is
wel
l en
ough
to
part
icip
ate.
Cons
umer
s ar
e ab
le t
o co
nsen
t to
tre
atm
ent
and
part
icip
ate
in
deve
lopi
ng t
heir
Adv
ance
Sta
tem
ents
–
Men
tal H
ealt
h.
The
init
ial a
sses
smen
t oc
curs
in c
risi
s; s
afet
y an
d su
perv
isio
n is
pr
iori
tise
d fo
r a
new
co
nsum
er c
omin
g in
to t
he
serv
ice.
Safe
ty is
sues
may
pr
eclu
de s
ome
part
s of
th
e m
anag
emen
t pl
ans
bein
g is
sued
or
disc
usse
d w
ith
cons
umer
s.
doc
umen
ted
evid
ence
of
cons
umer
par
tici
pati
on –
si
gned
file
cop
y of
ove
rall
man
agem
ent
plan
and
Ad
vanc
e St
atem
ents
–
Men
tal H
ealt
h.
Cons
umer
sat
isfa
ctio
n su
rvey
.
Cons
umer
s ar
e m
ade
awar
e of
pos
sibl
e in
terv
enti
ons
the
serv
ice
may
und
erta
ke t
o pr
otec
t th
eir
own
safe
ty a
nd t
hat
of o
ther
s.
Cons
umer
s ar
e ab
le t
o un
ders
tand
tr
eatm
ent
opti
ons.
Info
rmat
ion
is t
o be
pro
vide
d in
man
y fo
rmat
s -
verb
al a
nd w
ritt
en.
Cons
umer
s ar
e un
able
to
unde
rsta
nd t
reat
men
t op
tion
s or
pro
cess
es
and
requ
ire
a pr
oxy
or
guar
dian
.
Lack
of
awar
enes
s of
ad
voca
cy s
ervi
ces.
file
aud
it.
Serv
ice
polic
y.
Care
r/co
nsum
er s
urve
y
or in
terv
iew
.
No Lon
ger A
pplica
ble - R
escin
ded 7
Octo
ber 2
020
Policy and standards
23
NM
Hs
stan
dard
Crit
eria
Cond
itio
ns t
o Fu
lfilli
ng t
he C
rite
ria
Chal
leng
es t
o Fu
lfilli
ng
the
Crit
eria
Eval
uati
on o
r A
udit
M
etho
d
5. Treat the Risks (Management)
5.4
fam
ilies
and
car
ers
acti
vely
par
tici
pate
in
CRA
M P
lann
ing,
w
ithi
n th
e lim
its
of
confi
dent
ialit
y.
Care
rs,
pare
nts
or
prim
ary
care
give
rs a
re:
• M
ade
awar
e of
cl
inic
al r
isks
and
the
im
min
ence
/sev
erit
y of
th
at r
isk
and
poss
ible
in
terv
enti
ons
the
serv
ice
may
und
erta
ke
• E
duca
ted
and
inst
ruct
ed a
bout
re
mov
ing
mea
ns o
r m
etho
ds o
f ha
rm
• P
rovi
ded
wit
h in
form
atio
n ab
out
secu
ring
saf
ety
for
them
selv
es a
nd t
heir
fa
mily
mem
ber.
Care
rs,
pare
nts
or p
rim
ary
care
give
rs
are
acce
ssib
le,
able
and
will
ing
to
be e
ngag
ed in
, an
d im
plem
ent,
the
m
anag
emen
t pl
an w
ith
the
serv
ice
and
case
man
ager
.
Care
rs,
pare
nts
or p
rim
ary
care
give
rs
have
sup
port
, gi
ven
the
stre
ss
asso
ciat
ed w
ith
thei
r re
spon
sibi
litie
s.
Iden
tifie
d or
nom
inat
ed c
arer
s,
pare
nts
or p
rim
ary
care
give
rs h
ave
know
ledg
e of
and
are
pro
vide
d w
ith
a co
py o
f th
e sa
fety
pla
n or
Ad
vanc
e St
atem
ents
– M
enta
l Hea
lth.
(S
ee C
omm
unic
atin
g w
ith
Care
rs
and
Fam
ilie
s (O
ffice
of
the
Chie
f Ps
ychi
atri
st,
2007
)).
The
invo
lvem
ent
of c
arer
s, p
aren
ts o
r pr
imar
y ca
regi
vers
is d
eter
min
ed b
y co
nsid
erin
g th
e co
nsum
er’s
rig
ht t
o co
nfide
ntia
lity,
the
rig
ht t
o re
ceiv
e a
reas
onab
le s
tand
ard
of c
are,
and
chi
ld
prot
ecti
on is
sues
.
The
beha
viou
r of
the
pa
rent
or
prim
ary
care
give
r or
fam
ily
circ
umst
ance
s pl
aces
the
co
nsum
er a
t ri
sk.
Afte
r ne
goti
atio
n an
d w
ith
due
cons
ider
atio
n to
the
ir m
enta
l sta
te,
adul
t co
nsum
ers
refu
se t
o al
low
the
ir f
amily
to
be
cont
acte
d. (
See
Con
sent
to
Tre
atm
ent
Poli
cy f
or
the
Wes
tern
Aus
tral
ian
Hea
lth
Syst
em (
Offi
ce o
f Sa
fety
& Q
ualit
y, 2
006)
).
The
beha
viou
r of
the
pa
rent
or
prim
ary
care
give
r or
fam
ily
circ
umst
ance
s pl
aces
the
co
nsum
er a
t ri
sk.
Care
rs,
pare
nts
or
prim
ary
care
give
rs a
re
able
to
prov
ide
feed
back
to
the
cas
e m
anag
er
abou
t ch
ange
s in
ris
k.
Care
rs,
pare
nts
or p
rim
ary
care
give
rs
unde
rsta
nd h
ow t
o ac
cess
the
ser
vice
to
dis
cuss
clin
ical
ris
k is
sues
.
Care
rs,
pare
nts
or
prim
ary
care
give
rs a
re
dise
ngag
ed o
r no
t ab
le t
o be
con
tact
ed.
file
aud
it.
Care
r su
rvey
or
inte
rvie
w.
Whe
re t
he c
onsu
mer
re
fuse
s tr
eatm
ent
or is
no
t ab
le t
o be
eng
aged
, th
e m
anag
emen
t an
d co
ntai
nmen
t of
ris
k oc
curs
thr
ough
sup
port
ing
the
fam
ily o
r ca
rers
as
far
as p
ossi
ble.
Care
rs a
re w
illin
g to
man
age
the
risk
w
ith
the
supp
ort
of t
he s
ervi
ce.
