Date€¦ · Web viewNM - add to action plan D 2.3 Facilitating access to relevant orientation...

National Safety and QualityHealth Service Standards

DRAFTGuide for use in

Day Procedure Services

October 2011

Australian Commission on Safety and Quality in Health Care 1

National Safety and Quality Health Service Standards Guide for use in Day Procedure Services October 2011

© Commonwealth of Australia 2011This work is copyright. It may be reproduced in whole or in part for study or training purposes subject to the inclusion of an acknowledgement of the source. Requests and inquiries concerning reproduction and rights for purposes other than those indicated above requires the written permission of the Australian Commission on Safety and Quality in Health Care, GPO Box 5480 Sydney NSW 2001 or [email protected]

Suggested citation:Australian Commission on Safety and Quality in Health Care (2011), National Safety and Quality Health Service Standards Guide for use in Day Procedure Services, ACSQHC, Sydney.

Acknowledgments:This document was prepared by the staff of the Australian Commission on Safety and Quality in Health Care (ACSQHC) in collaboration with the Day Procedure Services Working Group. These individuals have freely given their time, expertise and documentation to support the development of this guide. The involvement and willingness of all concerned to share their experience and expertise is greatly appreciated.


mailto:[email protected]

Contents

Introduction................................................................................................................................................ 5

Standard 1: Governance for Safety and Quality in Health Service Organisations..............................9Criterion: Governance and quality improvement systems..............................................................10

Criterion: Clinical practice.................................................................................................................. 15

Criterion: Performance and skills management...............................................................................17

Criterion: Incident and complaints management.............................................................................20

Criterion: Patient rights and engagement.........................................................................................23

Standard 2: Partnering with Consumers...............................................................................................26Criterion: Consumer partnership in service planning.....................................................................27

Criterion: Consumer partnership in designing care........................................................................30

Criterion: Consumer partnership in service measurement and evaluation...................................31

Standard 3: Preventing and Controlling Healthcare Associated Infections.......................................33Criterion: Governance and systems for infection prevention, control and surveillance..............34

Criterion: Infection prevention and control strategies.....................................................................38

Criterion: Managing patients with infections or colonisations.......................................................42

Criterion: Antimicrobial stewardship................................................................................................45

Criterion: Cleaning, disinfection and sterilisation............................................................................47

Criterion: Communicating with patients and carers........................................................................49

Standard 4: Medication Safety...............................................................................................................50Criterion: Governance and systems for medication safety.............................................................51

Criterion: Documentation of patient information.............................................................................56

Criterion: Medication management processes.................................................................................58

Criterion: Continuity of medication management............................................................................62


Standard 5: Patient Identification and Procedure Matching................................................................65Criterion: Identification of individual patients..................................................................................66

Criterion: Processes to transfer care................................................................................................69

Criterion: Processes to match patients and their care....................................................................70

Standard 6: Clinical Handover................................................................................................................72Criterion: Governance and leadership for effective clinical handover...........................................73

Criterion: Clinical handover processes.............................................................................................74

Criterion: Patient and carer involvement in clinical handover........................................................77

Standard 7: Blood and Blood Products.................................................................................................78Criterion: Governance and systems for blood and blood product prescribing and clinical use. 79

Criterion: Documenting patient information.....................................................................................83

Criterion: Managing blood and blood product safety......................................................................85



Standards 8: Preventing and Managing Pressure Injuries..................................................................88Criterion: Governance and systems for the prevention and management of pressure injuries. .89

Criterion: Preventing pressure injuries.............................................................................................92

Criterion: Managing pressure injuries...............................................................................................95


Standard 9: Recognising and Responding to Clinical Deterioration in Acute Health Care..............97Criterion: Establishing recognition and response systems............................................................98

Criterion: Recognising clinical deterioration and escalating care................................................101

Criterion: Responding to clinical deterioration..............................................................................104

Criterion: Communicating with patients and carers......................................................................106

Standard 10: Preventing Falls and Harm from Falls...........................................................................109Criterion: Governance and systems for preventing falls...............................................................110

Criterion: Screening and assessing risks of falls and harm from falling.....................................113

Criterion: Preventing falls and harm from falling...........................................................................115

Criterion: Communicating with patients and carers......................................................................116

Action Plan Template............................................................................................................................ 116

Action Plan Template............................................................................................................................ 117

Glossary................................................................................................................................................. 118

References............................................................................................................................................. 124

Appendix 1 - Decision Support Tool for determining the level of performance to meet the NSQHS Standards............................................................................................................................................... 127

Appendix 2 - Summary table of items and actions in the NSQHS Standards to be audited or reviewed by health services................................................................................................................. 130

Appendix 3 - NSQHS Standards actions that require workforce training.........................................135

Appendix 4 - Summary table of not applicable actions for health service organisations to be accredited against the NSQHS Standards...........................................................................................136

Appendix 5 - Steps in determining not applicable actions................................................................138


IntroductionThis guide has been developed to assist health service organisations meet the requirements of the National Safety and Quality Health Service (NSQHS) Standards.

It provides an overview of the NSQHS Standards and their purpose, examples of evidence a health service organisation could use to demonstrate how they are meeting the NSQHS Standards, and additional information and resources and to support the implementation of the NSQHS Standards.

About the NSQHS StandardsThe NSQHS Standards were developed by the Australian Commission on Safety and Quality in Health Care (the Commission) following extensive consultation and collaboration with a wide range of stakeholders, including jurisdictions, technical experts, health professionals and consumers.

The NSQHS Standards aim to drive the implementation and use of safety and quality systems and to improve the quality of health service provision in Australia. The NSQHS Standards focus on areas that are essential to improving patient safety and quality of care and include:1. Governance for Safety and Quality in Health Service Organisations2. Partnering with Consumers3. Preventing and Controlling Healthcare Associated Infections4. Medication Safety5. Patient Identification and Procedure Matching6. Clinical Handover7. Blood and Blood Products8. Preventing and Managing Pressure Injuries9. Recognising and Responding to Clinical Deterioration in Acute Health Care10. Preventing Falls and Harm from Falls.

The first two Standards, ‘Governance for Safety and Quality in Health Service Organisations’ and ‘Partnering with Consumers’, set the overarching requirements for effective implementation of the remaining eight Standards, which address specific clinical areas of patient care.

The NSQHS Standards provide a nationally consistent statement of the level of care consumers should be able to expect from health services.

The NSQHS Standards were selected because they address areas where: the impact is on a large number of patients there is a known gap between the current situation and best practice outcomes, and improvement strategies exist that are evidence-based and achievable.


The Commission developed the NSQHS Standards to be applied across all settings of care. Health service organisations, such as hospitals and day procedure services, will be accredited against the NSQHS Standards. Other health services may choose to use the NSQHS Standards as part of their internal quality systems.

Structure and Content of the NSQHS Standards Each NSQHS Standard includes a: description of the Standard statement of intent statement on the context in which the Standard must be applied list of key criteria, and series of items and actions relevant to each criterion.

Core and Developmental ActionsThe NSQHS Standards apply to a wide variety of health services. Because of the variable size, structure, and complexity of health service delivery models, a degree of flexibility is required in the application of the NSQHS Standards.

To achieve this flexibility, each action within the Standards is designated as either:

core: which are critical for safety and quality, and which must be met in order to meet the Standard, or

developmental: which are aspirational targets. Health service organisations will not be required to achieve developmental actions in order to meet the Standard.

Core actions are considered fundamental to safe practice. All core actions must be met before a health service can achieve an accreditation award against the NSQHS Standards.

Developmental actions identify areas where health services can focus activities or investments that improve patient safety and quality. Health services do not need to meet development actions to achieve an accreditation award. A review of all core and developmental items will occur in 2015.

RatingsThe Commission has recommended that health service organisations meet the requirements of the NSQHS Standards. Assessment will be against a three point rating scale:

Not Met (NM) – the actions required have not been achieved. Satisfactorily Met (SM) – the actions required have been achieved. Met with Merit (MM) – in addition to achieving the actions required, measures of good

quality and a higher level of achievement are evident. This would mean a culture of safety, evaluation and improvement is evident throughout the organisation in relation to the action or Standard under review.

This rating system is used to rate individual actions within a Standard and to rate the Standard overall.


Individual accrediting agencies may choose to apply additional items, such as partially met in the rating scale when carrying out assessments. Health services can discuss this with their accrediting agency.

Not ApplicableIn exceptional circumstances, a criterion, item or action may be rated as ‘not applicable’. ‘Not applicable’ items are those which are inappropriate in a specific service context and/or for which assessment would be meaningless. If an item is rated as ‘not applicable’ an explanation must be provided for this decision to the accrediting agency. Appendix 5 describes the proposed process to apply for ‘not applicable’ actions.

About this Guide

Each Standard is presented in a separate section which details: the criteria, items and actions to meet each Standard examples of evidence that a health service organisation may use to demonstrate an action

is being met, and a self assessment tool.

The evidence provided includes examples that can be used to demonstrate that an item is being met – but it is not a checklist. Furthermore, the examples or suggestions provided do not represent an exhaustive ‘list’ of possible evidence. The service type, size, nature and location will influence the types of evidence that are appropriate and available. Please note, however, that organisations must provide sufficient evidence that each core item is being addressed in order to meet the NSQHS Standards.

The self assessment section (in column five) provides an opportunity for the health service organisation to review performance against the actions required and determine if current systems and processes meet the requirements. Self assessment is an important component of an accreditation process as it allows services to identify areas or issues that require attention prior to assessment by an external accrediting body.

An action plan template is provided on page 118 to assist practices to plan the changes needed to meet the NSQHS Standards. It also provides space to identify the potential risks and barriers to the actions; the strategies to be used to overcome these; the person responsible for the action; and the expected timeframes for completion.

Additional information that may assist in understanding and clarifying the NSQHS Standards has been included for some actions and this is identified within the table with the symbol (i).

A list of resources and tools for the implementation of safer systems is also included at the end of the section for each Standard.


Key for symbols used in the Guide for Day Procedure Services

C indicates that the action is core and therefore must be metD indicates that the action is developmental

N/A indicates that the action is not applicable

(i) indicates there is additional information to assist in interpretation of the Standards. Additional information specific to a particular action is included immediately below the relevant action

MM self assessment – ‘met with merit’.

SM self assessment – ‘satisfactorily met’.

NM - add to action plan self assessment – ‘not met’ and add action to action plan template provided on page 118.


Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services

Standard 1: Governance for Safety and Quality in Health Service OrganisationsHealth service organisation leaders implement governance systems to set, monitor and improve the performance of the organisation and communicate the importance of the patient experience and quality management to all members of the workforce. Clinicians and other members of the workforce use the governance systems.

The intention of this Standard is to: Create integrated governance systems that maintain and improve the reliability and quality of patient care, as well as improve patient outcomes.

ContextThis Standard provides the safety and quality governance framework for health service organisations. It is expected that this Standard will apply to the implementation of all other Standards in conjunction with Standard 2, ‘Partnering with Consumers’.

Criteria to achieve the Governance for Safety and Quality in Health Service Organisations Standard:Governance and quality improvement systemsClinical practicePerformance and skills managementIncident and complaints managementPatient rights and engagement



Criterion: Governance and quality improvement systemsThere are integrated systems of governance to actively manage patient safety and quality risks.

C/D This criterion will be achieved by:

Actions required Examples of evidence that can be used to demonstrate an action is being met.

