Open Disclosure Policy Template

What's in this template?

This Open Disclosure Policy gives Australian medical and allied health practices a complete policy aligned to the ACSQHC Australian Open Disclosure Framework, RACGP Standards 5th edition and the relevant State and Territory apology laws. Open disclosure is the clinician-led conversation that takes place after an adverse event in a patient's care, and it is the expected professional standard, the right thing to do, and a protected conversation under the apology laws.

The policy covers 18 sections plus a sign-off block:

1. Purpose: clinical and ethical obligation
2. Open disclosure vs complaints: initiated by, trigger, goal, process
3. When open disclosure applies: always offered, clinician judgement
4. Two levels of open disclosure: clinician-led (informal) and formal
5. Roles and responsibilities: clinician, Lead, Clinical Lead, manager, insurer
6. The eight principles (ACSQHC framework)
7. Apology laws: protection of expressions of regret across Australia
8. Process, clinician-led (informal) disclosure: recognise, prepare, disclose, document
9. Process, formal disclosure: escalate, prepare, meeting, written follow-up, continued engagement
10. Supporting the patient and family: practical, cultural, continued contact
11. Supporting the staff involved: second-victim phenomenon, EAP, debrief
12. Notifications and reporting: insurer, AHPRA, complaints commission, Coroner
13. Documentation and the register: open disclosure register
14. Learning and systemic improvement: incident review, QI log, close the loop
15. Confidentiality: same framework as clinical care
16. Training: induction, annual, Lead-level formal training
17. Related documents
18. Approval and review

Editable placeholder fields

• {{practice_name}}, {{practice_address}}
• {{clinical_lead}}, {{open_disclosure_lead}}, {{practice_manager}}
• {{indemnity_insurer}}, your medical indemnity insurer (Avant, MIGA, MIPS, MDA National)
• Sign-off blocks for Clinical Lead, Practice Manager and Open Disclosure Lead

Who needs an Open Disclosure Policy?

Every Australian medical and allied health practice. The Australian Open Disclosure Framework is the national standard, accreditors expect a policy, and medical indemnity insurers strongly recommend it. The template is suitable for:

• General practices: most common audit focus, common medico-legal exposure
• Specialist medical practices and day procedure clinics
• Allied health practices: psychology, OT, physio, podiatry, dietetics
• NDIS providers: open disclosure overlaps with NDIS incident management
• Aboriginal Community Controlled Health Services (ACCHOs): with cultural safety customisations

How it differs from complaints handling

The two overlap when a complaint reveals an adverse event the practice did not previously know about, both processes then run in coordination.

The eight principles (ACSQHC framework)

The Australian Open Disclosure Framework is built on eight principles:

1. Open and timely communication: say what is known, when it is known
2. Acknowledgement: recognise what has happened and its impact
3. Apology or expression of regret: including saying "sorry" or "we are sorry"
4. Supporting the patient and family: practical, cultural, ongoing
5. Supporting the staff involved: second-victim phenomenon
6. Integrated clinical risk management and systems improvement
7. Good governance
8. Confidentiality

Apology laws, say "I am sorry"

Every Australian State and Territory has an apology law (Civil Liability Act or equivalent) that protects expressions of regret from being treated as admissions of liability. "I am sorry this happened to you" is protected. Say it.

Factual statements (e.g. "the dose was incorrect") are not protected, they may be admissible, so factual statements should be accurate, considered, and ideally framed within the formal process supported by the medical indemnity insurer.

The clinician's instinct to apologise and stay engaged is the correct one, silence makes things worse, not better.

Two levels of open disclosure

How to customise this template

1. Download the Word document and replace every {{placeholder}} with your details
2. Nominate an Open Disclosure Lead: usually the Clinical Lead or a senior GP; the Lead coordinates formal disclosures with the indemnity insurer
3. Confirm your medical indemnity insurer's open disclosure pathway: most provide an advisory line that is used early in any formal event (Avant, MIGA, MIPS, MDA National all do)
4. Confirm the apology law for your jurisdiction: Civil Liability Act in NSW, QLD, VIC, ACT, SA, TAS; Civil Liability Act 2002 (WA); Personal Injuries (Liabilities and Damages) Act 2003 (NT), the indemnity insurer is the best source
5. Brief clinicians: open disclosure is a clinician-led conversation; they need to feel confident with it
6. Set up the register: date, patient, event, level, participants, next steps, outcome
7. Coordinate with the Complaints Policy: both processes share roles, escalation and learning
8. Schedule annual training: RACGP, ACSQHC and medical indemnity insurer modules

Related templates and tools

The Open Disclosure Policy is the heart of a safety-and-learning culture:

• Complaints Handling Policy: patient-initiated counterpart
• Incident and Hazard Report Form: every formal open disclosure triggers an incident review
• Clinical Risk Management: systemic review of patterns
• Patient Identification Policy: many adverse events are identification errors
• Health Records Management: documentation of the disclosure conversation
• Psychosocial Hazards and Workplace Wellbeing Policy: supports clinicians involved in adverse events
• Privacy Policy: confidentiality framework
• Quality Improvement Policy and Activity Log: receives the learning outputs

Frequently asked questions

Is open disclosure mandatory?

It is the expected professional standard supported by the ACSQHC framework and RACGP Standards. AHPRA and the State and Territory health complaints commissioners expect it. Some jurisdictions have specific statutory requirements for inpatient events. For general practice, the framework and the apology laws are the operating standard.

Will saying "sorry" be used against us in court?

No, when phrased as an expression of regret or sympathy. Every Australian State and Territory has an apology law that protects "I am sorry this happened to you" from being treated as an admission of liability. Factual statements about what happened are different, they may be admissible, and should be accurate, considered, and ideally framed within the formal process supported by the medical indemnity insurer.

What if we don't know exactly what happened yet?

Disclose what is known, acknowledge what is not yet known, and explain what is being done to find out. This is one of the eight ACSQHC principles. Patients prefer honest uncertainty to silence or delay.

Who delivers the disclosure?

For clinician-led (informal) disclosure, the treating clinician. For formal disclosure, typically the treating clinician with the Open Disclosure Lead present, supported by the medical indemnity insurer's advice. The clinician most involved in the patient's care is usually the right person.

What about staff who are distressed by the event?

The "second victim" phenomenon is real and recognised. The Clinical Lead offers a private debrief same day. The practice EAP, the medical indemnity insurer's peer support, and the Psychosocial Hazards and Workplace Wellbeing Policy are activated. Staff may need adjustment to workload or supervision while they recover. The policy covers this in section 11.

Do we need to notify AHPRA?

Only where the threshold under National Law is met, notifiable conduct or impairment placing the public at risk. Most adverse events do not meet this threshold. Seek indemnity insurer advice before any AHPRA notification. The policy covers other mandated notifications in section 12.

How is this different from incident reporting?

Incident reporting (Incident and Hazard Report Form) is internal, it captures what happened so the practice can learn. Open disclosure is external, it communicates with the patient and family. Every formal open disclosure also triggers an incident review; the two processes run together.

Will accreditors accept this template?

Yes, when populated and followed. The policy maps directly to the ACSQHC Australian Open Disclosure Framework and the RACGP Standards' expectation of patient-centred response to adverse events. The two-level structure, the eight principles, the apology law protection, the register, and the learning loop are what surveyors expect to see.