Introduction by Croakey: Safety was a strong thread running through the recent Royal Australasian College of Medical Administrators’ conference (#RACMA2026), with some stand-out sessions encouraging those working in healthcare to think beyond the usual parameters and definitions of safe practice.
In the post below, Marie McInerney reports for the Croakey Conference News Service on two such sessions: one that demonstrated the importance of tailoring safe care to individual needs and centring consumers in safety initiatives, and another highlighting the utility of looking at ”what went right” when working towards consistently safe care outcomes.
Marie McInerney writes:
Kristen Robinson, a clinician and clinical nurse consultant within the Disability Services team at Melbourne’s Western Health, has seen first-hand what can happen if hospital systems are too rigid.
In a team presentation at the Royal Australasian College of Medical Administrators’ conference (#RACMA2026), Robinson said healthcare systems are rightly built on policies, procedures, efficiencies, and budget utilisation.
However, she said, standard processes can also create significant barriers for the most vulnerable consumers.
Robinson shared the story of a patient with an intellectual disability, who was non-verbal and needed to have surgery.
Two previous efforts to get him into the operating theatre had failed, she said. He had “really struggled” in the waiting room, intruding on other people and their belongings.
As the waiting time continued, he had become more agitated and “his distress really escalated,” she said. He ended up hurting a staff member, before his carer, his elderly sister, eventually “pulled the pin” because it was all too much.
The right questions
An SOS went out to the disability team, who first spoke to the person who knew him best –his sister. Following this, the team met with the nursing, surgical and anaesthetic teams, to develop a behavioural plan to be shared with all relevant staff.
But then they went a bit further in their questions, Robinson said.
Could they put him in the top of the surgical list so he would be operated on first? Could a later arrival and shorter surgical preparation time be safely achieved? Could clerical staff do most of the paperwork over the phone with his carer the day before, instead of needing to see him face-to-face, particularly as he was non-verbal?
Instead of having to sit in the busy waiting room, could he not be taken into a quiet theatre space with low stimulus? And did they really need to make him take off the basketball jersey he felt comfortable in, or could it be done after he was sedated? Did he need to wear the identification bands that troubled him, or could they be taped to his clothes?
And could his sister accompany him for surgery induction and recovery, when it was clinically appropriate, as is often approved for parents with small children?
Responding to need
Robinson said she was not suggesting deviations of care that would put clinical safety at risk, but was urging health professionals to ask themselves whether there is another way of providing care “that meets the needs of that patient while keeping everyone safe”.
Being pleased to report that the man’s procedure was completed uneventfully, she challenged conference participants to consider: “Are we responding to the person in front of us or are we trying to ….fit them into a cookie cutter approach because nine times out of ten it works?”
“For me, this [case] demonstrates safe care,” she said. “It requires a multidisciplinary approach. We need open, honest communication about triggers, risks, communication needs, and practical strategies. We need to be prepared to question our usual processes, work collaboratively, and plan ahead.
Robinson said she recognised that not every useful adjustment can be made, and that not every outcome will be as good as it was in his case.
“But we should be able to demonstrate that we have genuinely considered the person, assessed the risks, and made reasonable efforts to keep them safe and staff as well,” she said.
“And I think we really need to build on a culture where safety is everyone’s responsibility, where risks are actively managed rather than simply reacted to, and where the needs of the patients, carers, and staff are considered together.”
Committing to inclusion
Robinson was speaking in a session at #RACMA2026, titled Who Gets to Define Safe? … Safety through the Consumer Voice, led by Western Health’s Rebecca Barbara, who told the conference, “there isn’t much value in asking people ‘what makes you feel safe and what we can do,’ if we’re not prepared to do much with it”.
Barbara is operations manager of Western’s Best Experience team, which involves a number of equity groups including for people with disabilities and an LGBTQIA+ liaison service.
The team also has a lived experience advisor program, the only one of its kind in Australia, which employs people with lived experience to ensure there is a consumer lens throughout a project. It also has about 200 consumer advisor volunteers.
Barbara told Croakey the main messages the team wanted to get across at RACMA were:
- Safety is more than clinical outcomes – care may be clinically appropriate but still leave consumers feeling unheard, excluded or unsafe.
- Lived experience is expertise – consumers and families bring valuable insights that can help identify gaps and improve care.
- Safety is individual – what feels safe for one person may not feel safe for another.
- Listening must lead to action – consumer voices need to influence decisions, service design and improvement.
- Shared decision-making is a safety strategy – consumer expertise complements clinical expertise to support safer, more person-centred care.