Care
rs,
pare
nts
or
prim
ary
care
give
rs a
re
dise
ngag
ed o
r no
t ab
le t
o be
con
tact
ed.
file
aud
it.
Care
r su
rvey
or
inte
rvie
w.
No Lon
ger A
pplica
ble - R
escin
ded 7
Octo
ber 2
020
Clinical Risk Assessment and Management in Western Australian Mental Health Services
24
NM
Hs
stan
dard
Crit
eria
Cond
itio
ns t
o Fu
lfilli
ng t
he C
rite
ria
Chal
leng
es t
o Fu
lfilli
ng
the
Crit
eria
Eval
uati
on o
r A
udit
M
etho
d5. Treat the Risks (Management)
5.5
The
clin
ical
ris
k is
m
anag
ed in
the
leas
t re
stri
ctiv
e m
anne
r po
ssib
le,
appr
opri
ate
to t
he t
ype
and
leve
l of
ris
k.
The
CRAM
Pla
n sh
ows
cons
ider
atio
n of
leas
t re
stri
ctiv
e st
rate
gies
, an
d m
ay in
clud
e a
rang
e of
car
e se
ttin
gs a
nd
stra
tegi
es s
uch
as:
• U
sing
Adv
ance
St
atem
ents
– M
enta
l H
ealt
h
• In
crea
sing
sup
ervi
sion
an
d re
duci
ng
oppo
rtun
itie
s fo
r ha
rm
• V
olun
tary
ho
spit
alis
atio
n.
Hos
pita
lisat
ion
may
pr
ovid
e th
e m
ost
appr
opri
ate
envi
ronm
ent
for
the
indi
vidu
al w
ith
cons
ider
atio
n to
ris
k fr
om
othe
rs,
absc
ondi
ng,
self
-ha
rm a
nd h
arm
to
othe
rs.
This
may
incl
ude:
• T
he u
se o
f ob
serv
atio
n an
d pr
oxim
ity
to t
he
nurs
ing
stat
ion
• M
anag
emen
t in
low
st
imul
us o
r hi
gh
depe
nden
cy a
rea
• U
se o
f Co
mm
unit
y Tr
eatm
ent
Ord
ers
unde
r th
e M
enta
l H
ealt
h A
ct 1
996
(WA
).
Ther
e is
a s
afe,
leas
t re
stri
ctiv
e ca
re
sett
ing
avai
labl
e.
Care
rs,
pare
nts
or p
rim
ary
care
give
rs
have
the
cap
acit
y an
d w
illin
gnes
s to
m
anag
e th
e ri
sk in
the
sho
rt-t
erm
.
Cons
umer
s ar
e ab
le t
o co
nsen
t to
tre
atm
ent
and
part
icip
ate
in
deve
lopi
ng t
heir
Adv
ance
Sta
tem
ents
–
Men
tal H
ealt
h
It is
saf
e fo
r th
e cl
inic
ian
to
imm
edia
tely
inte
rven
e.
Staf
f ha
ve t
rain
ing
in a
ppro
pria
te
man
agem
ent
stra
tegi
es,
incl
udin
g de
-es
cala
tion
and
con
flic
t re
solu
tion
.
Appr
opri
ate
staf
fing
num
bers
are
pr
ovid
ed c
ondu
cive
to
the
leve
l of
nurs
ing
obse
rvat
ion
requ
ired
.
Phys
ical
env
iron
men
t is
sec
ure,
in
clud
ing
colla
psib
le li
gatu
re p
oint
s in
ro
om o
r sh
ower
s, r
estr
icte
d ac
cess
to
nurs
ing
stat
ion,
line
of
sigh
t, r
emov
al
of p
oten
tial
ly h
arm
ful o
bjec
ts o
n ad
mis
sion
.
Cons
umer
s re
quir
ing
1:1
spec
ialli
ng
are
not
left
in t
he c
are
of r
elat
ives
, fr
iend
s or
unt
rain
ed s
taff
.
Any
rest
rain
t, s
eclu
sion
and
se
dati
on p
ract
ices
are
und
erta
ken
in
acco
rdan
ce w
ith
the
Men
tal
Hea
lth
Act
199
6 (W
A).
Inco
rpor
ate
the
Gui
deli
nes:
for
the
man
agem
ent
of d
istu
rbed
/vio
lent
beh
avio
ur i
n in
pati
ent
psyc
hiat
ric
sett
ings
(20
06).
The
risk
is e
xtre
me
and
requ
ires
invo
lunt
ary
hosp
ital
isat
ion,
incl
udin
g de
teri
orat
ing
men
tal
stat
e, u
nder
the
Men
tal
Hea
lth
Act
199
6 (W
A).
Oth
er f
acto
rs m
ake
it
unsa
fe f
or t
he c
linic
ian
to c
onti
nue
trea
ting
th
e ri
sk,
e.g.
phy
sica
l en
viro
nmen
t, la
ck o
f ba
ck-u
p st
aff,
pre
senc
e of
wea
pons
.
The
clin
ical
ris
k is
ill
egal
or
invo
lves
ill
egal
act
ivit
y th
at m
ay
put
othe
rs a
t ri
sk a
nd
requ
ires
rep
orti
ng t
o th
e ap
prop
riat
e au
thor
ity.
file
aud
it.
OSH
aud
it.
Serv
ice-
leve
l pol
icy.
AIM
S re
port
ing.
Offi
ce o
f Ch
ief
Psyc
hiat
rist
s (O
CP),
Co
unci
l of
Offi
cial
Vis
itor
s (C
OV)
and
Men
tal H
ealt
h Re
view
Boa
rd (
MN
RB)
repo
rtin
g.
Serv
ice
audi
ts.
Cons
umer
sat
isfa
ctio
n su
rvey
.
No Lon
ger A
pplica
ble - R
escin
ded 7
Octo
ber 2
020
Policy and standards
25
NM
Hs
stan
dard
Crit
eria
Cond
itio
ns t
o Fu
lfilli
ng t
he C
rite
ria
Chal
leng
es t
o Fu
lfilli
ng
the
Crit
eria
Eval
uati
on o
r A
udit
M
etho
d
5.6
Clin
ical
ris
k m
anag
emen
t ut
ilise
s ap
prop
riat
e pa
thw
ays
and
spec
ialis
ed
mod
els
of c
are
for
the
cons
umer
as
far
as p
ossi
ble.
Atte
mpt
s ar
e m
ade
to
refe
r an
d m
aint
ain
wit
hin
the
cons
umer
’s a
rea
and
appr
opri
ate
to t
heir
age
.
Appr
opri
ate
and
spec
ialis
ed r
esou
rces
an
d se
rvic
es a
re a
vaila
ble.