This is not a checklist. Use only those examples that show that you have met the Standards

Self assessment

C 1.1 Implementing a governance system that sets out the policies, procedures and/or protocols for: establishing and

maintaining a clinical governance framework

identifying safety and quality risks

collecting and reviewing performance data

implementing prevention strategies based on data analysis

analysing reported incidents

implementing performance management procedures

ensuring compliance with legislative requirements and relevant industry standards

communicating with and informing the clinical and non-clinical workforce

undertaking regular clinical audits with legislative requirements and

1.1.1 An organisation-wide management system is in place for the development, implementation and regular review of policies, procedures and/or protocols

Policies, procedures and/or protocols are in place for items listed in 1.1 Agenda papers, meeting minutes and /or reports of relevant committees that

oversee the development and review of policies, procedures and/or protocols A register of completed reviews of policies, procedures and/or protocols, including

the date of review and any changes made Bylaws outlining mandatory criteria for meetings

MM

SM

NM - add to action plan

(i) Policies, procedures and/or protocols should be based on best practice and identify legislative requirements. They should include: nationally agreed definitions where available the date the policy was implemented and the scheduled review date links to relevant resource materials and/or references amendments approved following either incident, national changes in policy or policy review mechanisms for checking compliance an approval for use in the organisation are accessible to the workforce

C 1.1.2 The impact on patient safety and quality of care is considered in business decision making

Business plans outlining the potential impact on patient safety and quality of care Agenda papers, meeting minutes and/or reports of relevant committees (such as

finance and audit committees or strategic planning committees)

MM

SM







Self assessment

relevant industry standards

C 1.2 The board, chief executive officer and/or other higher level of governance within a health service organisation taking responsibility for patient safety and quality of care governance

1.2.1 Regular reports on safety and quality indicators and other safety and quality performance data are monitored by the executive level of governance

Committee terms of reference outline the senior executive responsibilities for governance of patient safety and quality of care

Agenda papers, meeting minutes and/or reports from relevant committee(s) include safety and quality indicators and data

Safety and quality information presented to the senior executive and/or relevant committees

Data that reports trends in safety and quality issues are recorded, such as in meeting minutes or annual reports

MM

SM


C 1.2.2 Action is taken to improve the safety and quality of patient care

Risk register or log that includes actions to address identified risks Agenda papers, meeting minutes and/or reports of relevant committee(s) that

detail improvement actions taken Quality improvement plan includes actions to address issues identified Examples of improvement activities that have been implemented and evaluated Communication material developed for the workforce and/or patients

MM

SM


C 1.3 Assigning workforce roles, responsibilities and accountabilities to individuals for:

patient safety and quality in their delivery of health care

the management of safety and quality specified in each of these Standards

1.3.1 Workforce are aware of their delegated safety and quality roles and responsibilities

Policies, procedures and/or protocols outline the delegated safety and quality roles and responsibilities for the workforce

Descriptions of delegated safety and quality roles and responsibilities included in position descriptions, the workforce duty statements and/or employment contracts

Orientation and ongoing training resources on safety and quality roles and responsibilities across clinical areas

Records of attendance at training by the workforce Organisational structure chart that outlines relevant reporting lines Agenda papers, meetings minutes and/or reports from the workforce meetings Written communication to the workforce about roles and responsibilities Results of the workforce surveys regarding safety and quality roles and

responsibilities

MM

SM


C 1.3.2 Individuals with delegated responsibilities are supported to understand and perform their roles and responsibilities, in particular to meet the requirements of these Standards

Descriptions of delegated safety and quality roles and responsibilities included in position descriptions, the workforce duty statements and/or employment contracts

Orientation and ongoing training resources are provided to meet the requirements of the NSQHS Standards

Records of attendance at training by the workforce Performance appraisals that include feedback to the workforce on delegated

safety and quality roles and responsibilities. Results of the workforce surveys regarding safety and quality roles and

responsibilities

MM

SM







Self assessment

(i) Appendix 3 summarises the actions in the NSQHS Standards that require workforce training

C 1.3.3 Agency or locum workforce are aware of their designated roles and responsibilities

Policies, procedures and/or protocols that address the roles and responsibilities of locum and agency workforce

Contracts with locum and agency workforce specify designated roles and responsibilities

Position descriptions, workforce duty statements and/or employment contracts for locum and agency workforce specify designated roles and responsibilities

Orientation and ongoing training resources for locum and agency staff Attendance records of training for locum and agency staff

MM

SM


D1.4 Implementing training in the assigned safety and quality roles and responsibilities

1.4.1 Orientation and ongoing training programs provide the workforce with the skill and information needed to fulfil their safety and quality roles and responsibilities

Orientation and ongoing training resources regarding safety and quality roles and responsibilities for the workforce

Records of attendance at training by the workforce Results of workforce surveys regarding safety and quality roles and

responsibilities Information on current legislative and regulatory requirements and guidelines

accessible to all staff

MM

SM


D1.4.2 Annual mandatory training programs to meet the requirements of these Standards

Schedule of annual mandatory education and training sessions which includes the requirements of the NSQHS Standards

Orientation and ongoing training resources to address the requirements of the NSQHS Standards

Attendance records of mandatory training sessions Evaluation survey or report on training programs on staff safety and quality roles

and responsibilities

MM

SM


(i) Appendix 3 summarises the actions in the NSQHS Standards that require workforce training

D 1.4.3 Locum and agency workforce have the necessary information, training and orientation to the workplace to fulfil their safety and quality roles and responsibilities

Policies, procedures and/or protocols readily accessible to locum and agency staff

Observational audits show that internal communication systems that provide access to information about safety and quality information (for example Intranet, memos) are accessible to the locum and agency staff

Orientation and ongoing training resources for locum and agency workforce regarding their safety and quality roles and responsibilities

Attendance records of training for locum and agency staff Skills appraisals and/or record of competencies of locum and agency workforce Record of locum and agency workforce credentials (qualifications)

MM

SM


(i) Locum and agency workforce may also include clinical, clerical, and/or trades people. They may






Self assessment

include physiotherapy, clinical records coder, security or medical practitioners

D 1.4.4 Competency-based training is provided to the clinical workforce to improve safety and quality

Schedule of training for the workforce Orientation and ongoing training resources for locum and agency workforce

regarding their safety and quality roles and responsibilities Attendance records and/or results of competency based training for staff Evaluation of competency-based training courses

MM

SM


C 1.5 Establishing an organisation-wide risk management system that incorporates identification, assessment, rating, controls and monitoring for patient safety and quality

regularly monitored

1.5.1 An organisation-wide risk register is used and regularly monitored

Policies, procedures and/or protocols for implementing and monitoring the risk management system

Agenda papers, meeting minutes and/or reports of relevant committees that oversee the risk management system

Risk register or log that includes actions to address identified risks Orientation and ongoing training resources regarding the organisation’s risk

management system Records of attendance at training by the workforce

MM

SM


C 1.5.2 Actions are taken to minimise risks to patient safety and quality of care

A register of incident reports, adverse events and near misses Risk register or log that includes actions to address identified risks Risk assessment and analysis reports Organisational risk management plan Agenda papers, meeting minutes and/or reports from relevant committees include

data analysis for identified risks Audits of safety and quality indicators Quality improvement plan includes actions based on analysis of risk which are

regularly reviewed

MM

SM


C 1.6 Establishing an organisation-wide quality management system that monitors and reports on the safety and quality of patient care and informs changes in practice

1.6.1 An organisation-wide quality management system is used and regularly monitored

A designated committee or personnel with responsibility for the implementation, coordination and review of an organisation-wide quality management system

Audit of compliance with policies, procedures and/or protocols and other legislation or regulations

Evaluation reports on the safety and quality management system Position description or employment contract that requires participation in quality

management system Audit of the organisation’s quality improvement plan Feedback provided to workforce on safety and quality issues

MM

SM







Self assessment

(i) Management tools may include the Plan–Do–Check–Act (PDCA) cycle. The PDCA cycle is also known as the Plan–Do–Study–Act cycle, Deming’s cycle, Shewhart’s cycle and the Continuous Improvement cycle

C 1.6.2 Actions are taken to maximise patient quality of care

Register of incident reports, adverse events and near misses Results of patient satisfaction survey and organisational responses recorded Results of clinical audits and performance indicators identify areas requiring

action Evaluation report or review of strategies implemented Re-audits of identified deficiencies or areas requiring action Strategies and actions taken in response to identified risks are recorded, such as

in agenda papers, meeting minutes and/or reports of relevant committee(s) Quality improvement plan includes actions to address issues identified Examples of improvement activities that have been implemented and evaluated Information communicated to staff

MM

SM




Criterion: Clinical practice Care provided by the clinical workforce is guided by current best practice.




Self assessment

C 1.7 Developing and/or applying clinical guidelines or pathways that are supported by the best available evidence

1.7.1 Agreed and documented clinical guidelines and/or pathways are available to the clinical workforce

Policies, procedures and/or protocols for access and use of clinical guidelines and/or pathways

Observational audit that guidelines and and/or pathways are available in clinical areas (hard copy or electronic)

List of web addresses for accessing electronic copies of clinical guidelines and/or pathways

MM

SM


C 1.7.2 The use of agreed clinical guidelines by the clinical workforce is monitored

Audits of adherence to available clinical guidelines and/or pathways MM

SM


C 1.8 Adopting processes to support the early identification, early intervention and appropriate management of patients at increased risk of harm

1.8.1 Mechanisms are in place to identify patients at increased risk of harm

Patient clinical record shows that risk assessments are completed during admission, on admission and during an ongoing care

Organisational risk profile that details the most likely risks and their potential impact Register of incident reports, adverse events and near misses includes actions to

address issues identified Data on complaints and consumer feedback

MM

SM


C 1.8.2 Early action is taken to reduce the risks for at-risk patients

Supervision policies, procedures and/or protocols designed to reduce risk Instructions about which the workforce can perform procedures identified as being

at most risk Risk profile that includes an evaluation of risks and methods of eliminating or

reducing identifiable risks Risk management and action plans for identified risks Emergency plans for identified risks Analysis of the causes of adverse events and near miss incidents and the actions

taken to address the identified risks Documented early recognition and response system Orientation and ongoing training resources and training attendance records that

address the identified risks

MM

SM







Self assessment

C 1.8.3 Systems exist to escalate the level of care when there is an unexpected deterioration in health status

Policies, procedures and/or protocols regarding escalation of care Observation that signs, posters and/or stickers on how to call for assistance are

clearly displayed in areas where care is provided Orientation and ongoing education resources related to escalation of care Records of attendance at training by the workforce Record of operational and mechanical call device testing Incident reports about escalation of care

MM

SM


Link to Standard 9

C 1.9 Using an integrated patient clinical record that identifies all aspects of the patient’s care

1.9.1 Accurate, integrated and readily accessible patient clinical records are available to the clinical workforce at the point of care

Policies, procedures and/or protocols for ensuring patient clinical records are available at the point of care when a patient is transferred within the organisation and between organisations

Policies, procedures and/or protocols for obtaining patient clinical records from storage and other areas of the organisation

Audits of the accuracy, integration and currency of patient clinical records which meets best practice

Observational audits of the availability of patient clinical records to the clinical workforce at the point of care

MM

SM


(i) Patient clinical record is also known as patient medical record, client’s notes, clinical notes, progress notes, and/or procedure records

C 1.9.2 The design of the patient clinical record allows for systematic audit of the contents against the requirements of these Standards

A schedule of audits of the patient clinical record against the requirements of the NSQSH Standards is developed and maintained

Completed audits of patient clinical records

MM

SM




Criterion: Performance and skills management Managers and the clinical workforce have the right qualifications, skills and approach to provide safe, high quality health care.




Self assessment

C 1.10 Implementing a system that determines and regularly reviews the roles, responsibilities, accountabilities and scope of practice for the clinical workforce

1.10.1 A system is in place to define and regularly review the scope of practice for the clinical workforce

Policies, procedures and/or protocols regarding the scope of practice for the clinical workforce clinical supervision of students

Agenda papers, meeting minutes and/or reports from relevant committee(s) include information on the roles, responsibilities, accountabilities and scope of practice for the clinical workforce

Audits of policies, procedures and/or protocols and position descriptions, against the requirements and/or recommendations of clinical practice and professional guidelines

Audits of policies, procedures and/or protocols against scope of practice defined by credentialing bodies

Workforce performance appraisal and feedback records show a review of the scope of practice for clinical workforce

Peer review reports Agenda papers, meeting minutes and/or reports of relevant committee(s) with

responsibilities for determining and reviewing scope of practice

MM

SM


(i) The policy may have appointments and credentialing incorporated, including service framework and capability, and licensing agreement which lists the organisations available health services

C 1.10.2 Mechanisms are in place to monitor that the clinical workforce are working within their agreed scope of practice

Register of the workforce qualifications and areas of credentialed practice Audit of clinical workforce who have a documented performance appraisal Reports and/or reviews of clinical workforce key performance indictors Observational audits of clinical practice Audits of signatures and role designation in patient clinical records Audit of compliance with policies, procedures and/or protocols

MM

SM


(i) Patient clinical record is also known as patient medical record, client notes, clinical notes, progress notes, and/or procedure records






Self assessment

C 1.10.3 Organisational clinical service capability, planning, and scope of practice is directly linked to the clinical service roles of the organisation

Strategic plan outlines the organisation’s overall objectives and services provided Register of workforce qualifications suitable for clinical service roles of the

organisation Case mix audit of services provided Evaluation of clinical services targets Reports from clinical information systems Benchmarking reports Evaluation of the quality and safety of clinical services Annual reports detail the clinical service capability and clinical services provided

MM

SM


C 1.10.4 The system for defining the scope of practice is used whenever a new clinical service, procedure or other technology is introduced

