Open Disclosure Policy

Adora Day Surgeries (including Sydney Day Surgery - NSW, Greensborough Day Surgery - VIC and Craigie Day Surgery - WA), the day surgery division of Adora BidCo Pty Ltd (ACN 657 710 560) is committed to a consistent, person-centred approach to open disclosure when a patient experiences actual or potential harm or raises concerns about their care.

This policy aims to ensure timely, open and honest communication, support patients and their support persons throughout the process, promotes learning to improve the safety and quality of care to reduce the risk of future incidents.

This policy applies to all staff and Accredited Practitioners at all Adora Fertility and Day Surgery sites and shall be adopted as standard practice.

Download full PDF Version - Adora Fertility Open Disclosure Policy

Open Disclosure

Open disclosure is a principle-based approach to open, honest and timely discussion with a patient about an incident that resulted in actual or potential harm while they were receiving health care. It includes acknowledging what happened, offering an apology or expression of regret (including the word “sorry”), providing a factual explanation of the known information, an opportunity for the patient to relate their experience, and an explanation of the steps being taken to manage the event and prevent recurrence and provide ongoing communication and follow up.

Open disclosure is a person-centred process that involves discussions and an exchange of information that may take place over several meetings depending on the nature of the incident and the needs and preference of the patient and their chosen support person.

Responsibilities in the Open Disclosure

Adora Staff, Stakeholders and Accredited Practitioners

• Inform the manager immediately if there are concerns about patient safety or an incident has occurred.
• Take immediate action to ensure the safety of the patients, staff or facility; report incidents promptly and participate in the incident management as defined in this policy and associated policies and procedures.
• Provide an apology or expression of regret to a patient and their support person/s following and incident, including the words “I am sorry”, “We are sorry” as appropriate to their role or directed by their manager (e.g. DSU/IVF NUM, Lab Manager, SBM)
• Participate in open disclosure in a timely, honest, compassionate and respectful manner appropriate to their role and as directed by the manager (e.g. DSU/IVF NUM, Lab Manager, SBM)
• Ensure activities relating to the policy are implemented, reported and adhered to
• Complete education and training on open disclosure
• Communicate openly using factual information, avoiding speculation or attribution of blame, and clearly explain what is known and what is still being investigated.
• Treat patients, their families and chosen support persons with dignity, respect and empathy, and provide opportunities for them to ask questions, express concerns and share their experience.
• Respect the patient's individual communication needs, preferences, cultural background and values, including facilitating interpreter services or other communication supports where required.
• Support culturally safe care for Aboriginal and Torres Strait Islander peoples and people from diverse cultural and linguistic backgrounds.
• Maintain patient privacy and confidentiality throughout the open disclosure process.
• Participate in investigations, implementation of recommendations and quality improvement activities arising from incidents.

Managers (e.g DSU/IVF NUM, Lab Manager)

• Provide leadership to staff regarding policy implementation
• Document all relevant discussions and actions in accordance with organisational requirements.
• Undertake an initial, and if necessary, further, investigation and implementation and evaluation of recommendations as defined in this policy and associated procedures.
• Undertake open disclosure process with consumers and their nominated representative.
• Support staff following an incident including debriefing and /or counselling (external);
• Ensure incidents are recorded via the incident management system
• Ensure compliance with reporting requirements to State/s Department of Health and other statutory bodies.
• Ensure activities relating to this policy are implemented, reported and adhered to.
• Ensure all staff have completed training in the principles of open disclosure.
• Monitor and assist with investigation of incidents and implementation and evaluation of associated recommendations
• Provide reports to the Governing Body, State Medical Advisory Committee, National Fertility Governance Committee, WHS Committee and Consumer Advisory Committee on individual incidents and / or analysis of aggregate data as appropriate.

Senior Management (e.g National Director of Nursing DSU, National Operations Manager IVF, Scientific Director, National Quality and Risk Compliance Manager, State Business Manager)

• Determine the response level for open disclosure, ensure activities relating to this policy are implemented, reported and adhered to.
• Monitor and assist with investigation of incidents and implementation and evaluation of associated recommendations
• Provide reports to the Chief Executive Officer, State Medical Advisory Committee, National Fertility Governance Committee, WHS Committee and Consumer Advisory Committee on individual incidents and/ or analysis of aggregate data as appropriate.

Chief Executive

• Provides leadership for an organisational open disclosure culture
• Notify insurer or medico-legal counsel of incidents that are part of, or have the potential to, result in legal
  proceedings.

Process

Detection of an incident

When an incident is detected, the following immediate actions must be taken:

• Ensure patient safety and minimise the risk of further harm to the patient
• Provide prompt clinical care and support for the patient to prevent further harm
• Inform the line manager or clinician
• Report the incident in the incident management system.
• Consider whether immediate open disclosure is required based on the patient's needs and the nature of the incident.
  Preserve relevant information to support investigation where appropriate.

Note: Serious Notifiable Adverse Events must also be reported in line with State Regulatory and Legislative requirements

Assessment of an incident

The incident must be assessed by Adora Accredited Practitioners and senior managers to determine if the level of response required is low or high level.

The assessment should consider:

• the severity of the incident and any actual or potential harm;
• the patient's perspective and concerns;
• the patient's communication, cultural and support needs;
• whether a lower or higher-level response is appropriate; and
  any immediate actions required to support the patient and prevent recurrence.

Low- and High-Level Response

The level of open disclosure process required will depend on the outcome, nature, severity and circumstances of the incident considering the patient’s needs and preferences.

Initiation of Open Disclosure

The incident should be acknowledged to the patient and/or their support person irrespective of the response level required as soon as possible and generally within 24 hours. Communication must be respectful, compassionate, honest, culturally safe and person-centred throughout the process.

The initial discussion should include:

• acknowledgement of the incident and its impact on the patient
• a sincere apology or expression of regret, including the words "I am sorry" or "We are sorry";
• a factual explanation of what is known at the time, avoiding speculation or attribution of blame;
• an explanation of the immediate actions being taken to manage the patient's care and prevent further harm;
• an opportunity for the patient and/or their chosen support person(s) to ask questions, express concerns and share their experience;
• discussion of the next steps, including further meetings, investigation and follow-up;
• consideration of the patient's communication needs, cultural preferences and the use of interpreters or other support services where required.

Completing the Open Disclosure Process

The patient and their support person (if requested) should be provided with ongoing care, support and communication for as long as required.

The patient and their support person (if requested) should be given the opportunity to

• contribute to the investigation and actions where appropriate to prevent recurrence.
• discuss concerns and ask further questions throughout the process; and
• receive updates as additional information becomes available.

Once, the investigation is complete, a final written and verbal communication should be provided to the patient including details of the investigation findings, explanation of the report, information on measures to be implemented to prevent a similar incident from occurring, any ongoing care or follow up arrangements, available support services and complaint and feedback pathways.

Relevant information must be communicated to other healthcare providers where required.

Open Disclosure Policy Last Updated: 01/07/2026
We may review and update this open disclosure policy from time to time. Current versions will be made available here.

Download full PDF Version - Adora Fertility Open Disclosure Policy