No
appr
opri
ate
serv
ices
av
aila
ble
at t
hat
tim
e.Ex
cept
ion
repo
rtin
g.
file
aud
it.
6. Communicate and Consult
11.3.8
6.1
The
CRA
M P
lan
is c
omm
unic
ated
to
tho
se p
arti
es
invo
lved
in m
anag
ing
the
risk
.
The
cons
umer
’s r
ight
to
con
fiden
tial
ity
is
prot
ecte
d.
Ther
efor
e in
form
atio
n ca
n be
rel
ease
d w
here
co
nsen
t to
rel
ease
in
form
atio
n is
obt
aine
d.
faili
ng t
his,
info
rmat
ion
cann
ot b
e re
leas
ed
unle
ss:
• T
he c
linic
ian
is le
gally
di
rect
ed t
o di
sclo
se
info
rmat
ion,
e.g
. by
su
bpoe
na o
r w
arra
nt
to p
rodu
ce m
edic
al
reco
rds
• T
here
is a
n im
min
ent
thre
at o
f ha
rm t
o se
lf o
r ot
hers
and
in
form
atio
n is
rel
ease
d in
acc
orda
nce
wit
h lo
cal p
olic
ies.
Staf
f un
ders
tand
how
to
com
mun
icat
e ab
out
risk
, ta
king
into
acc
ount
:
• T
he li
mit
atio
ns o
f co
nfide
ntia
lity
and
taki
ng in
to a
ccou
nt
Com
mun
icat
ing
wit
h Ca
rers
and
Fa
mil
ies,
(O
ffice
of
the
Chie
f Ps
ychi
atri
st,
2007
);
• T
heir
dut
y to
pro
vide
a r
easo
nabl
e st
anda
rd o
f ca
re
• In
form
ed c
onse
nt
• T
he M
enta
l H
ealt
h A
ct 1
996
(WA
).
Safe
ty is
sues
may
pr
eclu
de s
ome
part
s of
th
e m
anag
emen
t pl
an
bein
g is
sued
or
disc
usse
d w
ith
cons
umer
s.
Prot
ecti
on o
f th
ird
part
ies.
Evid
ence
of
cons
ent
on
file.
NM
Hs
stan
dard
Crit
eria
Cond
itio
ns t
o Fu
lfilli
ng t
he C
rite
ria
Chal
leng
es t
o Fu
lfilli
ng
the
Crit
eria
Eval
uati
on o
r A
udit
M
etho
d
5. Treat the Risks (Management)
5.5
The
clin
ical
ris
k is
m
anag
ed in
the
leas
t re
stri
ctiv
e m
anne
r po
ssib
le,
appr
opri
ate
to t
he t
ype
and
leve
l of
ris
k.
The
CRAM
Pla
n sh
ows
cons
ider
atio
n of
leas
t re
stri
ctiv
e st
rate
gies
, an
d m
ay in
clud
e a
rang
e of
car
e se
ttin
gs a
nd
stra
tegi
es s
uch
as:
• U
sing
Adv
ance
St
atem
ents
– M
enta
l H
ealt
h
• In
crea
sing
sup
ervi
sion
an
d re
duci
ng
oppo
rtun
itie
s fo
r ha
rm
• V
olun
tary
ho
spit
alis
atio
n.
Hos
pita
lisat
ion
may
pr
ovid
e th
e m
ost
appr
opri
ate
envi
ronm
ent
for
the
indi
vidu
al w
ith
cons
ider
atio
n to
ris
k fr
om
othe
rs,
absc
ondi
ng,
self
-ha
rm a
nd h
arm
to
othe
rs.
This
may
incl
ude:
• T
he u
se o
f ob
serv
atio
n an
d pr
oxim
ity
to t
he
nurs
ing
stat
ion
• M
anag
emen
t in
low
st
imul
us o
r hi
gh
depe
nden
cy a
rea
• U
se o
f Co
mm
unit
y Tr
eatm
ent
Ord
ers
unde
r th
e M
enta
l H
ealt
h A
ct 1
996
(WA
).
Ther
e is
a s
afe,
leas
t re
stri
ctiv
e ca
re
sett
ing
avai
labl
e.
Care
rs,
pare
nts
or p
rim
ary
care
give
rs
have
the
cap
acit
y an
d w
illin
gnes
s to
m
anag
e th
e ri
sk in
the
sho
rt-t
erm
.
Cons
umer
s ar
e ab
le t
o co
nsen
t to
tre
atm
ent
and
part
icip
ate
in
deve
lopi
ng t
heir
Adv
ance
Sta
tem
ents
–
Men
tal H
ealt
h
It is
saf
e fo
r th
e cl
inic
ian
to
imm
edia
tely
inte
rven
e.
Staf
f ha
ve t
rain
ing
in a
ppro
pria
te
man
agem
ent
stra
tegi
es,
incl
udin
g de
-es
cala
tion
and
con
flic
t re
solu
tion
.
Appr
opri
ate
staf
fing
num
bers
are
pr
ovid
ed c
ondu
cive
to
the
leve
l of
nurs
ing
obse
rvat
ion
requ
ired
.
Phys
ical
env
iron
men
t is
sec
ure,
in
clud
ing
colla
psib
le li
gatu
re p
oint
s in
ro
om o
r sh
ower
s, r
estr
icte
d ac
cess
to
nurs
ing
stat
ion,
line
of
sigh
t, r
emov
al
of p
oten
tial
ly h
arm
ful o
bjec
ts o
n ad
mis
sion
.
Cons
umer
s re
quir
ing
1:1
spec
ialli
ng
are
not
left
in t
he c
are
of r
elat
ives
, fr
iend
s or
unt
rain
ed s
taff
.
Any
rest
rain
t, s
eclu
sion
and
se
dati
on p
ract
ices
are
und
erta
ken
in
acco
rdan
ce w
ith
the
Men
tal
Hea
lth
Act
199
6 (W
A).
Inco
rpor
ate
the
Gui
deli
nes:
for
the
man
agem
ent
of d
istu
rbed
/vio
lent
beh
avio
ur i
n in
pati
ent
psyc
hiat
ric
sett
ings
(20
06).
The
risk
is e
xtre
me
and
requ
ires
invo
lunt
ary
hosp
ital
isat
ion,
incl
udin
g de
teri
orat
ing
men
tal
stat
e, u
nder
the
Men
tal
Hea
lth
Act
199
6 (W
A).
Oth
er f
acto
rs m
ake
it
unsa
fe f
or t
he c
linic
ian
to c
onti
nue
trea
ting
th
e ri
sk,
e.g.
phy
sica
l en
viro
nmen
t, la
ck o
f ba
ck-u
p st
aff,
pre
senc
e of
wea
pons
.