Policies, procedures and/or protocols and bylaws regarding scope of practice Planning documents to introduce new services (including staffing, equipment,

procedures, scope of practice applications and approval for licensing) Defined competency standards for using new services, procedures and

technology are available to clinical staff Education resources for new services, procedures and technologies Attendance training records Meeting minutes and reports of clinical practice committees or similar groups Staff meeting minutes, memos, intranet messages and/or other methods of

communication with the workforce that define the scope of practice for new clinical services, procedures or other technology

MM

SM


C 1.10.5 Supervision of the clinical workforce is provided whenever it is necessary for individuals to fulfil their designated role

Descriptions of roles and responsibilities for designated clinical leaders included in position descriptions, staff duty statements and/or employment contracts

Documented review of qualifications and competencies for clinical staff Individual performance reviews documented for all the clinical workforce Observational audits of individuals clinical practice Register of workforce qualifications and areas of credentialed practice Audit of clinical workforce who have completed performance reviews

MM

SM


(i) Policies may detail both the clinical workforce requiring supervised practice such, as student nurses, and the extent of the supervision required






Self assessment

C 1.11 Implementing a performance development system for the clinical workforce that supports performance improvement within their scope of practice

1.11.1 A valid and reliable performance review process is in place for the clinical workforce

Policies, procedures and/or protocols on the performance review process for clinical workforce

A documented performance development system that meets professional development guidelines and credentialing requirements

Audit of compliance with policies, protocols and/or procedures on the performance review process for clinical workforce

Audit of clinical workforce with completed performance reviews Audit reports based on observational audits of individuals clinical practice Peer review reports

MM

SM


C 1.11.2 The clinical workforce participates in regular performance reviews that support individual development and improvement

Individual performance reviews documented for all the clinical workforce Records of workforce attendance at training and competency consist with

organisational policies and credential requirements Observational audits of clinical practice Workforce development plans and programs document training needs identified

through individual performance reviews

C 1.12 Ensuring that systems are in place for ongoing safety and quality education and training

1.12.1 The clinical and relevant non-clinical workforce have access to ongoing safety and quality education and training for identified professional and personal development

Education resources, plans, and attendance records of safety and quality education provided

Safety and quality resources and materials readily available to the workforce

MM

SM


C 1.13 Seeking regular feedback from the workforce to assess their level of engagement with, and understanding of, the safety and quality system of the organisation

1.13.1 Analyse feedback from the workforce on their understanding and use of safety and quality systems

Agenda papers, meeting minutes and/or reports of relevant committees responsible for safety and quality systems

Records of workforce feedback regarding the use of safety and quality systems Analysis of workforce survey results regarding the use of safety and quality

systems Evaluations of workforce training Workforce communication books

MM

SM


C 1.13.2 Action is taken to increase workforce understanding and use of safety and quality systems

Succession plans for key safety and quality positions Risk register or log that includes actions to address identified risks Agenda papers, meeting minutes and/or reports of relevant committee(s) that


MM

SM


Criterion: Incident and complaints management



Patient safety and quality incidents are recognised, reported and analysed, and this information is used to improve safety systems.


Actions required Examples of evidence that can be used to demonstrate an item is being met.

This is not a checklist, use only those examples to show that you have met the standards

Self assessment

C1.14 Implementing an incident management and investigation system that includes reporting, investigating and analysing incidents (including near misses), which all result in corrective actions

1.14.1 Processes are in place to support the workforce recognition and reporting of incidents and near misses

Policies, procedures and/or protocols for reporting, investigating and analysing incidents and near misses

Risk assessment, incident and near miss reporting forms A current register of incident reports, adverse events and near misses that may

include actions to address identified risks Orientation and ongoing training on the recognition, reporting, investigating and

analysing of incidents, adverse events and near misses Records of attendance at training by the workforce

MM

SM


C1.14.2 Systems are in place to analyse and report on incidents

A current register of incident reports, adverse events and near misses that includes actions to address identified risks

Data that reports trends in incidents, adverse events and near misses are recorded, such as in meeting minutes or annual reports

Agenda papers, meeting minutes and/or reports of relevant committees include information and data from incident reports


MM

SM


C1.14.3 Feedback on the analysis of reported incidents is provided to the workforce

Meeting minutes of relevant committee(s) that contain an analysis of incidents and near misses are available to workforce

Material distributed to workforce on incidents and trends Incident reports are available to the workforce Agenda papers, meeting minutes and reports of workforce meetings include

information on incidents, adverse events and near misses

MM

SM


(i) Incident reports provided to the workforce may be limited to major incidents and/or aggregated reports of all incidents that have been reported

C1.14.4 Action is taken to reduce risks to patients identified through the incident management system

Same evidence options as 1.13.2 MM

SM







Self assessment

C1.14.5 Incidents and analysis of incidents are reviewed at the highest level of governance in the organisation

Record or report of evidence-based interventions that have been initiated for identified risks

Risk assessments and action plans Strategies and actions taken in response to identified risks are recorded, such

as in agenda papers, meeting minutes and/or reports of relevant committee(s) Information on incidents presented to the senior executive and/or relevant

committees

MM

SM


C1.15 Implementing a complaints management system that includes partnership with patients and carers

1.15.1 Processes are in place to support the workforce to recognise and report complaints

Policies, procedures and/or protocols detail processes for recording and reporting patient and carers complaints (complaints management)

Comments and complaints forms for patients to complete Secure patient comments and complaints ‘box’, or similar device, in publicly

accessible places Patient brochure, information sheets, or equivalent, that outline internal and

external complaints mechanisms Orientation and ongoing training on the complaints management system Records of attendance at training by the workforce

MM

SM


C1.15.2 Systems are in place to analyse and implement improvements in response to complaints

A current complaints register which includes responses and actions to address identified issues

Agenda papers, meeting minutes and/or reports of relevant committees or groups with responsibility for complaints management

Reports or briefings on analysis of complaints Quality improvement plan includes actions to address issues identified Examples of improvement activities that have been implemented and

evaluated

MM

SM


C1.15.3 Feedback is provided to the workforce on the analysis of reported complaints

Complaints data recorded in agenda papers, meeting minutes and/or or reports of relevant committees

Material provided to workforce on complaints and trends in complaints

MM

SM


C1.15.4 Patient feedback and complaints are regularly reviewed at the highest level of governance in the organisation

Agenda papers, meeting minutes and/or reports of relevant committees or groups with responsibility for complaints management


Data that reports trends in safety and quality issues is included in meeting minutes or annual reports

Risk management plan that includes strategies for managing complaints Evaluation reports note the effectiveness of responses and improvements in

service delivery

MM

SM







Self assessment

C1.16 Implementing an open disclosure process based on the national open disclosure standard

1.16.1 An open disclosure program is in place and is consistent with the national open disclosure standard

Policies, procedures and/or protocols consistent with the principles and processes outlined in the national open disclosure standard

Documented reports on open disclosure processes in the organisation Information and data on open disclosure presented to the senior executive

and/or relevant committees

MM

SM


C1.16.2 The clinical workforce are trained in open disclosure processes

Orientation and ongoing training resources on the open disclosure processes Records of attendance at training by the workforce MM

SM




Criterion: Patient rights and engagement Patient rights are respected and their engagement in their care is supported


Actions Required Examples of evidence that can be used to demonstrate an item is being met.


Self assessment

C1.17 Implementing through organisational policies and practices a patient charter of rights that is consistent with the current national charter of healthcare rights

1.17.1 The organisation has a charter of patient rights that is consistent with the current national charter of healthcare rights

Policies, procedures and/or protocols regarding the implementation and use of a charter of patients rights

Charter of rights consistent with the Australian Charter of Healthcare Rights

MM

SM


C1.17.2 Information on patient rights is provided and explained to patients and carers

A patient charter of rights is displayed in areas accessible to the public Brochures, information sheets or other documents that explain the charter of rights

are given to patients Charter of patient rights is available in a range of languages and formats, consistent

with the patient profile Admission checklist that includes provision and explanation of patient charter of

rights

MM

SM


Link with Standard 2

C1.17.3 Systems are in place to support patients who are at risk of not understanding their healthcare rights

A register of interpreter and other advocacy and support services is available for the workforce and patients

Patient clinical records reflect assessment of need and support provided Analysis of consumer feedback regarding healthcare rights Results of patient and/or carer satisfaction surveys regarding healthcare rights

MM

SM


C1.18 Implementing processes to enable partnership with patients in decisions about their care, including informed consent to treatment

1.18.1 Patients and carers are partners in the planning for their treatment

Patient clinical records include:o information provided to patient and/or carers about their proposed treatment o patient and/or carer involvement in pre-operative assessment o patient and/or carer involvement in discharge planning o case conference records with patients and/or carerso completed consent forms

Observational audits of consumers participating in making decisions about their care Analysis of consumer feedback regarding consumer participation in making

decisions about their care Results of patient and/or carer satisfaction surveys regarding consumer participation

in making decisions about their care

MM

SM







Self assessment

C 1.18.2 Mechanisms are in place to monitor and improve documentation of informed consent

Patient information packages or resources about treatments Translated patient information sheets/resources A register of interpreter and other advocacy and support services is available for the

workforce and patients Audits of patient clinical records and informed consent forms Results of patient and/or carer satisfaction surveys and actions taken to address

issues identified regarding informed consent

MM

SM


D 1.18.3 Mechanisms are in place to align the information provided to patients with their capacity to understand

Policies, protocols and/or procedures on communicating and providing information to patients and/or carers

Agenda papers, meeting minutes and/or reports note consumer involvement on committee(s) responsible for development of patient information materials

Consumers evaluation reports regarding patient information material Patient information sheets or resources available in a range of languages and

formats, consistent with the patient profile Results of patient and/or carer satisfaction surveys regarding patient information

material

MM

SM


Link with Standard 1.17.3 and Standard 2

D 1.18.4 Patients and carers are supported to document clear advanced care directives and/or treatment-limiting orders

Policies, procedures and/or protocols on advanced care and end of life care that are consistent with jurisdictional guidelines and directives

Patient information packages or resources about advanced care directives A register of interpreter and other advocacy and support services that are available

for the workforce and patients Patient clinical records note information provided to patients on advanced care or

end of life directives Audit of patient clinical records that contain advanced care directives or end of life

plans

MM

SM


N/A

Link with Standard 9.8 if applicable

C 1.19 Implementing procedures that protect the confidentiality of patient clinical records without compromising appropriate

1.19.1 Patient clinical records are available at the point of care

Policies, procedures and/or protocols on retrieving patients clinical records and protecting patient confidentiality

Observational audits of the workforce accessing electronic or hard copies of patient clinical records and maintaining confidentiality in clinical areas

MM

SM







Self assessment

clinical workforce access to patient clinical information

C 1.19.2 Systems are in place to restrict inappropriate access to and dissemination of patient clinical information

Policies, procedures and/or protocols on sharing patient information by telephone, electronically and other methods, consistent with federal and state or territory privacy legislation and department and insurers requirements

Code of conduct that includes privacy and confidentiality of patient information Secure archival storage system Secure storage system in clinical areas Workforce confidentiality agreements Computers that are password protected Patient clinical records that include consent for transfer of information to other

service providers or national health related register/s Record of ethics approval for research activities

MM

SM


C 1.20 Implementing well designed, valid and reliable patient experience feedback mechanisms and using these to evaluate the health service performance

1.20.2 Data collected from patient feedback systems are used to measure and improve health service in the organisation

Data analysis and reports of consumer feedback Results of patient and/or carer satisfaction surveys Register of patient comments and complaints Quality improvement plan includes actions to address issues identified Strategic, business and quality improvement plans describe how patient and/or

carer feedback was used to evaluate the health service performance

MM

SM



Additional information and resources

Australian Charter of Healthcare Rights. Australian Commission on Safety and Quality in Health Care: http://www.health.gov.au/internet/safety/publishing.nsf/content/com-pubs_ACHR

National Safety and Quality Framework. Australian Commission on Safety and Quality in Health Care: www.safetyandquality.gov.au

Open Disclosure Standard: A National Standard for Open Communication in Public and Private Hospitals, following an Adverse Event in Health Care. Australian Council for Safety and Quality in Health Care, 2005: http://www.health.gov.au/internet/safety/publishing.nsf/Content/C3D94BA657FEE027CA2573E00000B3FA/$File/opendisclfact.pdf

http://www.health.gov.au/internet/safety/publishing.nsf/Content/a-zpublicationss-u/$File/credentl.pdf

http://www.health.gov.au/internet/safety/publishing.nsf/Content/a-zpublicationss-u/$File/credentl.pdf

http://www.health.gov.au/internet/safety/publishing.nsf/Content/C3D94BA657FEE027CA2573E00000B3FA/$File/opendisclfact.pdf

http://www.safetyandquality.gov.au/

http://www.health.gov.au/internet/safety/publishing.nsf/content/com-pubs_ACHR

http://www.health.gov.au/internet/safety/publishing.nsf/content/com-pubs_ACHR


Standard 2: Partnering with ConsumersLeaders of a health service organisation implement systems to support partnering with patients, carers and other consumers to improve the safety

and quality of care. Patients, carers, consumers, clinicians and other members of the workforce use the systems for partnering with consumers.

