Peter Williams

Onecare Limited

Applying Critical Systems Analysis to Serious Incidents in the Aged Care Sector

Thursday 13 October 2022

11:45am – 12:15pm

Speaker Bio

Pete is a Registered nurse and currently the CEO for OneCare Limited, a large not-for-profit aged care provider in Tasmania supporting over 1000 consumers in residential, home care and independent living.

Pete has worked across many sectors of health from public to private hospitals, metropolitan and regional, community services and now aged care.  He has held state and national roles with a strong focus on governance, education, quality and risk management.  He has published journal articles specifically in health and aged care and has been presented at several Australian healthcare conferences on systems analysis, accreditation preparation and leadership.

Pete has a deep connection with the philosophy of servant leadership and has a proven track record in building a strong and positive work place culture where respect, transparency, team success and quality of service thrive.


Presenting Author: Mr Peter Williams, CEO, OneCare Limited Tasmania –BNursing, MEd (Honours), MBA, GradCertAgeing, MACN


The Serious Incident Reporting Scheme (SIRS) commenced 1 April 2021.  The intent of this scheme was to strengthen aged care systems, reduce risk, build skills to better understand causation of serious incidents, drive improvements and reduce recurrence. OneCare Limited has implemented a process that supports the SIRS intent, enabling providers to critically analyse serious incidents to better understand causation and to implement improvements in process and systems that reduce future harm to those receiving care. There is also the capacity to share lessons learnt across the aged care sector.



In 2021, Critical Systems Analysis (CSA) was introduced into OneCare Limited to assist managers and senior nurses critically review incidents.  As the first clinical CEO in OneCare’s history and co-designer of this process, the CSA tool has been designed using internationally recognised incident review methodologies associated with Root Cause Analysis (RCA), The London Protocol (LP) and the Human Error and Patient Safety (HEAPS) principles.   Whilst the RCA, LP and HEAPS processes provide a way to analysis serious incidents in the acute healthcare setting, the aged care sector required a less resource intensive, more user-friendly process that could be applied to both complex and lower level incidents. The value of the CSA tool can assist providers improve their awareness of serious incidents (priority 1 and 2), demonstrate to the Commission how their service manages serious incidents, provide staff education and training and use the information gained using the CSA to change processes, apply open disclosure and provide a level of transparency needed in our industry.




    Over the past twelve (12) months, fourteen (14) CSA’s have been completed across OneCare Limited.   CSA reviews explored themes around unexpected death, clinical deterioration, fractures, pressure injury development and infection outbreak management.  The main contributing factors were identified as staff knowledge and education, followed by communication break down and information gaps.  Improvement opportunities focused on staff education and training, collaboration with GP’s and allied health services as well as improved processes to identify and manage deterioration.



    Since its introduction, the CSA approach has proven invaluable in unpacking incidents to better understand what happened, why it happened and what can be done to reduce the same or similar event from happening again. The outcomes provide a platform for case study education, the application of open disclosure as well as creating a common language among providers where lesson learnt can be shared across industry.


    Critical systems analysis, unpacking serious incidents in aged care #CSA#Opportunity’