The
clin
ical
ris
k is
ill
egal
or
invo
lves
ill
egal
act
ivit
y th
at m
ay
put
othe
rs a
t ri
sk a
nd
requ
ires
rep
orti
ng t
o th
e ap
prop
riat
e au
thor
ity.
file
aud
it.
OSH
aud
it.
Serv
ice-
leve
l pol
icy.
AIM
S re
port
ing.
Offi
ce o
f Ch
ief
Psyc
hiat
rist
s (O
CP),
Co
unci
l of
Offi
cial
Vis
itor
s (C
OV)
and
Men
tal H
ealt
h Re
view
Boa
rd (
MN
RB)
repo
rtin
g.
Serv
ice
audi
ts.
Cons
umer
sat
isfa
ctio
n su
rvey
.
No Lon
ger A
pplica
ble - R
escin
ded 7
Octo
ber 2
020
Clinical Risk Assessment and Management in Western Australian Mental Health Services
26
NM
Hs
stan
dard
Crit
eria
Cond
itio
ns t
o Fu
lfilli
ng t
he C
rite
ria
Chal
leng
es t
o Fu
lfilli
ng
the
Crit
eria
Eval
uati
on o
r A
udit
M
etho
d6. Communicate and Consult
Com
mun
icat
ion
of
rele
vant
clin
ical
in
form
atio
n, in
clud
ing
the
CRAM
Pla
n sh
ould
oc
cur
wit
hin
best
-pr
acti
ce s
tand
ards
and
ti
mef
ram
es.
Best
-pra
ctic
e is
defi
ned
acco
rdin
g to
urg
ency
and
clin
ical
nee
d.
deg
rees
of
urge
ncy
can
rang
e fr
om
imm
edia
te (
wit
hin
the
hour
) to
urg
ent
(ove
rnig
ht)
to r
outi
ne (
two
to t
hree
da
ys).
dis
char
ge in
form
atio
n is
sen
t to
re
leva
nt t
reat
ing
part
ies
prio
r to
di
scha
rge.
Reso
urce
s, t
rain
ing
or p
olic
ies
are
not
reas
onab
ly a
vaila
ble
or g
eogr
aphi
cally
ac
cess
ible
.
ACEM
Tri
age
Benc
hmar
ks.
Serv
ice
polic
y an
d re
ferr
al p
athw
ays.
Risk
is c
omm
unic
ated
an
d ex
plai
ned
(as
far
as
poss
ible
in t
he p
rese
nce
of t
he c
onsu
mer
),
incl
udin
g:
• In
form
atio
n on
the
cu
rren
t m
enta
l sta
te
of t
he c
onsu
mer
, m
edic
atio
n,
prec
ipit
ants
of
the
clin
ical
ris
k an
d th
e de
gree
of
risk
• N
otin
g a
cont
act
pers
on
or o
rgan
isat
ion
for
furt
her
urge
nt s
uppo
rt
on a
24
hour
bas
is
• A
dvis
ing
abou
t th
e le
vel o
f su
perv
isio
n th
at t
he c
onsu
mer
re
quir
es.
The
care
r is
abl
e to
res
pond
to
chan
ges
in t
he s
tate
of
the
cons
umer
.
The
care
r ha
s kn
owle
dge
of,
and
is
prov
ided
wit
h a
copy
of,
the
saf
ety
plan
and
/or
Adva
nce
Stat
emen
ts
– M
enta
l Hea
lth,
sho
uld
furt
her
dete
rior
atio
n oc
cur.
The
care
r is
aw
are
of t
he p
ossi
bilit
y of
incr
ease
d/ad
diti
onal
res
tric
tive
tr
eatm
ent
and
invo
lunt
ary
trea
tmen
t an
d th
at t
he p
olic
e m
ay b
e ca
lled
in
emer
genc
ies.
Care
rs,
pare
nts
or
prim
ary
care
give
rs a
re
dise
ngag
ed o
r no
t ab
le t
o be
con
tact
ed.
Care
r do
es n
ot h
ave
the
capa
city
or
abili
ty t
o re
spon
d.
Invo
lvem
ent
may
co
mpr
omis
e th
e ca
rer’
s w
elfa
re.
Cons
umer
’s m
enta
l st
ate
prec
lude
s ac
tive
pa
rtic
ipat
ion
and/
or m
ay
com
prom
ise
the
proc
ess
of c
omm
unic
atio
n w
ith
care
rs.
Ther
e is
a s
igni
fican
t an
d ra
pid
chan
ge in
ci
rcum
stan
ces.
file
aud
it.
Cons
umer
and
car
er
surv
ey.
No Lon
ger A
pplica
ble - R
escin
ded 7
Octo
ber 2
020
Policy and standards
27
NM
Hs
stan
dard
Crit
eria
Cond
itio
ns t
o Fu
lfilli
ng t
he C
rite
ria
Chal
leng
es t
o Fu
lfilli
ng
the
Crit
eria
Eval
uati
on o
r A
udit
M
etho
d
6. Communicate and Consult
Risk
is c
omm
unic
ated
to
othe
r tr
eati
ng p
arti
es
and
refe
rrer
s, in
clud
ing
Gen
eral
Pra
ctit
ione
rs
(GPs
), w
ho a
re a
ctiv
ely
invo
lved
in m
anag
emen
t.
Copi
es o
f th
e CR
AM P
lan
are
prov
ided
to
oth
er t
reat
ing
part
ies
and
refe
rrer
s, m
eeti
ng t
he r
equi
rem
ents
of
the
con
sum
er’s
rig
ht t
o co
nfide
ntia
lity,
the
dut
y to
pro
vide
a
reas
onab
le s
tand
ard
of c
are
and
child
pr
otec
tion
issu
es.
Info
rmat
ion
syst
ems
are
unab
le t
o co
mm
unic
ate
wit
h on
e an
othe
r, e.
g.
PSO
LIS,
Em
erge
ncy
depa
rtm
ent
Info
rmat
ion
Syst
em (
EdIS
).
Info
rmat
ion
proc
esse
s ar
e no
t co
nsis
tent
or
data
is n
ot u
pdat
ed o
r m
aint
aine
d.
Acti
ve t
reat
ing
part
ies
and
refe
rrer
s ar
e un
able
or
unw
illin
g to
par
tici
pate
in
the
CRA
M P
lan.
file
aud
it.
6.2
Rec
ordi
ng a
nd
docu
men
tati
on o
f th
e CR
AM P
lan
is
stan
dard
ised
and
cl
earl
y id
enti
fiabl
e in
th
e cl
inic
al n
otes
and
on
PSO
LIS.
doc
umen
tati
on is
ac
cura
te a
nd o
bjec
tive
an
d ac
cord
ing
to W
A H
ealt
h re
cord
-kee
ping
st
anda
rds.