The intention of this Standard is to:

Create a health service that is responsive to patient, carer and consumer input and needs.

Context

This Standard provides the framework for active partnership with consumers by health service organisations. It is expected that this Standard will

apply in conjunction with Standard 1, ‘Governance for Safety and Quality in Health Service Organisations’, in the implementation of all other

Standards.

Criteria to achieve the Partnering with Consumers Standard:

Consumer partnership in service planning

Consumer partnership in designing care

Consumer partnership in service measurement and evaluation



Criterion: Consumer partnership in service planning Governance structures are in place to form partnerships with consumers and/or carers.




Self Assessment

D 2.1 Establishing governance structures to facilitate partnership with consumers and/or carers

2.1.1 Consumers and/or carers are involved in the governance of the health service organisation

Policies, procedures and/or protocols on how to engage consumers and carers in the governance of the health service organisations are in place

Consumers and carers are represented and supported on boards and/or committees

Mechanisms used to engage consumer representatives of the local community are reflected in policy, committee terms of reference and position descriptions

Financial and physical resources are available to support consumer participation and input at the governance level

Agenda papers, meeting minutes and/or reports of relevant committee(s) show consumer involvement in governance activities

MM

SM


(i) Clinical leaders and senior managers will need to draw on a wide range of sources and types of information when involving consumers in the health service organisation’s processes – formal and informal, real-time and periodic, quantitative and qualitative, ad hoc and systematic. The key to maximizing the benefits of consumer input is to triangulate various sources of intelligence.

D 2.1.2 Governance partnerships are reflective of the diverse range of backgrounds in the population served by the health service organisation, including those people that do not usually provide feedback

Demographic profile of the organisation Consumer representatives reflect the population profile of the health service Consumer representation in governance activities reflects diverse population

serviced by health care organisation

MM

SM


(i) Consumer engagement strategies should address the diversity in the population service by the health service organisation . Strategies may include: mechanisms such as meetings, conferences, forums, working groups, surveys, interviews and

morning tea) to ensure that input is provided by a range of consumers and community members formal and informal mechanisms to engage consumers in the short and long term interpreters or advocates for people with special needs activities that recognise and engage with members of the community who may find it difficult to

participate in traditional governance structures including elderly people, people with disabilities, youth, the homeless, traumatised individuals, people who as individuals or communities have had previous negative experiences with health services, for example refugees, some Aboriginal people, Holocaust survivors.






Self Assessment

C 2.2 Implementing policies, procedures and/or protocols for partnering with patients, carers and consumers in: strategic

and operational/services planning

decision making about safety and quality initiatives

quality improvement activities

2.2.1 The health service organisation establishes mechanisms for engaging consumers and/or carers in the strategic and/or operational planning for the organisation

Policies, procedures and/or protocols on involving patients, carers and consumers in organisational decision making

Documentation and records of processes used to establish a representative body of patients, carers and consumers who provide input into strategic and/or operational planning.

Agendas, meeting minutes and/or reports of the relevant committee(s) that show input form consumers and/or carers into strategic or operational planning

Consultation strategies and reports detailing involvement of consumers in decision making

MM

SM


C 2.2.2 Consumers and/or carers are actively involved in decision making about safety and quality

Policies, procedures and/or protocols on involving patients, carers and consumers in organisational decision making about safety and quality

Agendas, meeting minutes and reports of relevant committee meetings reflect consumer involvement in decision making about safety and quality

Consultation strategies and reports detailing involvement of consumers in decision making

MM

SM


D 2.3 Facilitating access to relevant orientation and training for consumers and/or carers partnering with the organisation

2.3.1 Health service organisations provide orientation and ongoing training for consumers and/or carers to enable them to fulfil their partnership role

Information brochure for consumer representatives (which outlines roles and responsibilities, key policies and so on)

Orientation and ongoing training resources for consumers and/or carers Records of attendance at training by patients, carers and consumers at training Consumer evaluation reports of orientation or training sessions

MM

SM


(i) Patients’ or consumers’, and carers’ training may include: orientation to the service consumer mentoring consumer buddy system (consumer to consumer) briefing and debriefing science and advocacy training

C2.4 Consulting consumers on patient information distributed by the organisation

2.4.1 Consumers and/or carers provide feedback on patient information publications prepared by the health service organisation (for distribution to patients)

Reports describe patient, carer and consumer feedback sought and where feedback has been utilised

Reports of focus groups including consumer input into the identification of barriers to health information

MM

SM







Self Assessment

C2.4.2 Action is taken to incorporate consumer and/or carers’ feedback into publications prepared by the health service organisation for distribution to patients

Reports describe patient, carer and consumer feedback sought and where feedback has been utilised

Risk register or log that includes actions to address identified risks Communication material developed for the workforce and/or patients

MM

SM




Criterion: Consumer partnership in designing careConsumers and/or carers are supported by the health service organisation to actively participate in the improvement of the patient experience and patient health outcomes.




Self Assessment

D 2.5 Partnering with consumers and/or carers to design the way care is delivered to better meet patient needs and preferences

2.5.1 Consumers and/or carers participate in the design and redesign of health services

Consultation strategies and reports that detail active participation and contribution of patients, carers and consumer, and the modifications made as a result

Project planning and implementation reports detailing patient, carer and consumer involvement

Programs incorporating or modified following consumer feedback

MM

SM


C 2.6 Implementing training for clinical leaders, senior management and the workforce on the value of and ways to facilitate consumer engagement and how to create and sustain partnerships

2.6.1 Clinical leaders, senior managers and the workforce access training on patient-centred care and the engagement of individuals in their care

Ongoing training resources for clinical leaders, senior managers and the workforce on patient-centred care

Attendance records for workforce training on patient-centred care Evaluation reports of patient-centred care training program

MM

SM


D 2.6.2 Consumers and/or carers are involved in training the clinical workforce

Records of consumers and/or carers engaged in the development of training content and material to the clinical workforce

Records of consumers and/or carers engaged in the delivery of training to the clinical workforce

Record of input from consumers incorporated into training Record of consumer and/or carer feedback from their participation in clinical

workforce training

MM

SM




Criterion: Consumer partnership in service measurement and evaluationConsumers and/or carers receive information on the health service organisation’s performance and contribute to the ongoing monitoring, measurement and evaluation of performance for continuous quality improvement.




Self Assessment

C 2.7 Informing consumers and/or carers about the organisation’s safety and quality performance in a format that can be understood and interpreted independently

2.7.1 The community and consumers are provided with information that is meaningful and relevant to the organisation’s safety and quality performance

Agenda papers, meeting minutes and/or reports of relevant committees that involve consumers in safety and quality projects

Feedback from patients, carers and consumers related to the organisations safety and quality performance from sources such as surveys, complaints information, feedback box or from consumers on committees

Annual report and/or newsletters detailing action taken to address identified safety and quality issues

Safety and quality outcomes information provided to patients in areas such as patient waiting areas

MM

SM


D 2.8 Consumers and/or carers participating in the analysis of safety and quality performance information and data, and the development and implementation of action plans

2.8.1 Consumers and/or carers participate in the analysis of organisational safety and quality performance

Consultation strategies and reports detailing patient, carer and consumer involvement

Project plans and implementation reports detailing patient, carer and consumer involvement.

Agenda papers, meeting minutes, and/or notes of meetings with patients

MM

SM


D 2.8.2 Consumers and/or carers participate in the planning and implementation of quality improvements

Record of consumer involvement in safety and quality projects Quality improvement plan includes actions to address issues identified Examples of improvement activities that have been implemented and evaluated

MM

SM


D 2.9 Consumers and/or carers participating in the evaluation of patient feedback data and

2.9.1 Consumers and/or carers participate in the evaluation of patient feedback data

Agenda papers, meeting minutes and reports of relevant committees record actions related to patient feedback

Record of consumer input into setting areas of priority and improvement strategies from patient impression survey data

Consumer recommendations are included in agenda papers, meeting minutes and/or reports of relevant committees

MM

SM







Self Assessment

development of action plans

D 2.9.2 Consumers and/or carers participate in the implementation of quality activities relating to patient feedback data

Record of consumer input into setting areas of priority and improvement strategies from patient feedback data

Agenda papers, meeting minutes and reports of relevant committees record actions related to patient feedback

MM

SM



The Australian Commission on Safety and Quality in Health Care Patient-centred care: Improving quality and safety through partnerships with patients and consumers http://www.safetyandquality.gov.au/internet/safety/publishing.nsf/Content/PCCC


http://www.safetyandquality.gov.au/internet/safety/publishing.nsf/Content/2D1DB0E58A0E79C0CA2578E900077EB6/$File/PCC_Paper_August.pdf


Standard 3: Preventing and Controlling Healthcare Associated Infections

Clinical leaders and senior managers of a health service organisation implement systems to prevent and manage healthcare associated infections and communicate these to all workforce to achieve appropriate outcomes. Clinicians and other members of the workforce use the healthcare associated infection prevention and control systems.

The intention of this Standard is to: Prevent patients from acquiring preventable healthcare associated infections and effectively manage infections when they occur by using evidence-based strategies.

ContextIt is expected that this Standard will be applied in conjunction with Standard 1, ‘Governance for Safety and Quality in Health Service Organisations’ and Standard 2, ‘Partnering with Consumers’.

Criteria to achieve the Preventing and Controlling Healthcare Associated Infections Standard:Governance and systems for infection prevention, control and surveillanceInfection prevention and control strategiesManaging patients with infections or colonisationsAntimicrobial stewardshipCleaning, disinfection and sterilisationCommunicating with patients and carers



Criterion: Governance and systems for infection prevention, control and surveillance

Effective governance and management systems for healthcare associated infections are implemented and maintained.

C/D This criterion will be achieved by: Actions required

Examples of evidence that can be used to demonstrate an action is being met.


Self assessment

C3.1 Developing and implementing governance systems for effective infection prevention and control to minimise the risks to patients of health care associated infections

3.1.1 A risk management approach is taken when implementing policies, procedures and/or protocols for:

standard infection control precautions

transmission-based precautions

aseptic non-touch technique

safe handling and disposal of sharps

prevention and management of occupational exposure to blood and body substances

environmental cleaning and disinfection

antimicrobial prescribing

outbreaks or unusual clusters of communicable infection

processing of reusable medical devices

single-use devices surveillance and

reporting of data where relevant

reporting of communicable and notifiable diseases

provision of risk assessment guidelines to workforce

Policies, procedures and/or protocols are in place for items listed in 3.1.1 Policies, procedures and/or protocols

o are based on best practice and identifying legislative requirements, including Australian Guidelines for the Prevention and Control of Infections in Health Care (NHMRC 2010) and/or additional jurisdictional protocols

o use nationally agreed definitions for healthcare associated infections (HAI)o include the date the policy was implemented and scheduled review dateo provide links to relevant resource materialo incorporate amendments approved following incidence, national changes in

policy or policy reviewo specify the mechanisms and tools for checking compliance with infection

control policies A risk assessment tool, such as the AS/NZS 31000:2009 Risk Management

Standards is in use throughout the organisation

MM

SM







Self assessment

exposure-prone procedures

C3.1.2 The use of policies, procedures and/or protocols is regularly monitored.

