Incident management system at Victoria’s Health Department not yet fully implemented: state auditor

The Victorian Auditor-General’s Office has published a review of Victoria’s Department of Health to determine if it has improved clinical governance over the past five years. 

While the department did make “some clinical governance improvements,” it still has “limited” ability to assure the health system’s safety quality, according to the report.


Among findings, the VAGO noted that the DH still has not fully implemented a statewide incident management system to detect systemic risks. 

In 2009, the then-Department of Health Human Services (DHHS) introduced the Victorian Health Incident Management System (VHIMS), which categorises all incidents occurring in public health services by four incident severity ratings, from “no harm” to “severe”. It was envisioned to provide reliable accurate incident data from all health services for regular systematic analysis of clinical incidents. 

However, there was no data dictionary established that comprehensively defines all data fields in the system, which led health services to use inconsistent data collection methods rendered flaws in statewide incident reporting. 

In turn, this made the DH incapable of comparing reports results between public health services to detect system-level risks proactively detect underperformance or emerging risks across the system by analysing lower-severity incidents.

Another major report finding was that the DH only implemented one out of the 11 capability frameworks ensuring the safe delivery of healthcare across the state’s public health services. The frameworks were supposed to be completely enforced by 2019 as previously recommended. “As a result, DH has not fully addressed the risk that Victorian health services could be knowingly or unknowingly operating outside their safe scope of practice,” the report said. 

The DH is working to develop implement the remaining frameworks though it claimed that the disruptions caused by the COVID-19 pandemic made the process difficult. 


The present audit came after an independent review in 2016 that found the DHHS incapable of assuring the safety quality of the health system. This previous review was launched following reported deaths of babies at Djerriwarrh Health Services between 2012 2014.

In the latest report, the VAGO made an overall 18 recommendations – 11 on overseeing managing risks across the health system seven on producing using information to identify reduce risks; according to the state auditor, the DH has accepted all of them. 


A project to introduce dashboards that deliver real-time patient data is being implemented across public hospitals in Victoria. The digital dashboards are said to benefit a number of areas, such as clinical governance, prevention control of healthcare-associated infections medication safety. It is also important for hospitals’ accreditation of safety quality in health services. 

The A$2.1-million project ($1.5 million) is funded by the federal government-backed Digital Health Cooperative Research Centre is led by the Faculty of Information Technology Eastern Health Clinical School, both institutions under Monash University.

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