Staf
f ha
ve t
rain
ing
on,
or a
re a
ble
to a
cces
s, W
A H
ealt
h re
cord
-kee
ping
st
anda
rds.
Nil.
file
aud
it.
Reco
rdin
g fo
r th
e CR
AM
Plan
is s
tand
ardi
sed
acro
ss t
he s
tate
.
The
stan
dard
ised
rec
ordi
ng f
orm
at is
no
t us
ed f
or a
sses
sing
and
pre
dict
ing
risk
. It
refl
ects
whe
re r
isk
is r
ecor
ded
and
can
be f
ound
.
A M
enta
l Hea
lth
Net
wor
k re
com
men
dati
on a
nd a
Sta
te H
ealt
h Ex
ecut
ive
foru
m d
irec
tive
is g
iven
to
impl
emen
t th
e st
anda
rdis
ed r
ecor
ding
of
the
CRA
M P
lan.
Resi
stan
ce b
y st
akeh
olde
rs t
o st
anda
rdis
ed r
ecor
ding
of
the
CRAM
Pla
n.
file
aud
it.
Revi
ew t
imef
ram
es
for
the
CRAM
Pla
n ar
e do
cum
ente
d.
Staf
f un
ders
tand
whe
n to
und
erta
ke a
re
view
of
the
CRAM
Pla
n.N
il.fi
le a
udit
.
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ger A
pplica
ble - R
escin
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ber 2
020
Clinical Risk Assessment and Management in Western Australian Mental Health Services
28
NM
Hs
stan
dard
Crit
eria
Cond
itio
ns t
o Fu
lfilli
ng t
he C
rite
ria
Chal
leng
es t
o Fu
lfilli
ng
the
Crit
eria
Eval
uati
on o
r A
udit
M
etho
d
Reas
sess
men
t is
do
cum
ente
d w
ith
any
chan
ges
to t
he
risk
(in
crea
se o
r de
crea
se)
and
why
the
re
asse
ssm
ent
was
don
e
is d
ocum
ente
d.
Staf
f un
ders
tand
whe
n to
rea
sses
s ri
sk.
Nil.
file
aud
it.
7. Monitor and Review
11.3.14, 11.3.17, 11.3.18, 11.6.4
7.1
The
clin
ical
ris
k is
re-
asse
ssed
and
CRA
M
Plan
is m
onit
ored
, ev
alua
ted
and
revi
ewed
.
The
clin
ical
ris
k is
re
view
ed w
ithi
n be
st-
prac
tice
sta
ndar
ds a
nd
tim
efra
mes
, ba
sed
on t
he
leve
l of
risk
.
A re
view
of
risk
the
refo
re
occu
rs:
• W
hen
ther
e ha
s be
en
a si
gnifi
cant
cha
nge
in
the
pers
on’s
men
tal
stat
e or
cir
cum
stan
ces,
e.
g. f
ollo
win
g a
seri
ous
inci
dent
(vi
olen
ce,
self
-in
jury
) or
a s
igni
fican
t lif
e ev
ent
such
as
loss
•
Whe
n a
cons
umer
is
dis
char
ged
or
tran
sfer
red
• A
t cl
inic
al t
eam
rev
iew
s (a
t a
min
imum
, ev
ery
thre
e m
onth
s)•
In t
he e
vent
tha
t th
e co
nsum
er f
ails
to
atte
nd
the
serv
ice
(did
Not
At
tend
(d
NA)
out
pati
ent
appo
intm
ent)
or
open
ly
refu
ses,
in a
dvan
ce o
f th
e ap
poin
tmen
t, t
o at
tend
.
Risk
esc
alat
ion
prot
ocol
s un
der
Stan
dard
5.1
app
ly.
The
serv
ice
is a
ble
to s
uppo
rt a
nd
reso
urce
sta
ff t
o m
anag
e th
e ri
sk.
Spec
ific
appo
intm
ents
are
mad
e av
aila
ble
to r
evie
w r
isk.
Out
pati
ent
follo
w-u
p fo
r co
nsum
ers
indi
cati
ng
chro
nic
suic
idal
ity
is a
pri
orit
y.
Reas
sess
men
t of
ris
k is
tri
gger
ed b
y di
seng
agem
ent,
non
-com
plia
nce
or
non-
atte
ndan
ce.
Cons
umer
is u
ntra
ceab
le
or in
form
atio
n ab
out
them
is u
nava
ilabl
e.
file
aud
it.
Cons
umer
sur
vey.
No Lon
ger A
pplica
ble - R
escin
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Octo
ber 2
020
Policy and standards
29
NM
Hs
stan
dard
Crit
eria
Cond
itio
ns t
o Fu
lfilli
ng t
he C
rite
ria
Chal
leng
es t
o Fu
lfilli
ng
the
Crit
eria
Eval
uati
on o
r A
udit
M
etho
d
7. Monitor and Review
7.2
Ser
vice
s ut
ilise
ex
isti
ng s
yste
ms
that
rep
ort,
rec
ord
and
revi
ew c
linic
al
inci
dent
s an
d ne
ar
mis
ses
(e.g
. AI
MS,
PS
OLI
S an
d O
SH).
Serv
ices
hav
e cl
ear
guid
elin
es f
or t
he t
ypes
of
inci
dent
s th
at s
houl
d be
rep
orte
d, s
uch
as:
• V
erba
l as
wel
l as
phys
ical
agg
ress
ion
from
wha
teve
r so
urce
• In
cide
nts
that
wer
e po
tent
ially
dan
gero
us
or h
arm
ful b
ut w
ere
reso
lved
(‘n
ear
mis
ses’
).
Staf
f un
ders
tand
the
impo
rtan
ce
of r
epor
ting
eve
n ap
pare
ntly
min
or
inci
dent
s, b
ecau
se o
f:
• T
he a
dver
se e
ffec
ts o
f re
peat
ed
expo
sure
to
‘low
leve
l’ in
cide
nts
• T
he p
ossi
bilit
y th
at m
inor
pro
blem
s ca
n le
ad t
o de
velo
pmen
t of
sy
stem
s to
res
pond
to
mor
e se
riou
s in
cide
nts.
Repo
rtin
g an
d re
cord
ing
syst
ems
are
acce
ssib
le a
nd s
taff
are
fam
iliar
wit
h th
eir
use.
Nil.
Serv
ice
polic
y.