Infection control, clinical risk or other relevant committee terms of reference, agenda papers, meeting minutes and/or reports

Organisational strategic plans that describe the mechanisms for identifying, escalating and reviewing HAI risks and mechanisms for organisation consultation

Register or report on review of infection risks or data for interventions to manage HAI risks

Observational audits and/or reports from data systems

MM

SM


Link to Standard 1.2

C3.1.3 The effectiveness of the infection prevention and control systems are regularly reviewed at the highest level of governance in the organisation

Detail of strategies for improvement recorded in, for example, agenda papers, meeting minutes and/or reports of relevant committees

Education resources and training attendance records Infrastructure (such as hand basins), instruments (such as sterile packs),

and other equipment (such as solutions) necessary to comply with policy, protocol and procedures available and accessible to the workforce

MM

SM


D3.1.4 Action is taken to improve the effectiveness of infection prevention and control policies, procedures and/or protocols



MM

SM


C3.2 Undertaking surveillance of healthcare associated infections

3.2.1 Surveillance systems for healthcare associated infections are in place

Data on healthcare associated infections for Staphylococcus aureus bacteraemia from any sources that may include central-line associated blood stream infections multi-resistant organisms, catheter-associated urinary tract infection or other causes of high risk infection that is appropriate to the organisation

Surveillance for infections on discharge for specified organisational surgical procedures

Data collection forms or format Clinical audits and action plans

MM

SM


(i) Access to infection control personnel and/or microbiologists will differ between metropolitan and rural areas. Metropolitan health service organisations will have infection control personnel and/or microbiologists onsite whereas rural health service organisations may be required to access infection






Self assessment

control personnel and/or microbiologists off site, for example from a private pathology service, as a resource

C3.2.2 Healthcare associated infections surveillance data are regularly monitored by the delegated workforce and/or committees

Relevant committee papers, including infection control, clinical risk or other committees with delegated responsibilities for health care associated infection surveillance

Reports to senior executive committees Annual reports containing healthcare associated infections surveillance data Regular reports to owners, regulators, insurers and health departments Clinical workforce monitoring proformas, review schedules and audit

records Infection prevention plans and strategies, or equivalent documents that are

reviewed and regularly revised in consultation with relevant stakeholders such as infection control personnel and infectious diseases physicians

Information generated from the surveillance system that may:o shows trends in healthcare associated infections following improvement

actions o provide benchmarked data on preventable healthcare associated infections

MM

SM


C 3.3 Developing and implementing systems and processes for reporting, investigating and analysing health care associated infections, and aligning these systems to the organisation’s risk management strategy

3.3.1 Mechanisms to regularly assess the healthcare associated infection risks are in place

Guidelines, tools and supports, such as the Australian Guidelines for the Prevention and Control of Infections in Health Care (NHMRC 2010) that are accessible to the workforce responsible for assessing HAI risks

Records of healthcare associated infection incidents collected and analysed Completed risk assessment documents Terms of reference, agenda papers, meeting minutes and reports of

relevant committees Current risk management plan and register Accountabilities for acting on HAI in job descriptions

MM

SM


v3.3.2 Action is taken to reduce the risks of healthcare associated infections

Description of action/s taken in forums and formats such as, presentations, posters and reports



MM

SM


C3.4 Undertaking quality improvement activities

3.4.1 Quality improvement activities are implemented to

A continuous quality improvement plan that shows implementation, regular review and revision

An amended register or log of implemented improvement activities and

MM

SMAustralian Commission on Safety and Quality in Health Care 36





Self assessment

to reduce healthcare associated infections through changes to practice

reduce and prevent healthcare associated infections

outcomes Risk register or log that includes actions to address identified risks


C3.4.2 Compliance with changes in practice are monitored

Observational audits and/or reports from data systems Usage rates of specified products and equipment Data collected and monitored from pre and post change implementation Data base of the workforce completion of in-service and other education on

practice changes

MM

SM


D3.4.3 The effectiveness of changes to practice are evaluated

Amended policies, procedures and/or protocols Evaluation reports and follow up audits Review of outcomes Performance indicator trends demonstrating improvements

MM

SM




Criterion: Infection prevention and control strategiesStrategies for the prevention and control of healthcare associated infections are developed and implemented.

C/DThis criterion will be achieved by: Actions required



Self assessment

C 3.5 Developing, implementing and auditing a hand hygiene program consistent with the current national hand hygiene initiative

3.5.1 Workforce compliance with current national hand hygiene guidelines is regularly audited

Results of audited clinical environments against the 5 Moments for Hand Hygiene audit tool

Observational audits of hand hygiene Audits of the amounts of hand hygiene products used Records of completed hand hygiene education and training consistent with

guidelines such as the Australian Guidelines for the Prevention and Control of Infections in Health Care (NHMRC 2010)

Analysis of trends in healthcare associated infection rates in the organisation Hand hygiene plan endorsed by management Business plan to resource hand hygiene project

MM

SM


C3.5.2 Compliance rates from hand hygiene audits are regularly reported to the highest level of governance in the organisation

Agenda papers, meeting minutes and/or reports for the senior executive and/or committees or equivalent

Medical advisory committee agenda papers, meeting minutes and/or reports that include hand hygiene compliance rates

MM

SM


C3.5.3 Action is taken to address non-compliance, or the inability to comply, with the requirements of the current national hand hygiene guidelines

Agenda papers, meeting minutes and/or reports of relevant committees that include details of hand hygiene strategies and actions

Risk assessment that identifies reasons for hand hygiene non-compliance and actions

Amended procedures, protocols or work practices that address issues of hand hygiene non-compliance

Records of education and training on hand hygiene Review of equipment, supplies and products required to comply with hand

hygiene requirements

MM

SM


C3.6 Developing, implementing and monitoring a risk-based workforce immunisation program in accordance with the current National Health and Medical Research Council Australian immunisation guidelines

3.6.1 A workforce immunisation program that complies with current national guidelines is in use

Agenda papers, meeting minutes and/or reports of relevant committees Policies, procedures and/or protocols that are consistent with national

guidelines and jurisdictional legislation and policy directives on immunisation Register, report or review of vaccinations’ availability and correct storage of

vaccine such as the ‘cold chain’ system Documents accessible to authorised personnel that:

o identify healthcare workers’ immunisation status at commencement of employment and throughout their period of employment

o identify subsequent additional vaccination requirements for healthcare workerso record immunisation refusals and organisational responses to refusals

MM

SM







Self assessment

(i) Some health care organisations may outsource their immunisation requirements

C3.7 Promoting collaboration with occupational health and safety programs to decrease the risk of infection or injury to healthcare workers

3.7.1 Infection prevention and control consultation related to occupational health and safety policies, procedures and/or protocols are implemented to address:

communicable disease status

occupational management and prophylaxis

work restrictions personal protective

equipment assessment of risk

to healthcare workers for occupational allergy

evaluation of new products and procedures

Policies, procedures and/or protocols for the management of occupational exposures

Policies, procedures and/or protocols that address vaccination refusal Risk assessments for healthcare workers undertaking exposure prone

procedures Occupational exposure data assessed prior to the introduction of safety

devices and equipment that minimises the risks to healthcare workers and patients Assessments of skin conditions related to dermatitis or allergy to personal

protective equipment, skin antiseptics or hand hygiene products Audits of healthcare workers who have completed competency assessments

in the use of personal protective equipment such as gloves, gowns, plastic aprons, face shields, protective eye wear and masks

Information from monitoring healthcare workers infected or colonised with an infectious agent

Audits of usage of personal protective equipment Documented health worker vaccination program consistent with current

Australian immunisation guidelines

MM

SM


C 3.8 Developing and implementing a system for use and management of invasive devices based on the current national guidelines for preventing and controlling infections in health care

3.8.1 Compliance with the system for the use and management of invasive devices is monitored

Policies, procedures and protocols based on evidence-based guidelines and the Australian Guidelines for the Prevention and Control of Infections in Health Care (NHMRC 2010)

Policies, procedures and/or protocols which include a strict single use policy Infection control, clinical risk or other relevant committee terms of reference,

agenda papers, meeting minutes and/or reports Organisational strategic plan that identifies, escalates and reviews the risks of

invasive devices and has included consultation across the organisation Register or reports on invasive device risks and/or interventions to manage

these risks Observational and clinical audit tools and/or data collection systems Observational audits on the integrity of critical instruments storage and

packaging

MM

SM


C3.9 Implementing protocols for invasive device procedures regularly performed

3.9.1 Education and competency-based training in invasive devices protocols and use is provided for the

Orientation and induction programs on use of invasive devices Records detailing the numbers or percentage of the workforce who have

undertaken education and training related to the use of invasive devices Education materials related to use of invasive devices Education plans for ongoing education and training of the workforce who

MM

SM






Self assessment

within the organisation workforce who perform procedures with invasive devices

perform procedures with invasive devices Evaluations of education and competency-based training needs


C3.10 Developing and implementing protocols for aseptic non-touch technique

3.10.1 The clinical workforce is trained in aseptic non-touch technique

Orientation program resources and training attendance records relating to aseptic non-touch technique

Education resources and attendance records, and learning packages related to aseptic non-touch technique

Records detailing the numbers or percentage of the workforce who have undertaken education and training related to aseptic non-touch technique

Plans for ongoing education and training of the workforce who perform procedures requiring aseptic non-touch technique

Evaluations of education and competency-based training needs

MM

SM


C3.10.2 Compliance with aseptic non-touch technique is regularly audited

Policies, procedures and protocols on aseptic non-touch techniques consistent with relevant policies and guidelines, including the Australian Guidelines for the Prevention and Control of Infections in Health Care (NHMRC 2010)


Organisational plans or reports detailing routine measures to audit compliance Register or reports on reviews of aseptic non-touch technique across the

organisation Observational audits and/or reports from data systems

MM

SM


C3.10.3 Action is taken to increase compliance with the aseptic non-touch technique protocols

Educational resources and training attendance records relating to aseptic non-touch techniques

Audits of accessibility of infrastructure, instruments and other equipment necessary to comply with policies, procedures and/or protocol



MM

SM


(i) Additional information on aseptic non-touch technique (ANTT) is found in the NHMRC guidelines, section B1.7.2: http://www.nhmrc.gov.au/_files_nhmrc/file/publications/synopses/CD33_InfectionControlGuidelines2010.pdf


http://www.nhmrc.gov.au/_files_nhmrc/file/publications/synopses/CD33_InfectionControlGuidelines2010.pdf


Criterion: Managing patients with infections or colonisationsPatients presenting with, or acquiring an infection or colonisation during their care are identified promptly and receive the necessary management and treatment.




Self assessment

C3.11 Implementing systems for using standard precautions and transmission- based precautions

3.11.1 Standard precautions and transmission-based precautions consistent with the current national guidelines are in use

Policies, procedures and protocols based on current national guidelines, including the Australian Guidelines for the Prevention and Control of Infections in Health Care (NHMRC 2010)

Observational audits of workplace practices, for example, environmental and hand hygiene practices, and personal protection equipment usage

Education resources and training attendance records on systems for using standard precautions and transmission- based precautions

Observation of accessible personal protective equipment Standard and transmission based precaution signage available and accessible

to the health workforce

MM

SM


C3.11.2 Compliance with standard precautions is monitored


Organisational strategic plans that review compliance and include consultation across the organisation

Register or reports on review of compliance with standard precautions Observational audits and/or reports from data systems and surveillance

programs

MM

SM


C3.11.3 Action is taken to improve compliance with standard precautions

Risk register or log that includes actions to address identified risks Agenda papers, meeting minutes and/or reports of relevant committee(s) that detail

improvement actions taken Quality improvement plan includes actions to address issues identified Examples of improvement activities that have been implemented and evaluated Communication material developed for the workforce and/or patients Provision of infrastructure, instruments, and other equipment necessary to

comply with policies, procedures and/or protocols

MM

SM


C3.11.4 Compliance with transmission-based precautions is monitored


Organisational strategic plans that review compliance that has included consultation across the organisation

Register or reports on review of compliance with transmission-based precautions Observational audits and/or reports from data systems Education resources and training attendance records associated with

transmission-based precautions

MM

SM







Self assessment

C3.11.5 Action is taken to improve compliance with transmission-based precautions


SM


D 3.12 Assessing the need for patient placement based on the risk of infection transmission

3.12.1 A risk analysis is undertaken to consider the need for transmission-based precautions including:

accommodation based on the means of transmission

environmental controls through air flow

transportation within and outside the facility

cleaning procedures

equipment requirements

Policies procedures and protocols based on risk assessment, analysis and risk management processes

Risk assessment reports, register or log Laboratory-based data reports Patient clinical records and case notes Infection control, clinical risk or other relevant committee terms of reference,

agenda papers, meeting minutes and/or reports Audits of risk assessment practices against guidelines and policies

MM

SM


C3.13 Developing and implementing protocols relating to the admission, receipt and transfer of patients with an infection

3.13.1 Mechanisms are in use for checking for pre-existing healthcare associated infection or communicable disease on presentation for care

Policies, procedures and/or protocols addressing identification of pre-existing healthcare associated infection or communicable disease


Policies, procedures and/or protocols addressing receipt and transfer of patients with infections

Audits of patient histories Number of requests for medical records of previous admissions Audits of screening for healthcare associated infections or communicable

diseases in accordance with local/state screening policies

MM

SM


C3.13.2 A process for

Policies, procedures and/or protocols related to transfer of care MMAustralian Commission on Safety and Quality in Health Care 42





Self assessment

communicating a patient’s infectious status is in place whenever responsibility for care is transferred between service providers or facilities

Handover sheets, discharge forms or similar documents stating infectious status Electronic flagging of medical notes and discharge summaries Transfer policy and transfer form

SM




Criterion: Antimicrobial stewardship Safe and appropriate antimicrobial prescribing is a strategic goal of the clinical governance system.




