Oral Presentation (max 20 mins) National Suicide Prevention Conference 2025

The Regional Outcome Review Initiative (RORI) was launched in November 2022 by the North-East Metro Health Service Partnership, a collaboration between suicide prevention, mental health and alcohol and other drugs services across Northeast and Eastern Melbourne. RORI aims to improve the capacity of health systems to learn from incident reviews, an area identified as crucial for system improvement. Drawing on recommendations from the Royal Commission into Victoria’s Mental Health System and stories and experiences of people with lived and living experience, RORI seeks to transform service delivery through collaborative learning and review processes.

Objectives:
RORI’s goal is to improve the quality of suicide prevention and mental health support by:

1. Enhancing Service Delivery through joint incident reviews that provide a holistic perspective on service improvement.
2. Driving Collaboration and Continuous Learning by uniting stakeholders in monthly Collective Learning Forums to share insights and foster regional partnerships.
3. Strengthening Incident Review Rigor by enhancing access to independent panel members and supporting staff development.

Methodology:
The initiative involves multiple participants including people with lived and living experience, five hospitals, seven community health services, NGO’s and the local Primary Health Network and health service partnership. Key elements included the formation of a commitment to Joint Reviews which provide a comprehensive understanding of incidents, a Panel Pool of independent review experts and monthly Collective Learning Forums that facilitate open, blame-free discussions to identify learnings from de-identified incidents.

Outcomes and Findings:
RORI has demonstrated its capacity to embed learning from incidents into everyday practice. Principle outcomes include:

• Increased collaboration between services, fostering shared understandings and trust.
• System-level insights leading to procedural and policy changes, enhancing clinical governance and consumer safety.
• A significant rise in completed Joint Reviews, with 100% of suitable incidents reviewed in the past three months of the pilot.
• Positive feedback from all participating members, indicating that RORI has been a worthwhile and transformative initiative.

Conclusion:
Within two years, RORI has transitioned from a pilot initiative to business-as-usual (BAU) in the region. The initiative has had a profound impact on professional development, policy shifts, and cultural changes within organisations. It serves as a model for how collaborative action can prevent similar adverse incidents and improve long-term outcomes across the suicide prevention and mental health service systems. Future evaluation will assess the long-term success of this collaborative framework in reducing incidents and fostering sustainable system improvement.