Sent
inel
eve
nts
and
adve
rse
inci
dent
s ar
e re
port
ed in
a
tim
ely
man
ner
and
in a
ccor
danc
e w
ith
stat
utor
y re
port
ing
requ
irem
ents
.
Serv
ices
ens
ure
that
loca
l pro
toco
ls
exis
t fo
r re
port
ing.
Nil.
Serv
ice-
leve
l pol
icy
Serv
ice
audi
ts
Appr
opri
ate
auth
orit
ies
are
noti
fied
(OSH
, O
CP,
dir
ecto
r G
ener
al (
dG
)),
in
acco
rdan
ce w
ith
stan
ding
ope
rati
onal
di
rect
ives
.
Nil.
OSH
aud
it.
Serv
ice-
leve
l pol
icy.
OCP
, CO
V an
d M
HRB
re
port
ing.
Serv
ice
audi
ts.
The
revi
ew o
f se
ntin
el
even
ts a
nd a
dver
se
inci
dent
s ar
e co
nsid
ered
a
syst
em r
espo
nsib
ility
, un
derp
inne
d by
a j
ust
cult
ure.
Root
Cau
se A
naly
sis
(RCA
) is
use
d;
RCA
proc
esse
s ar
e in
pla
ce a
nd
docu
men
ted.
Iden
tifie
d st
aff/
Man
ager
s ha
ve t
rain
ing
in R
CA.
Serv
ice-
leve
l pol
icy.
OCP
rep
orti
ng.
Serv
ice
audi
ts.
No Lon
ger A
pplica
ble - R
escin
ded 7
Octo
ber 2
020
Clinical Risk Assessment and Management in Western Australian Mental Health Services
30
NM
Hs
stan
dard
Crit
eria
Cond
itio
ns t
o Fu
lfilli
ng t
he C
rite
ria
Chal
leng
es t
o Fu
lfilli
ng
the
Crit
eria
Eval
uati
on o
r A
udit
M
etho
d7. Monitor and Review
7.3
fol
low
ing
an a
dver
se
even
t, s
enti
nel o
r cr
itic
al in
cide
nt
invo
lvin
g se
riou
s as
saul
t or
abu
se,
inju
ry o
r de
ath,
th
e re
stor
atio
n an
d m
axim
isat
ion
of
the
wel
l-be
ing
and
men
tal h
ealt
h of
all
invo
lved
is a
ser
vice
pr
iori
ty.
Prop
er s
uppo
rt a
nd
trea
tmen
t is
pro
vide
d fo
r in
juri
es,
phys
ical
or
psyc
holo
gica
l, f
or s
taff
, ca
rers
and
con
sum
ers.
Line
man
ager
s an
d cl
inic
ians
are
tr
aine
d in
:
• E
ffec
tive
pos
t-in
cide
nt r
evie
win
g an
d ha
ve a
sys
tem
of
refe
rral
for
cr
itic
al s
tres
s su
ppor
t
• T
he t
ypes
of
post
-tra
uma
and
crit
ical
inci
dent
rea
ctio
ns t
o ex
pect
.
Prop
er s
uppo
rt a
nd t
reat
men
t fo
r st
aff
may
incl
ude:
• P
ost-
inci
dent
rev
iew
(op
erat
iona
l)
• D
efus
ing
(im
med
iate
sup
port
)
• P
rofe
ssio
nal c
riti
cal i
ncid
ent
(acu
te
trau
ma)
sup
port
.
Care
of
self
and
oth
ers
is p
rom
oted
fo
llow
ing
an in
cide
nt a
nd s
taff
are
al
ert
to s
igns
of
dist
ress
in o
ther
s an
d w
ays
of g
ivin
g ef
fect
ive
help
.
Acce
ss t
o ex
tern
al
reso
urce
s an
d av
aila
bilit
y of
tra
ined
sta
ff.
OSH
aud
it.
Serv
ice-
leve
l pol
icy.
OCP
, CO
V an
d M
HRB
re
port
ing.
Serv
ice
audi
ts.
A po
st-i
ncid
ent
revi
ew
take
s pl
ace
wit
hin
72
hour
s. It
aim
s to
sup
port
st
aff
and
cons
umer
s,
seek
s to
lear
n le
sson
s an
d re
-est
ablis
h th
e th
erap
euti
c re
lati
onsh
ip
wit
h af
fect
ed c
onsu
mer
s.
Serv
ices
hav
e sy
stem
s an
d sk
illed
sta
ff
in p
lace
for
pos
t-in
cide
nt s
uppo
rt a
nd
revi
ew m
echa
nism
s.
Thos
e in
volv
ed h
ave
the
oppo
rtun
ity
to d
efus
e/de
brie
f an
d re
ceiv
e fe
edba
ck a
bout
the
inci
dent
. M
anag
ers
info
rm a
nd/o
r re
fer
staf
f on
fo
r sp
ecia
list
debr
iefin
g, c
ouns
ellin
g an
d su
ppor
t if
nec
essa
ry.
The
trea
tmen
t of
con
sum
ers
exhi
biti
ng v
iole
nt b
ehav
iour
is n
ot
com
prom
ised
and
the
ir d
igni
ty is
pr
eser
ved.
Rem
oten
ess
of s
ervi
ce.
Lack
of
avai
labi
lity
of
trai
ned
staf
f.
Una
ble
to a
cces
s th
ose
invo
lved
in t
he in
cide
nt
wit
hin
the
tim
efra
me.
Staf
f ar
e tr
aine
d an
d su
ppor
ted
in t
he p
roce
ss
of ‘
Ope
n d
iscl
osur
e’.
Serv
ice-
leve
l pol
icy.
OCP
rep
orti
ng.
Serv
ice
audi
ts.
Cons
umer
fee
dbac
k su
rvey
s.
No Lon
ger A
pplica
ble - R
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020
Policy and standards
31
3. Implementation
staged ImplementationAchieving the standards outlined in this policy should be regarded as a long-term investment in safe practice. It will take time and, as such, there will be a gap between the release of the policy and full compliance at a local service level. Therefore, whatever processes and procedures services currently have in place should continue on the proviso that services demonstrate they are moving toward compliance. Services are therefore encouraged to take a staged approach to implementation. These stages might include:
1. Services reviewing policy and standards.
2. developing service-level audit tools in line with the standards.
3. Auditing services against the policy, identifying compliance with the standards and any gaps, and identifying current practice, such as checklists/tools used in services.
4. developing an implementation plan to address compliance gaps, including roll-out of training, identification of resources, and budgeting.
5. Using the implementation plan to undertake activities toward compliance with the policy.
6. Identifying full compliance.
Given that Area Health Services (AHSs) operate with different structures and capacities, the duration of each phase will differ and consequently, some AHSs may take longer to become compliant than others.
