Incident Management Feedback Loop

The reporting half of this loop is thoroughly designed. The learning half — the part that would actually reduce recurrence — is not evidenced anywhere in the eight process documents reviewed.

Loop health

Partially closes

Reporting closes; learning doesn't

Process stages mapped

Linked BlueWorks Live "To-Be" maps

Self-acknowledged gaps

"Share Lessons" dead-end + "Service Delivery (not mapped)"

External review still open

Unresolved

4 Commission matters, awaiting feedback as of report date

Loop diagram

flowchart TD
    A(["Incident Occurs"]) --> B["Respond to Incident\n(Frontline Staff / Incident Observer)\nEnsure safety, notify supervisor within ASAP/30min if CEO-notifiable"]
    B --> C["Create Incident Report\n(VisiCase)\nCategory, severity, linked incidents"]
    C -->|"Insig/Min"| D["Review & Approve\n(Service Coordinator / Manager)"]
    C -->|"Mod/Major/Catastrophic"| D2["Review & Approve\n(escalated — all Service Managers+\nnotified via email/SMS)"]
    D --> E{"Satisfactory?"}
    D2 --> E
    E -->|"No"| F["Work with observer to improve\nform / make updates"]
    F --> E
    E -->|"Yes"| G["Assess & Close\nRisk assessment + action plan\n(SC & SM collaborate)"]
    G --> H["Incident Reporting & Analysis\nExport CSV → Power BI"]
    H --> I["Share Any Information\nand Lessons"]
    I -.->|"no documented feedback path\nto frontline practice, training or policy"| GAP[["GAP — loop ends here"]]
    H --> J["Manage Incident Reporting to OCG\n(7-day / 30-day / entity report,\nno review/approval gate before submission)"]
    H --> K["Manage Incident Reporting to\nNDIS/QNS Commission\n(24hr initial + 5-day report,\nGM review & release required)"]
    J --> L["Upload outcomes to client file\n(only if not subject of allegation)"]
    K --> M["GM Review & Release Draft"]
    L -.->|"'Service Delivery (not mapped)'\n— gap acknowledged in source doc"| GAP2[["GAP — explicitly unmapped"]]
    M --> N(["End"])

Stage-by-stage narrative

1–2. Incident occurs → respond → create report

Frontline staff or an Incident Observer ensures safety, calls emergency services if needed, preserves evidence, and notifies a supervisor "ASAP" by phone; if CEO-notifiable, the Service Manager must be notified within 30 minutes. The report is created in VisiCase — category, type, severity (guided by a referenced but unavailable "severity guide"), linked incidents, and reviewer selection. CEO-notifiable incidents branch to a parallel manual process: optional phone notification to the COO, a PDF report emailed, ongoing updates also by email.

02.00 Incident Management End-to-End (To-Be)02.01 Respond to Incident (To-Be)02.02 Create Incident Report (To-Be)

3–4. Review & approve → assess and close

Service Manager or Coordinator receives the item as a VisiCase to-do, reviews it, can reallocate it, and either works with the observer to fix an unsatisfactory report or sends it forward. The Service Coordinator then opens the Incident Dashboard, collaborates with the Service Manager (phone/in person — not system-mediated), completes a risk assessment and/or action plan, and closes the incident with commentary.

02.03 Review & Approve Incident Report (To-Be)02.04 Assess and Close Incident (To-Be)

5. Incident reporting & analysis

Owned by the Customer, Practice & Quality Team. Incident data is exported as a CSV and uploaded into Power BI for analysis, and lessons are "shared." This is also the trigger point for both external-reporting sub-processes.

02.07 Incident Reporting _ Analysis (To-Be)

6–7. External reporting — OCG vs NDIS Commission

The OCG pathway (owned by CEO / EGM of Quality) submits three statutory notifications (7-day, 30-day, entity report) via a portal with no review or approval gate before submission. The Commission pathway (owned by Service Manager and General Manager) requires an initial 24-hour report and a 5-day follow-up, and — unlike OCG — both submissions require GM sign-off before release. Same compliance-critical class of external reporting, two different governance standards.

02.05 Manage Incident Reporting to OCG (To-Be)02.06 Manage Incident Reporting to QNS Commission (To-Be)

Where it breaks down

Biggest structural gap

The process ends at "Share Any Information and Lessons" with no linked step, system, or owner for what happens next — not connected back to Respond to Incident, to Skills & Competencies Management, or to any policy-update process. This is not an inference; it's the literal end of the documented chain.

Self-acknowledged gaps in the source documents

OCG pathway ends at a step literally labelled "Service Delivery (not mapped)" — flagged by the process designers themselves, not inferred by us.
Filename numbering (02.0x) doesn't match internal document numbering (03.0x) across all eight files — consistent enough to look like an unreflected folder renumbering.
02.06's internal title is copy-pasted from the OCG template ("...to OCG") despite being unambiguously about Commission reporting.

Real-world evidence the loop doesn't yet catch systemic issues

The June 2026 CEO Report describes a 13% non-currency rate in mealtime management plans, caught by a proactive manual review — not by this process or any embedded control: "Current compliance relies heavily on individual manager oversight and periodic audit rather than embedded controls." The intended fix was scoped into Connect but "could not be delivered due to system constraints."

6.1 CEO Report.pdf

An open external feedback loop, unresolved as of the most recent report

The NDIS Quality and Safeguards Commission raised four matters (Aug 2024–Jan 2026); Achieve gave verbal clarification 4 June 2026 and additional information 15 June 2026, and was still awaiting feedback as of the report date. No process document shows where an eventual Commission response would land, who owns actioning it, or how it flows back into the incident/CI loop.

6.1 CEO Report.pdf

Missing information

The severity guide itself — referenced by both 02.00 and 02.02 but not in the document set; materially affects how the whole loop triggers.
What "Share Any Information and Lessons" means in practice — channel, audience, frequency, whether it's tracked or actioned anywhere.
Whether incident-analysis output feeds Skills and Competencies Management (03.01.03) or any training/induction content — no process document links them.
Actual incident volumes, severity distribution, and trend data — all eight documents are process design, not operational reporting.
Whether OCG/Commission responses are logged anywhere once received, and who is accountable for closing that loop.
Rationale for the OCG vs Commission review-gate asymmetry — confirm whether intentional.
Current system — these processes reference VisiCase, but Connect (live since 2 June 2026) includes "a redesigned incident management system." Unclear whether these documents (last modified 10 Nov 2025) describe the old process, the new module, or an unbuilt future state.

Sources used

02.00 Incident Management End-to-End (To-Be).pdf 02.01 Respond to Incident (To-Be).pdf 02.02 Create Incident Report (To-Be).pdf 02.03 Review & Approve Incident Report (To-Be).pdf 02.04 Assess and Close Incident (To-Be).pdf 02.05 Manage Incident Reporting to OCG (To-Be).pdf 02.06 Manage Incident Reporting to QNS Commission (To-Be).pdf 02.07 Incident Reporting _ Analysis (To-Be).pdf 6.1 CEO Report.pdf (operational sections only)