Self assessment

C 3.14 Developing, implementing and regularly reviewing the effectiveness of the antimicrobial stewardship system

3.14.1 An antimicrobial stewardship program is in place

Organisation-wide antimicrobial prescribing policies, guidelines and tools that are consistent with guidelines such as Therapeutic Guidelines: Antibiotic

Agenda papers, meeting minutes and/or reports of relevant committees Reports and recommendations from a antimicrobial management team Educational resources and training attendance records associated with

addressing antimicrobial usage, development of resistance, and judicious prescribing

Audits of antimicrobial usage, particularly in high antimicrobial usage areas Restriction, approval or review systems to guide the use of broad spectrum

antimicrobials Referral to specialist infection disease practitioner and/or microbiologist

MM

SM


C3.14.2 The clinical workforce prescribing antimicrobials have access to current endorsed therapeutic guidelines on antibiotic usage

Access by clinical workforce prescribing antimicrobials to current endorsed therapeutic guidelines on antibiotic usage (Therapeutic Guidelines: Antibiotic) MM

SM


C3.14.3 Monitoring of antimicrobial usage and resistance is undertaken

Prescribing guidelines, policies procedures and/or protocols Agenda papers, meeting minutes and reports of relevant committees Medication audits Records of antibiotic consumption Reviews of antibiotic usage and feedback to prescribers Laboratory-based data including analysis of antimicrobial resistance

MM

SM


(i) This may not be applicable for some day surgeries. Examples may include: specialist proceduralist scope of practice laboratory surveillance and antimicrobial medication resistance prescribing behaviour practices and prescribing guidelines standing orders for antimicrobial medication and prescribing

C3.14.4 Action is taken to improve the effectiveness of antimicrobial


SM






Self assessment

stewardship NM - add to action plan



Criterion: Cleaning, disinfection and sterilisation Healthcare facilities and the associated environment are clean and hygienic. Reprocessing of equipment and instrumentation meets current best practice guidelines.




Self assessment

C3.15 Using risk management principles to implement systems that maintain a clean and hygienic environment for patients and healthcare workers

3.15.1 Policies, procedures and/or protocols for environmental cleaning that address the principles of infection prevention and control are implemented, including:

maintenance of building facilities

cleaning resources and services

risk assessment for cleaning and disinfection based on transmission-based precautions and the infectious agent involved

waste management within the clinical environment

laundry/linen transportation cleaning and storage

appropriate use of personal protective equipment

Environmental cleaning policies, procedures and protocols consistent with current guidelines such as the Australian Guidelines for the Prevention and Control of Infections in Health Care (NHMRC 2010)

Maintenance schedules for infrastructure Cleaning schedules Risk assessments Audits of the collection, transport and storage of linen Waste management plan Material safety data sheets or chemical register of cleaning resources utilised Observational audits of the use of personal protection equipment Service schedules for infection prevention and control equipment

MM

SM


C 3.15.2 Policies, procedures and/or protocols for environmental cleaning are regularly reviewed

Documentation and/or data related to routine review of policies, procedures and protocols may include:

Agenda papers, meeting minutes and/or reports of relevant committees Completed reviews Schedule of reviews

MM

SM







Self assessment

C3.15.3 An established environmental cleaning schedule is in place and environmental cleaning audits are undertaken regularly

Cleaning schedules that are consistent with current guidelines such as the Australian Guidelines for the Prevention and Control of Infections in Health Care (NHMRC 2010)

Agenda papers, meeting minutes and/or reports of relevant committees Environmental cleaning audit results Work instructions and job descriptions Audits of compliance with cleaning schedule

MM

SM


D3.16 Reprocessing reusable medical equipment, instruments and devices in accordance with relevant national or international standards and manufacturers’ instructions

3.16.1 Compliance with relevant national or international standards and manufacturer’s instructions for cleaning, disinfection and sterilisation of reusable instruments and devices is regularly monitored

Agenda papers, meeting minutes and/or reports of relevant committees Records of sterilisation verifying reprocessing is consistent with legislation Maintenance schedules for sterilising equipment Audits of monitoring systems for sterilisers Risk assessments where there are deviations in the requirements of relevant

standards and the manufacturer’s instructions Observational audits of cleaning, disinfection and sterilisation processes Audit results for sterile stock integrity and supply

MM

SM


C3.17 Implementing systems to enable the identification of patients on whom the reusable medical devices have been used

3.17.1 A traceability system that identifies patients who have a procedure using sterile reusable medical instruments and devices is in place

Agenda papers, meeting minutes and/or reports of relevant committees Register or record of patients who have, or have had, procedures using

reusable instruments and devices Audits of medical records (patient clinical records and case notes or records

regarding the use of reusable medical instruments and devices)

MM

SM


C3.18 Ensuring workforce who decontaminate reusable medical devices undertake competency-based training in these practices

3.18.1 Action is taken to maximise coverage of the relevant workforce trained in a competency-based program to decontaminate reusable medical devices

Agenda papers, meeting minutes and/or reports of relevant committees that detail improvement actions

Education and training outlines or materials and attendance data Schedule of competency based training and targets Numbers or proportion of workforce who has completed orientation programs

and ongoing education and training Relevant current standards and guidelines such as the Australian Guidelines

for the Prevention and Control of Infections in Health Care (NHMRC 2010) are accessible to the relevant workforce

MM

SM




Criterion: Communicating with patients and carers

Information on healthcare associated infections is provided to patients, carers, consumers and service providers.




Self assessment

C 3.19 Ensuring consumer specific information on the management and reduction of healthcare associated infections is available at the point of care

3.19.1 Information on the organisation’s corporate and clinical infection risks and initiatives implemented to minimise patient infection risks is provided to patients and/or carers

Communication materials used for patient education Patient education materials translated into languages other than English Risk alert information and materials provided to patients and their carers, for

example respiratory precautions Public health risk alert material placed on public display in areas such as

reception and waiting areas Publication of information on infection rates and risks that are accessible to the

public Web site information available to the public Information provided to visiting medical specialist for distribution to patients Information included in pre-admission information dedicated to infection control

practices

MM

SM


(i) National Health and Medical Research Council (NHMRC) has an example of consumer fact sheets at: www.nhmrc.gov.au

D 3.19.2 Patient infection prevention and control information is evaluated to determine if it meets the needs of the target audience

Results of patient satisfaction survey on patient infection prevention and control information

Documented comments and complaints received from patients and carers Reports on the evaluation of patient information Terms of reference, agenda papers, meeting minutes and reports of relevant

committees Consumer representation on relevant focus groups, committees or working

parties

MM

SM



Additional information and resourcesHealthcare Associated Infection (HAI) Program, Commission on Safety and Quality in Health Care (ACSQHC) HREF="http://www.safetyandquality.gov.au/internet/safety/publishing.nsf/Content/PriorityProgram-03"

Additional information in relation to Hand Hygiene may be found on the Hand Hygiene Australia website: www.hha.org.au

National Health and Medical Research Council, Australian Guidelines for the Prevention and Control of Infections in Health Care. NHMRC, 2010: www.nhmrc.gov.au

National Health and Medical Research Council, Australian Guidelines for the Prevention and Control of Infection in Healthcare, Consultation Draft, 7January 2010:.www.nhmrc.gov.au

Therapeutic Guidelines: Antibiotic is located by the following link: www.tga.org.au

Cleaning schedules guidelines are found in: Australian Guidelines for the Prevention and Control of Infections in Health Care: Section B5.1 (NHMRC) 2010. www.nhmrc.gov.au

http://www.nhmrc.gov.au/

http://www.tga.org.au/

http://www.nhmrc.gov.au/


Standard 4: Medication Safety

Clinical leaders and senior managers of a health service organisation implement systems to reduce the occurrence of medication incidents, and

improve the safety and quality of medicine use. Clinicians and other members of the workforce use the systems to safely manage medicines.


Ensure competent clinicians safely prescribe, dispense and administer appropriate medicines to informed patients and carers.

Context

It is expected that this Standard will be applied in conjunction with Standard 1 ‘Governance for Safety and Quality in Health Service Organisations’

and Standard 2 ‘Partnering with Consumers’.

Criteria to achieve the Medication Safety Standard:

Governance and systems for medication safety

Documentation of patient information

Medication management processes

Continuity of medication management



Criterion: Governance and systems for medication safety Health service organisations have mechanisms for the safe prescribing, dispensing, supplying, administering, storing, manufacturing, compounding and monitoring of the effects of medicines.




Self assessment

C4.1 Developing and implementing governance arrangements and organisational policies, procedures and/or protocols for medication safety, which are consistent with national and jurisdictional legislative requirements, policies and guidelines

4.1.1 Governance arrangements are in place to support the development, implementation and maintenance of organisation-wide medication safety systems

Policies, procedures, protocols and/or guidelines for safe management and quality use of medicines

Agenda papers, meeting minutes and/or reports of relevant committee(s) such as management committee or governance committee

Strategic and operational plans detaining the development, implementation and maintenance of organisational wide medication safety systems

Responsibility organisation wide medication safety systems at all levels of the organisation designated for board or owners, senior executive or senior managers, unit or facility managers and clinicians

Information used to identify patient safety and quality medication risks Quality improvement plan outlines designated responsibilities and timeframes for

completion of improvement actions Orientation and ongoing training resources for the workforce on their roles,

responsibilities and accountabilities for the medication management system Records of attendance at training by the workforce on the medication

management systems and medication safety A mechanism for dissemination of medication safety alerts Observational audit of the workforce access to online and hard copy resources

such as MIMS, therapeutic guidelines, pharmacy manual and guidelines for administration of injectable medicines

MM

SM


Link to Standard 1C

4.1.2 Policies, procedures and/or protocols are in place that are consistent with legislative requirements, national, jurisdictional and professional guidelines

Policies, procedures, protocols and/or guidelines related to safe management and quality use of medicines

Policies, procedures, protocols and/or guidelines are accessible to the clinical workforce, managers and the senior executive

Actions taken to implement policies, procedures and/or protocols throughout the organisation such as distribution list for policies, procedures and/or protocols

Observational audit of the accessibility and use of policy documents by the workforce

Audits of compliance with medication management policies

MM

SM







Self assessment

Link to Standards 1.1.1, 1.3.1 and 1.3.2

(i) The policy framework for medication management should apply across the whole organisation and cover the steps and process and medication management cycles outlined in the Australian Pharmaceutical Advisory Council’s Guiding Principles to achieve continuity in medication management. Examples of subject areas could include (but are not limited to): governance arrangements for the medication management system including the evaluation and

introduction of new medicines roles, responsibilities and accountabilities for clinical and organisational medication management

activities procedures for safe prescribing, dispensing, supplying, administering, storing, manufacturing,

compounding and monitoring of the effects of medicines procedures for managing high risk medicines including a list of high risk or alert medicines procedures for labelling injectable medicines, fluids and lines list of approved abbreviations used in prescribing and administering of medicines list of medicine approved for use in the facility procedure for procuring medicines procedures for reporting medication incidents and adverse drug reactions orientation and ongoing training requirements for all clinical the workforce medication

management system and medication safety evaluation, audit and feedback






Self assessment

C4.2 Undertaking a regular, comprehensive assessment of medication use systems to identify risks to patient safety and implementing system changes to address the identified risks

4.2.1 The medication management system is regularly assessed

Completed risk assessments of: o systems for managing medicines in the organisationo processes for handling high risk medicines and’ action plans

Separate risk assessments, registers and/or action plans completed for each unit or service area

Audits of compliance with policies, procedures and/or protocols on medication management systems

Risk register or log that includes actions to address identified risks Data from the incident reporting system Agenda papers, meeting minutes and/or reports of relevant committee(s)

such as drug and therapeutics committee, clinical governance committee or senior executive committee that include medication incident reports

Safety and quality presentations delivered to the executive and/or management committees

Reports on the implementation of recommendations from National and State or Territory medication safety alerts

