Systemic investigations

Systemic issues are the concerns, problems, processes, practices or changes identified in the way health services are provided which adversely affect users of the health service or the quality of the health service, or have the potential to do so.

These may be identified or caused by, but not limited to:

• a change in the way a health service delivers their services
• changes in the performance of a health service
• issues identified in clinical incident reports
• a policy or procedure change
• a lack of policy or procedure
• a lack of clear regulatory guidelines
• regulatory non-compliance
• deficiencies in organisational governance
• gaps in quality assurance processes

The investigation will be conducted in accordance with the Health Ombudsman Act 2013.

During the investigation, the investigator may:

• source relevant information regarding the potential systemic issues;
• conduct interviews with staff;
• seek expert advice where appropriate.

While the office works collaboratively with stakeholders, powers under section 228 of the Health Ombudsman Act 2013 are utilised to require the provision of information. This ensures that the organisation served with the section 228 notice is protected from liability in releasing confidential information to the office and provides clarity around the office’s expectations.

Once a matter is accepted for systemic investigation, the following principles underpin all investigative activities:

Focus: by focussing on the underlying systemic issues, the office investigates the provision of health services using best-practice research methodologies.

Engagement: the office demonstrates readiness, responsiveness and transparency in dealing with relevant stakeholders and keeps them at the forefront of activities.

Due Professional Care: due professional care is taken when conducting systemic investigations and in preparing related reports. Investigations and reports must:

• be independent, objective, impartial, ethical, accurate and thorough
• meet legislative requirements, use appropriate investigation methods/techniques, and be conducted and reported on in a timely manner.

Value: through investigation, the office evaluates and reports on whether providers deliver quality, fit-for-purpose and responsive health services, and makes recommendations to providers to address concerns and to improve the delivery and quality of health services.

There are a number of possible outcomes following a health service or systemic investigation. These include:

• Making findings on the issues which address the concerns raised by the consumer/complainant and identify options for resolution by the health service provider

• Making findings on the issues which identify areas for service improvement or specific actions required by the health service provider

• Making findings that the concerns/issues cannot be substantiated and that there are no systemic issues or areas for service improvement

These outcomes may result in the Health Ombudsman deciding:

• To make recommendations to the health service provider to consider the findings of the report and options to respond and resolve the issues with the person who raised the complaint, which may include a referral to conciliation if appropriate

• To make recommendations on areas for service improvement and then take no further action on the specific matter

• To make formal recommendations for improvement and action by the health service provider which will be monitored

• To take no further action because it has been determined that there are no issues to address, or the issues have already been addressed by the health service provider

If the Health Ombudsman makes formal recommendations to improve health service delivery, the office is committed to protecting the health and safety of the public through the monitoring of, and reporting on, the implementation of recommendations. The health service provider will be asked to provide evidence of the progress and completion of the service improvement recommendations and we may also ask seek information from other parties to support/confirm the evidence provided. The systemic investigation team’s recommendation monitoring activities mitigate against the risk of adverse healthcare incidents reoccurring in the future, and promote and support systemic improvements in the safety and quality of healthcare.