AuditingAs outlined above, an audit of existing policy, procedures and/or training against the policy will assist services to identify current good practice and any gaps. There are two parts to the audit process:
1. Operationalising the policy by assessing compliance with the policy through examining existing practice and identifying any gaps in comparison to the standards.
2. Defining strategies and activities in order to achieve compliance, including training.
The first step can be achieved through the development of an audit tool, against the standards. This tool should pay particular attention to the five-step CRAM process outlined in the standards, enabling assessment against the criteria for each standard. The tool should form part of the clinical audit tool, under clinical governance. An example of an audit tool is included in the Policy Pack.
The series of strategies and activities arising from the audit will form the implementation plan. Area Health Services will need to allocate adequate resources for auditing and implementation drive, and coordinate this implementation plan at a local level. That is, each health service will need to allocate sufficient human and other resources to embed the policy.
Training and DevelopmentSafe practice in mental health requires a combination of mental health skills, a collaborative attitude, willingness to work with consumers, carers and colleagues and knowledge about clinical risks. As such, training and skill development activities will assist in achieving and sustaining the standards of safe practice outlined in the policy.
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Clinical Risk Assessment and Management in Western Australian Mental Health Services
32
Skill development occurs where there are opportunities for clinicians to learn, practice and reflect. Therefore, it may take many forms, including face-to-face workshops, in-situ exposure, team discussion of cases, clinical supervision and peer mentoring.
The clinical experience of clinicians can vary greatly and different clinicians will have different needs for skill development. In addition, effective clinical risk assessment and management is part of, and synonymous with, effective treatment. As such, some skills and knowledge are pre-requisites for, or should be developed alongside, those required for clinical risk assessment and management. At a minimum, these are:
Interview, communication and therapeutic engagement skills
Mental State Examination
de-escalation of aggressive incidents
Understanding the Mental Health Act 1996 (WA)
Consumer perspectives training.
As part of the implementation of the CRAM Policy, Area Mental Health Services and the Mental Health division will collaborate to develop and roll out a standardised Clinical Risk Assessment and Management Training package for WA.
Policy Reviewfollowing the completion of the project, the state-wide CRAM Project Reference Group intends to review its Terms of Reference and continue to meet four times per year to review the implementation of the policy. The Project Reference Group will report to the Mental Health Network regarding its deliberations.
The CRAM policy is a living document and, particularly within the first twelve months of release, will require regular reviews against implementation progress in Area Health Services to trouble-shoot any difficulties in interpretation of the standards. Following this, the policy will be reviewed by the Mental Health Network and the Mental Health division every three years or earlier, as required.
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Policy and standards
33
4. Acknowledgements
The Mental Health division wishes to thank the members of Clinical Risk Assessment and Management Project Reference Group for their time, expert input and commitment to developing and drafting the policy:
dr Steve Patchett (Chair) Executive director, Mental Health division
Mr David Bowdidge Regional Manager, Goldfields Mental Health Service
Mr Patrick Byrnes Clinical Nurse Specialist, Graylands Hospital
dr Johann Combrink Clinical director, Psychiatric Emergency Team
Ms Karla Finikin Clinical Planning Officer, North Metropolitan Area Health Service Child and Adolescent Mental Health Service
Mr Michael finn Nursing director, fremantle Mental Health Service and Adjunct Research fellow, Curtin University School of Nursing
Mr Martin fisher Clinical Nurse Specialist, South-West Mental Health Service
Mr John Gardiner Senior Clinical Psychologist, Psychological Medicine, Women & Children’s Health Service
Mr Trevor Gee Community Mental Health Nurse, Bentley Inpatient Adult Mental Health Service
Ms Yvonne Hopper Clinical Nurse Specialist, Osborne Park Older Adult Mental Health Service
Mr darren Lloyd Specialist Clinical Psychologist, Armadale Child and Adolescent Mental Health Service
Ms Harriet Sawer Mental Health Consumer Consultant, Peel-Rockingham-Kwinana Mental Health Service
Ms Beverley Seth Consumer Representative
Ms Elaine Symons Clinical Nurse Specialist, South-West Mental Health Service
Mr Ken Thomson Regional Manager, Mid-West Mental Health Service
Ms Carolyn Williams Area Coordinator, Older Adult Mental Health Service, South Metropolitan Area Health Service
Mr Keith Wilson Carer Representative
The Mental Health Division also acknowledges the significant contribution of the following people who provided comment, advice and support:
Ms Kath Alloway Program Officer, Clinical Governance and Performance, North Metropolitan Mental Health Service
Ms Joanne Clarke Executive Officer, Clinical Governance and Performance, North Metropolitan Mental Health Service
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Clinical Risk Assessment and Management in Western Australian Mental Health Services
34
Mr Ray dhondea director, Staff development, Graylands Hospital
Ms Carole Harrison Staff development Educator, Osborne Park Older Adult Mental Health Service
Mr Jeff Keen Risk Management Coordinator, Office of the Director General of Health
Ms Carmel Loughney Staff development Educator, fremantle Hospital and Health Service
Ms Jo Mabbs Staff development Educator, fremantle Hospital and Health Service
Dr Theresa Marshall Consultant, Office of the Chief Psychiatrist
Ms Anabelle May Office of Safety and Quality in Health Care
Mr Ian Matthews Acting Manager, Governance and Performance North Metropolitan Mental Health Service
Ms deborah Porter Acting Senior Legal Adviser, Legal and Legislative Services, Health System Support
Ms Lorraine Powell Mental Health Consumer Consultant
Mr Mark Scully Senior Policy Officer, Office of Safety and Quality in Health Care
Ms Sue Thistlethwaite Staff development Educator, Swan Kalamunda Mental Health Service
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5. Glossary
Advance Statements – A document that contains the instructions of a person with mentalMental Health: health problems setting out their requests in the event of a relapse,
an incident of disturbed/violent behaviour, etc. It sets out the treatment that they do not want to receive and any treatment preferences that they may have in the event that they become violent. It also contains people they wish to be contacted and any other personal arrangement that they wish to be made. (See the National Institute for Health and Clinical Excellence (NICE) Guideline 25, 2005)
Adverse events: An incident in which harm results to a person. Harm includes death, disease, injury, suffering and/or disability (Australian Council for Safety and Quality in Health Care, cited in Office of Safety and Quality (OSQ), 2006).
Biopsychosocial: In the health field, the biopsychosocial model is a general model or approach that posits that biological (including medical, physical and genetic), psychological (including thoughts, emotions, and behaviors) and social factors all play a significant role in human functioning in the context of disease or illness.
Clinical risk: The risk of clinical errors and adverse incidents which may affect the quality of healthcare that patients receive.