MM

SM


Link to Standard 4.4.1

(i) Risk assessment tools may include: self assessment tools such as the Self Assessment of Medication Safety in Australian Hospitals,

Self Assessment of Antithrombotic Therapy in Australian Hospitals Failure Mode Effect and Analysis procedure to identify risks when implementing practice

changes, systems redesign audits in areas where there is a risk to patient safety such as: prescribing, dispensing and

administration of chemotherapy and other high risk medications

C4.2.2 Action is taken to reduce the risks identified in the medication management system

Risk register or log that includes actions to address identified risks Agenda papers, meeting minutes and/or reports of relevant committee(s)

that detail improvement actions taken Quality improvement plan includes actions to address issues identified Examples of improvement activities that have been implemented and

evaluated Communication material developed for the workforce and/or patients such

as memos and patient information leaflets

MM

SM







Self assessment

C4.3 Authorising the relevant clinical workforce to prescribe, dispense and administer medications

4.3.1 A system is in place to verify that the clinical workforce have medication authorities appropriate to their scope of practice

Policies, procedures and/or protocols detailing roles responsibilities and accountabilities of clinical workforce for medication management processes

Delegations detaining clinic positions that have the authority to prescribe dispense or administer medicines

A list of individual workforce members with authority to prescribe medicines Position descriptions detailing responsibilities, accountabilities and scope of

practice of the workforce in medication management Orientation and ongoing training resources for the clinical workforce who

prescribe, dispense and administer medications Record of attendance at training by the clinical workforce on the medication

system

MM

SM


(i) Policy, procedures and/or protocols for authorising clinical workforce to prescribe, dispense and administer medicines could include: prescribing policy medicines that enrolled nurses may administer and conditions on their practice. standing orders for registered nurses to administer medicines list of nurse initiated medicines attendance at orientation and ongoing training sessions on the facility’s medication management

system and safe medication managementC

4.3.2 The use of the medications authorisation system is regularly monitored

Audits verifying that practitioners prescribing, supplying and administering medicines are authorised to do so.

Regular audits of schedule 8 registers Agenda papers, meeting minutes and/or reports of relevant committee(s)

reporting on the analysis of medication incidents

MM

SM


C4.3.3 Action is taken to increase the effectiveness of the medication authority system


SM







Self assessment

C4.4 Using a robust organisation-wide system of reporting, investigating and managing change to respond to medication incidents

4.4.1 Medication incidents are regularly monitored, reported and investigated

Policies, procedures and/or protocols for reporting and managing medication incidents and adverse medication incidents

Incident reporting management system, such as a register or log, that documents analysis and review of medication incidents

Agenda papers, meetings minutes and/or reports that demonstrate adverse medication incidents are routinely reviewed

Documented adverse medication incidents investigated Reports of root cause analyses of medication errors resulting in patient harm Audits of patient clinical records and case notes that demonstrate reporting and

investigation of adverse medication incidents, for example using trigger tools to identify adverse medicines events

Audit of compliance with policies, procedures and/or protocols

MM

SM


C4.4.2 Action is taken to reduce the risk of adverse medication incidents


SM


C4.5 Undertaking quality improvement activities to improve the safety of medicines use

4.5.1 The performance of the medication management system is regularly assessed

Results of activities such as monitoring quality use of medicines indicators and other performance measures of medication safety.

Regular (annual) auditing of the National Inpatient Medication Chart to monitor standard of documentation of prescribing and administering of medicines.

Agenda papers, meeting minutes or reports of relevant committees that show reports of audits and/or results

MM

SM


(i) Performance measures for monitoring safety and quality of medicines use could include: drug use evaluation studies use of clinical indicators such as the Clinical Indicators for Quality Use of Medicines in Australian

Hospitals audit of National Inpatient Medication Chart using national audit tool

C4.5.2 Quality improvement activities are undertaken to reduce the risk of patient harm and increase the quality and effectiveness of medicines use

Agenda papers, meeting minutes and/or reports of relevant committee(s) that detail improvement actions taken

Quality improvement plan includes actions to address issues identified Examples of improvement activities that have been implemented and evaluated Communication material developed for the workforce and/or patients regarding

changes implemented as result of medication safety audits

MM

SM




Criterion: Documentation of patient information The clinical workforce accurately records a patient’s medication history and this history is available throughout the episode of care.




Self assessment

C4.6 The clinical workforce taking an accurate medication history when a patient presents to a health service organisation, or as early as possible in the episode of care, which is then available at the point of care

4.6.1 A best possible medication history is documented for each patient

Policies, procedures and/or protocols for obtaining and documenting a best possible medication history including prescription, over the counter and complementary medicines

Admission form includes section for medication history Patient clinical records include medication history documentation and a record of

medicines the patient was taking prior to admission (including prescription, over the counter and complementary medicines)

MM

SM


(i) Policy for obtaining and recording best possible medication history could include: roles and responsibilities for the clinical workforce medication risk assessment required documentation: specifying record content, how and where to document the medication history detail of previous adverse drug reaction

C4.6.2 The medication history and current clinical information is available at the point of care

Policies, procedures and/or protocols for accessing medication history on admission and clinical information at the point of care

Observation of patient clinical records accessible at point of patient care

MM

SM


Link to Standard 1.9.1C

4.7 The clinical workforce documenting the patient’s previously known adverse drug reactions on initial presentation and updating this if an adverse reaction to a medicine occurs during the episode of care

4.7.1 Known medication allergies and adverse drug reactions are documented in the patient clinical record

Policies, procedures and/or protocols for documenting, managing and reporting adverse drug reactions

Policies, procedures and/or protocols for checking adverse drug reaction history prior to prescribing, dispensing or administering medicines

Audit of patient’s clinical records whose known adverse drug reactions are documented on the current medication chart

Audit of patient’s clinical records and case notes shows information on new adverse drug reactions and allergies is recorded, such as completed adverse drug reaction form, alert in record

Audit of electronic medicines management systems for prescribing, dispensing and administering medicines include adverse drug reaction alert systems

MM

SM


(i) Examples of performance measures for this action may include: Indicators from Clinical Indicators for Quality Use of Medicines in Australian Hospitals Results form audit of the National Inpatient Medication Chart Audit, for examples, the number of patients

administered a medication to which they have had an allergy or previous adverse drug reaction






Self assessment

C4.7.2 Action is taken to reduce the risk of adverse reactions

Policies, procedures and/or protocols for documenting, managing and reporting of adverse drug reactions

Record of the clinical workforce attending education on adverse drug reaction documentation and reporting

Audit of patient clinical records and case notes identifies patients who were administered a medication to which they have had an allergy or previous adverse drug reaction

Audit of patient clinical record confirms the adverse drug reaction (ADR) information was given to patients with a new ADR and that a copy was communicated to the primary care clinician

Register of adverse drug reactions includes actions to address the identified risks Review of the workforce feedback on adverse drug reactions Agenda papers, meeting minutes or reports of relevant committees includes reports on

adverse drug reactions Quality improvement plan includes actions to address issues identified Examples of improvement activities that have been implemented and evaluated such

as change to policy and/or procedure, feedback to the workforce

MM

SM


C4.7.3 Adverse drug reactions are reported within the organisation and to the Therapeutic Goods Administration

Policies, procedures and/or protocols reporting adverse drug reactions within the organisations and to the Therapeutic Goods Administration

Agenda papers, meeting minutes and/or reports of relevant committee(s) include actions taken to address adverse drug reaction risks

Register of adverse drug reactions includes actions to address the identified risks Record of adverse drug reaction and/or reports submitted to Therapeutic Goods

Administration

MM

SM


D 4.8 The clinical workforce reviewing the patient’s current medication orders against their medication history and prescriber’s medication plan, and reconciling any discrepancies

4.8.1 Current medicines are documented and reconciled at admission and transfer of care between healthcare settings

Policies, procedures and/or protocols on reconciling the medication orders with the medication history on admission, transfer and discharge to another health setting

Audit of patients’ clinical records in relation to current medicines reconciliation on admission, transfer and/or discharge

Audit of patient clinical records includes review of discharge prescriptions

MM

SM


Link to Standard 4.2.2, 4.6.1 and 4.12.4

(i) Examples of performance measures for this action may include: Indicators from Clinical Indicators for Quality Use of Medicines in Australian Hospitals



Criterion: Medication management processes The clinical workforce is supported for the prescribing, dispensing, administering, storing, manufacturing, compounding and monitoring of medicines.




Self assessment

C4.9 Ensuring that current and accurate medicines information and decision support tools are readily available to the clinical workforce when making clinical decisions related to medicines use

4.9.1 Information and decision support tools for medicines are available to the clinical workforce at the point of care

Current version of medicines reference texts available in patient care areas (hard copy or electronic)

Records of clinical workforce access to medicines information systems Clinical decision support tools (manual and/or electronic) accessed by staff

MM

SM


(i) Clinical decision support tools may include: medicines information texts such as Australian Medicines Handbook, Therapeutic Guidelines, Intravenous

Drug Administration Guidelines facility protocols, guidelines, medicines information tools (such as dosing cards, pocket references) inbuilt clinical decision support in electronic medication management systems including alerts for allergies,

drug interactions, access to protocols, medicines informationC

4.9.2 The use of the information and decision support tools are regularly reviewed

Risk assessment of medicines information system such as using the drug information domain in Medication Safety Self Assessment in Australian Hospitals

Agenda papers, meeting minutes and/or reports of relevant committee(s) responsible for implementing and maintaining information resources and clinical decision support tools

Workforce feedback and suggestions on decision support tools

MM

SM


(i) Review of use of electronic decision support tools used for prescribing, dispensing and administering medicines could include: reports on functions used acceptance of or bypassing of alerts for allergies, drug interactions, contraindications

C4.9.3 Action is taken to improve the availability and effectiveness of information and decision support tools


SM




C4.10 Ensuring that medicines are distributed and stored securely, safely and in accordance with the manufacturer’s directions, legislation, jurisdictional orders and operational directives

4.10.1 Risks associated with secure storage and safe distribution of medicines are regularly reviewed

Policies, procedures protocols and/or guidelines for safe distribution and storage of medicines.

Completed risk assessment of system for distributing and storing medicines Audits of compliance with policies, procedures and/or protocols

MM

SM


C4.10.2 Action is taken to reduce the risks associated with storage and distribution of medicines

Same evidence options as 4.2.2’ Documented use of ‘Tall Man’ Lettering’ system to reduce errors from look alike sound

alike medicines names. Observational audit of separation of products with similar packaging.

MM

SM


C4.10.3 The storage of temperature-sensitive medicines is monitored

Policies, procedures, protocols and/or guidelines for monitoring temperature of refrigerators and freezers used to store medicines and vaccines throughout the facility

Record of daily checks and scheduled maintenance of the medicines and vaccines refrigerator(s)

Audit of compliance with processes for daily checks of medicines and vaccines refrigerators

Document of temperature reading devices in fridges/alarm settings review, and contact processes

An alarm system and documentation of the response mechanism to activated alarms Risk register or log that includes actions to address identified risks

MM

SM


C4.10.4 A system that is consistent with legislative and jurisdictional requirements for the disposal of unused, unwanted or expired medications is in place

Policies, procedures and/or protocols on the disposal of unused, unwanted or expired medicines that align with legislative and jurisdictional requirements including Schedule 8 medicines, chemotherapy and hazardous substances

Orientation and ongoing education resources related to the disposal of unused, unwanted or expired medications

Record of attendance at training by the workforce Observation of workforce access to infrastructure and equipment necessary to comply

with policy, protocol and procedures

MM

SM


C4.10.5 The system for disposal of unused, unwanted or expired medications is regularly monitored

Audits of compliance with policies, procedures and/or protocols Risk register or log that includes actions to address identified risks MM

SM


C4.10.6 Action is taken to increase compliance with the system for storage, distribution and disposal of medications

Same evidence options as 4.2.2 Documented use of ‘Tall Man’ Lettering’ system to reduce errors from look alike sound

alike medicines names. Observational audit of separation of products with similar packaging

MM

SM




C4.11 Identifying high-risk medicines in the organisation and ensuring they are stored, prescribed, dispensed and administered safely

4.11.1 The risks for storing, prescribing, dispensing and administration of high-risk medicines are regularly reviewed

Policies, procedures and/or protocols for storing, prescribing, dispensing, administering and monitoring high risk medicines

Guidelines for prescribing, dispensing, administering and monitoring specific high risks medicines such as anticoagulants, chemotherapy, opioids, insulin are available to the clinical workforce

A list of high risk medicines as a subset of medicines used in the facility Information on actions to be taken in response to medication incidents and near

misses available in the pharmacy and clinical areas Audit of compliance with specific storage requirements for high risk medicines such as

concentrated injectables (potassium, electrolytes), opioids Audit of compliance with procedures for labelling injectable medicines, fluids and lines Completed risk assessment of management of high risk medicines Risk register or log that includes actions to address identified risks Incident reports that identify trends and implementing actions and strategies

implemented Physical security that restricts access to high risk medicines Audit of compliance with protocol, procedures and guidelines for prescribing,

dispensing, administering and monitoring specific high risks medicines such as anticoagulants, chemotherapy, opioids, insulin

MM

SM


Link with Standard 4.10.1 and Standard 5

(i) Risk assessment tools may include: Medication Safety Self Assessment in Australian Hospitals of drug standardisation, storage and

distributions domain Medication Safety Self Assessment for Antithrombotic Therapy

Quality improvement tools include indicators for safe and effective use of medicines in the Indicators for Quality Use of Medicines in Australian Hospitals, for example Audit of storage of potassium ampoules Audit of prescribing of cytotoxic chemotherapy treatment guided by a hospital approved chemotherapy

treatment protocolC

4.11.2 Action is taken to reduce the risks of storing, prescribing, dispensing and administering high-risk medicines


SM




Criterion: Continuity of medication management The clinician provides a complete list of a patient’s medicines to the receiving clinician and patient when handing over care or changing medicines.