Dr Shefton Parker, co-chair of Western Health’s Community Advisory Committee, later told Croakey he believed Western Health was ahead of the curve in terms of building a partnership with community, but he was pleased to see more health services also working similarly.
Parker said healthcare could be impacted by misinformation and disinformation.
“Partnership is the most authentic way to develop that trust between community, services and the hospital,” he said.
Listening up
The session also heard from Joanie Winter, whose adult daughter Rachel has cognitive and physical disabilities, and endured unnecessary suffering during treatment and surgery at Western Health a few years ago, when her supports were withdrawn due to COVID-19 restrictions.
Rachel experienced “untold pain”, Winter told the conference, “but people assumed that was part of her disability”.
Winter has spoken publicly of the experience many times, and of her satisfaction with the way Western Health responded by including her in the subsequent adverse event review process.
She said that what her daughter endured was “my biggest grief still today”, and that she shares Rachel’s story because she is determined it must not happen to anyone else.
“Noone who is that vulnerable coming into hospital should experience profound suffering”.
The session also heard from Monash University researcher Dr Erin Mills about a 2020 study which demonstrated that listening to parents could play a crucial role in preventing adverse outcomes in paediatric patients.
Mills said the research, published last year in The Lancet Child & Adolescent Health and prompting global headlines, found that a parent expressing concern that their child was deteriorating in hospital was as strongly associated with serious illness as abnormalities in vital signs like heart and respiratory rate or blood pressure.
“What we found was that when a parent said, ‘I’m worried’, [that child] was four times more likely to go to the intensive care unit,” she said.
What went well?
A root cause analysis, which effectively looks at what went wrong in serious adverse events, is one of the most widely used methods in healthcare.
But fewer organisations have a process in place to examine what went well in favourable outcomes, particularly when the cases are unusual and have wider teaching benefits beyond the team that produced the good result, #RACMA2026 participants were told in another presentation.
Dr Komal Bajaj, a professor of obstetrics and gynaecology and chief medical officer at private United States health company Biote, previously spent nearly two decades working at New York City Health and Hospitals, where she led system-wide initiatives in patient safety, clinical excellence, simulation, and value-based care.
That included the development and use of a ‘success cause analysis’ framework.
Bajaj told the conference by live video that healthcare has myriad outstanding successes: where a bone in the leg becomes part of the jaw, a tumour is removed, a patient who arrived in Emergency “at death’s door” later walks out of the hospital, and where astute clinicians shorten someone’s rare disease odyssey from a matter of years to just months.
“Each and every day there are amazing things that happen across all our sites that we can learn from,” she told the conference.
Bajaj said a root cause analysis, which focuses on uncovering the root cause of problems or failures, in order to prevent recurrence, is useful but can have limitations.
As she has written: “A focus only on unfavourable outcomes may limit innovation and adaptability and undermine worker morale and engagement.”
A success cause analysis shifts the paradigm, she said. It uses familiar root cause analysis methodology to really understand the factors that contribute to a favourable outcome and “then develop action plans to advance system change”.
Bajaj offered a case study to illustrate the analysis: A patient was treated for a rare and life-threatening anaesthetic reaction known as malignant hyperthermia while undergoing a procedure in a hospital outpatient environment. A multidisciplinary response included escalation and administration of specialised medications.
The case was seamlessly executed, the patient had a swift recovery and was discharged a few days later, she said.
“Beyond high-fiving each other, maybe wiping a sweaty brow, maybe having a pizza or a snack, the team decided to conduct a success cause analysis to really understand what factors led to this outcome and to hardwire learnings for the future.”
The analysis identified two standout factors: a prominently displayed sign detailing the escalation process and the outpatient team’s regular participation in simulations.
Baja told the conference the success cause analysis doesn’t have to be about the most significant or most serious outcomes, but should be something considered where an incident or outcome might be uncommon, or required “a lot of different choreography to get things right.”
And she said it should be open for wider learning.
While root cause analyses are usually led by a hospital’s risk management or regulatory team with discussions largely closed, additional trainees and other health professionals were welcome to join the success cause analyses, to spread the lessons.
Bajaj said New York Hospital also began to “infuse” some of the success cause analysis methodology into root cause analysis, “because even when a devastating, potentially unfavourable outcome is being discussed, oftentimes there are really crucial actions that the team took that can be understood and hardwired for the future”.
She said success cause analysis can be “a really powerful tool for culture change and for engagement.”
“’What went well?’ It is very amazing when you ask that question,” she said.
Bookmark this link to follow Croakey Conference News Service’s coverage of #RACMA2026.
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