Clinical risk can never be completely eradicated – some degree of risk is inherent in the patient’s lifestyle and initial condition, in the nature of medicine and of human performance in stressful conditions – but some risks are avoidable and the process of identifying, assessing and managing them will contribute to improving professional practice and the quality of healthcare provision (British Medical Association (BMA), 2002).
dignity of risk: (Sometimes known as the ‘Balance of Risk’). The concept of the ‘dignity of risk’ states that the complete removal of risk may also remove personal dignity and that taking risks is part of life.
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formulation (of risk): Risk formulation is a process of identifying the risk factors, analysing and summarising these factors to make a clinical decision about the potential risk of an adverse event and therefore, potential strategies to mitigate the risk. It provides the information base for, and is an important component in communicating about, risk management and treatment.
Person-centred: ‘Person-centered’ usually denotes a way of engaging with the patient that is non-directive and supportive of the patient’s wishes and thoughts about their own treatment and/or illness.
Risk: The chance of an event occuring that will have an impact upon values, goals or intentions. It is assessed in terms of repercussions and likelihood.
Risk assessment: A gathering of information and analysis of the potential outcomes of identified behaviours. Identifying specific risk factors of relevance to an individual, and the context in which they may occur. This process requires linking historical information to current circumstances, to anticipate possible future change. (Morgan, 2000, p.2).
Risk factors: The responses to the symptomatology of the disorder, pre-morbid patterns of behaviour and circumstances that alone or in combination lead to an increased risk.
Reasonable standard of The special nature of the relationship between a health worker andcare and duty of care: their client has been recognised at law as giving rise to a duty of
care. A health worker may be liable for negligence where they fail to take steps that a reasonable person would have taken to prevent a reasonably foreseeable risk of harm to a client or other person to whom they owe a duty of care.
Risk management: (Clinical) risk management aims to minimise the likelihood of adverse events within the context of the overall management of an individual. It provides the opportunity for targeted interventions to minimise the causative factors to achieve the best possible outcome and deliver safe, appropriate, effective care. Risk management can occur with the individual clinician and at a systemic level, such as the development of relapse prevention, training, environmental design.
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Sentinel events: Rare events that lead to catastrophic patient outcomes. Sentinel events required to be reported to the Chief Medical Officer at the WA department of Health are:
Procedures involving the wrong patient or body part
Suicide of a patient in an inpatient unit (under the Mental Health Act 1996 (WA), Mental Health Services are required to report to the Chief Psychiatrist episodes of unexpected death. See Operational Circular OP 2061/06)
Retained instruments or other material after surgery requiring re-operation or further surgical procedure
Intravascular gas embolism resulting in death or neurological damage
Haemolytic blood transfusion reaction resulting from ABO incompatibility
Medication error leading to the death of a patient reasonably believed to be due to incorrect administration of drugs
Maternal death or serious morbidity associated with labour or delivery
Infant discharged to wrong family or infant abduction
Other catastrophic event resulting in serious patient harm or patient death.
Structured clinical The process of using assessment methods constructed on evidencejudgement: about both historical (static) and clinical (dynamic) risk factors using
assessment tools in combination with a clinician’s judgement.
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6. References
Australian Council for Safety and Quality in Health Care, cited in Office of Safety and Quality in Health Care (2006). Clinical Incident Management Policy for Western Australian Health Services using the Advanced Incident Management System (AIMS) - Information Series No. 4. East Perth Western Australia: Western Australian department of Health.
British Medical Association (2002). Patient Safety and Clinical Risk. London: Health Policy and Economic Research Unit, BMA.http://www.bma.org.uk/ap.nsf/AttachmentsByTitle/PdfPatientSafety/$fILE/PatientSafety.pdf
doyle, M. & dolan, M. (2002). Violence risk assessment: Combining actuarial and clinical information to structure clinical judgements for the formulation and management of risk. Journal of Psychiatric and Mental Health Nursing, 9, 649-657
Mental Health Reference Group (2000). Risk Management. Scottish Office Department of Health.
Ministry of Health (1998). Guidelines for Clinical Risk Assessment and Management in Mental Health Services. Wellington, New Zealand: Ministry of Health.
Morgan, S. (2000). Clinical Risk Management. A Clinical Tool and Practitioner Manual. London: The Sainsbury Centre for Mental Health.
Office of the Chief Psychiatrist, Department of Health (2007). Communicating with Carers and Families. Perth, Western Australia: department of Health.
Office of Safety & Quality, Department of Health (2006). Consent to Treatment Policy for the Western Australian Health System. Perth, Western Australia: department of Health. www.health.wa.gov/safetyandquality/
Office of Safety and Quality, Department of Health (2005). Clinical Risk Management Guidelines for the Western Australian Health System. (Information Series No. 8). Perth, Western Australia: department of Health.
Top End Mental Health (2004). Risk Assessment Tracking Tool. Northern Territory: department of Health and Community Services.
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Acronyms
ACEM Australasian College of Emergency Medicine
AHS Area Health Service
AIMS Advanced Incident Management System
BMA British Medical Association
COV Council of Official Visitors
CRAM Clinical Assessment and Management System
DG Director General
DNA Did Not Attend
EDIS Emergency Department Information System
GP General Practitioner
ICAG Interim Clinical Advisory Group
IOP Institute Of Psychiatry
JDF Job Description Form
MHRB Mental Health Review Board
MMHS Metropolitan Mental Health Service
NICE National Institute for Health and Clinical Excellence
NMHS National Mental Health Standards
OCP Office of Chief Psychiatrists
OSH Occupational Safety and Health
OSQ Office of Safety and Quality
PSOLIS Psychiatric Services On-line Information System
RCA Root Cause Analysis
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© Department of Health, State of Western Australia (2008) Copyright to this material produced by the Western Australian (WA) Department of Health belongs to the State of Western Australia, under the provision of the Copyright Act 1968 (Commonwealth of Australia). Apart from any fair dealings for personal, academic, research or non-commercial use, no part may be reproduced without written permission of the Mental Health Division, WA Department of Health. The WA Department of Health is under no obligation to grant this permission. Please acknowledge the WA Department of Health when reproducing or quoting material from this source. Disclaimer All advice and information in this document is given in good faith and is based on sources believed to be reliable and accurate at the time of release. The State of Western Australia, the WA Department of Health and their respective officers, employees and agents do not accept legal liability or responsibility for the content of this advice or information or any consequences arising from its use.
Suggested reference:
Mental Health Division, WA Department of Health (2008). Clinical Risk Assessment and Management (CRAM) in Western Australian Mental Health Services: Policy and Standards. Perth, Western Australia: Department of Health.
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