KEY MESSAGES

1
KEY MESSAGES

• System wide relevance
• Managers clinicians need to work together
• Systems perspective

2
SYSTEMS

• Accreditation credentialing
• Incident reporting
• Performance
• Policies procedures
• Consumers
• Complaints

3
BRISTOL

• Closed culture
• Failure of response
• Quality systems
• Errors adverse events management
• Communication with patients/families
• Complaints management
• Training credentialing
• Morbidity mortality monitoring
• Poor outcomes

4
IMPLICATIONS

• Need to review our systems
• Management structures
• Culture
• Consumer involvement
• Change management

5

• HOW WOULD OUR ORGANISATIONS
• RESPOND IN SIMILAR
• CIRCUMSTANCES?