Self assessment

C4.12 Ensuring a current comprehensive list of medicines, and the reason(s) for any change, is provided to the receiving clinician and the patient during any clinical handovers

4.12.1 A system is in use that generates and distributes a current and comprehensive list of medicines and explanation of changes in medicines

Policies, procedures and/or protocols related to the medicines information required for transfer and discharge communication documents.

Patient clinical record that contains a medicines list and explanation of changes used at handover of care such as transfer or discharge summary

Audit of use of policies, procedures and/or protocols related to the medicines information required for transfer and discharge communication documentation.

MM SM NM - add to action plan

C4.12.2 A current comprehensive list of medicines is provided to the patient and/or carer when concluding an episode of care

Audit of patient clinical records to identify patients provided with a current comprehensive list of medicines on discharge when medicines changed during the episode of care


C4.12.3 A current comprehensive list of medicines is provided to the receiving clinician during clinical handover

Patient clinical record that shows a current list of medicines, including reasons for changes, was provided to the receiving clinician

Documented feedback from receiving clinicians Audit of patient clinical records to identify the proportion of transfer and/or

discharge summaries that contain a current comprehensive list of medicines, medication therapy changes and explanations for changes when medicines changed during the episode of care


Link with Standard 6C

4.12.4 Action is taken to increase the proportion of patients and receiving clinicians that are provided with a current comprehensive list of medicines during clinical handover

Same evidence options as 4.2.2 MM SM NM - add to action plan



Criterion: Communicating with patients and carers The clinical workforce informs patients about their options, risks and responsibilities for an agreed medication management plan.

C/DThis criterion will be achieved by:



Self assessment

C4.13 The clinical workforce informing patients and carers about medication treatment options, benefits and associated risks

4.13.1 The clinical workforce provides patients with patient-specific medicine information, including medication treatment options, benefits and associated risks

Policies, procedures and/or protocols define the roles and responsibilities of the clinical workforce in informing patients and carers about medication treatment options, benefits and associated risks.

Patient clinical records that shows patient-specific information was provided to patients

Records of patient education provided such as information on chemotherapy to oncology or haematology patients

MM

SM



4.13.2 Information that is designed for distribution to patients is readily available to the clinical workforce

Materials used in patient education such as brochures, fact sheets, posters Observation that patient specific medicines information is available in the

workplace. Patients clinical record that shows patient-specific medicines information such as

consumer medicines information was provided

MM

SM



4.14 Developing a medication management plan in partnership with patients and carers

4.14.1 An agreed medication management plan is documented and available in the patient’s clinical record

Patients clinical record shows that written information was provided on medications to be continued by patient post discharge MM

SM


D 4.15 Providing current medicines information to patients in a format that meets their needs whenever new medicines are prescribed or dispensed

4.15.1 Information on medicines is provided to patients and carers in a format that is understood and meaningful

Patients clinical record shows that information was provided to the patient and/or carer when medicine was supplied on discharge

Results of patient experience survey on medicines information provided

MM

SM





D 4.15.2 Action is taken in response to patient feedback to improve medicines information distributed by the health service organisation to patients


SM



Australian Injectable Dugs Handbook (AIDH) 5th edition, 2011, The Society of Hospital Pharmacists of Australia, Melbourne.

Guiding principles for medication management in the community. Australian Pharmaceutical Advisory Council, Canberra: Commonwealth of Australia 2006.

Guiding principles to achieve continuity in medication management. Australian Pharmaceutical Advisory Council, Commonwealth of Australia. (APAC)

Indicators for Quality Use of Medicines in Australian Hospitals. NSW Therapeutic Advisory Group.

Medication Safety Self Assessment in Australian Hospitals and Medication Safety Self Assessment for Antithrombotic Therapy in Australian Hospitals. Clinical Excellence Commission and NSW Therapeutic Advisory Group.

Medication Safety Self Assessment for Australian Hospitals. Clinical Excellence Commission and NSW Therapeutic Advisory Group.

National Medicines Policy (2000) www.health.gov.au/internet/publishing.nsf/content/nmp-objectives-policy.htm

Medication Management Plan by the ACSQHC is found by the following link: http://www.health.gov.au/internet/safety/publishing.nsf/Content/com-pubs_Medication_Management_Plan

Rossi, S (ed), 2011, Australian Medicines Handbook 2011, Australian Medicines Handbook Pty Ltd, Adelaide.

Therapeutic guidelines. Melbourne: Therapeutic Guidelines Limited; 2010. www.tg.org.au

Examples of high risk medications may be found at The Institute for Safe Medication Practices (ISMP): www.ismp.org


http://www.health.gov.au/internet/safety/publishing.nsf/Content/com-pubs_Medication_Management_Plan

http://www.health.gov.au/internet/safety/publishing.nsf/Content/com-pubs_Medication_Management_Plan

http://www.health.gov.au/internet/publishing.nsf/content/nmp-objectives-policy.htm


Standard 5: Patient Identification and Procedure Matching

Clinical leaders and senior managers of a health service organisation establish systems to ensure the correct identification of patients and correct

matching of patients with their intended treatment. Clinicians and other members of the workforce use the patient identification and procedure

matching systems.


Correctly identify all patients whenever care is provided and correctly match patients to their intended treatment.

Context

It is expected that this Standard will be applied in conjunction with Standard 1, ‘Governance for Safety and Quality in Health Service Organisations’

and Standard 2, ‘Partnering with Consumers’.

Criteria to achieve the Patient Identification and Procedure Matching Standard:

Identification of individual patients

Processes to transfer care

Processes to match patients and their care



Criterion: Identification of individual patients At least three approved patient identifiers are used when providing care, therapy or services.




Self assessment

C5.1 Developing, implementing and regularly reviewing the effectiveness of a patient identification system including the associated policies, procedures and/or protocols that: define approved

patient identifiers require at least three

approved patient identifiers on registration or admission

require at least three approved patient identifiers when care, therapy or other services are provided

require at least three approved patient identifiers whenever clinical handover, patient transfer or discharge documentation is generated

5.1.1 Use of an organisation-wide patient identification system is regularly monitored

Policies, procedures and/or protocols that are consistent with the national standard and require the three patient identifiers to be recorded in the patient clinical records

Documented process that identifies patients with multiple identifiers (for example more than one medical record number) and then applies a unique identifier for the health service

Policies, procedures and/or protocols that specify the approved patient identifiers for all clinical services

Policies, procedures and/or protocols that describe the audits and auditing process to be undertaken for monitoring compliance with the patient identification policy

Approved or required checklists for various procedures Audit of patient clinical record for the use of three patient identifiers

MM

SM


Link with Standards 1 and 2

(i) Patients with multiple identifiers may be an issue with multiple site facilities and after hours admissions via an Emergency Department where the medical record is not available or has been destroyed.

Examples of approved patient identifier: full name (family and given names) stated by the patient date of birth stated by the patient gender home address in full as stated by the patient photographic image of the patient attached to the patient file appointment day or date and time correctly stated by the patient a valid card or document stating the patient’s family name the patient’s personal identifier stated by the patient






Self assessment

C5.1.2 Action is taken to improve compliance with the patient identification matching system

Risk register or log that includes actions to address identified risks Agenda papers, meeting minutes and/or reports of relevant committees that

detail Improvement actions Quality improvement plan includes actions to address issues identified Orientation and ongoing education resources Training attendance records regarding the organisation’s patient identification

and management protocol Documented strategies for minimising risks of misidentification, patient

identification and procedure matching Results of patient feedback regarding patient identification Record/s of regular reviews of policy, protocols and/or procedures Examples of improvement activities that have been implemented and

evaluated Communication material developed for the workforce and/or patients

MM

SM


C5.2 Implementing a robust organisation-wide system of reporting, investigation and change management to respond to any patient care mismatching events

5.2.1 The system for reporting, investigating and analysis of patient care mismatching events is regularly monitored

Risk register or log that includes actions to address identified risks Agenda papers, meetings minutes and/or reports that demonstrate mismatch

incidents are routinely reported to and reviewed by management Incident reporting management system, register or log of near misses and

incidents of patient mismatching events Root cause analysis of policy or protocol breaches that result in a serious

breach or sentinel event Audits of patient clinical records include the reporting and investigation of care

mismatching events

MM

SM


C5.2.2 Action is taken to reduce mismatching events


detail improvement actions taken Quality improvement plan includes actions to address issues identified Examples of improvement activities that have been implemented and


MM

SM







Self assessment

C 5.3 Ensuring that when a patient identification band is used, it meets the national specifications for patient identification bands

5.3.1 Inpatient bands are used that meet the national specifications for patient identification bands

Patient identification and procedure matching policies, procedures and/or protocols comply with Australian Specifications for Patient Identification Bands

Audits of patient identification bands compliance with the Australian Specifications for Patient Identification Bands

Review of related policies, such as blood administration and medication administration policies, amended based on audit results of the use of patient bands

Audit of compliance of patient identification bands with Australian specifications

MM

SM


(i) Australian Standard for Patient Identification Bands found at: http://www.health.gov.au/internet/safety/publishing.nsf/Content/EAC2DBC0F547 77B5CA2574DE00111B73/$File/Specs-PatID-Band.pdf


http://www.health.gov.au/internet/safety/publishing.nsf/Content/EAC2DBC0F547%0977B5C%09A2574DE00111B73/$File/Specs-PatID-Band.pdf

http://www.health.gov.au/internet/safety/publishing.nsf/Content/EAC2DBC0F547%0977B5C%09A2574DE00111B73/$File/Specs-PatID-Band.pdf


Criterion: Processes to transfer care A patient’s identity is confirmed using three approved patient identifiers when transferring responsibility for care.




Self assessment

C 5.4 Developing, implementing and regularly reviewing the effectiveness of the patient identification and matching system at patient handover, transfer and discharge

5.4.1 A patient identification and matching system is implemented and regularly reviewed as part of structured clinical handover, transfer and discharge processes

Patient handover, transfer and discharge policies, procedures and/or protocols include the use of three patient identifiers

Schedule of routine policy reviews or review dates on policies Audit of transfer or discharge summaries of patients transferred to another

healthcare organisation for use of three patient identifiers Agenda papers, meeting minutes and/or reports of the senior executive and

management teams record audit results of handover sheets, transfer forms and discharge summaries

Workforce meeting minutes, memos, and reports related to feedback on results of audits on handover, transfer and discharge sheets, forms and summaries

Annual report that provides results of audits on transfer and discharge processes


Link with Standards 6



Criterion: Processes to match patients and their careHealth service organisations have explicit processes to correctly match patients with their intended care.




Self assessment

C 5.5 Developing and implementing a documented process to match patients to their intended procedure, treatment or investigation and implementing consistent national guidelines for patient procedure matching protocol or other relevant protocols

5.5.1 A documented process to match patients and their intended treatment is in use

Policies, procedures and/or protocols that document when a specific patient identification procedure is to be used by the workforce. This may include: o surgical safety checklist o handover checklistso medication management plan

Policies, procedures and/or protocols for procedure matching including ‘time out’ to be carried out

Register and/or record that shows review dates for policies, procedures or protocols and the future scheduled review dates

MM

SM


C 5.5.2 The process to match patients to any intended procedure, treatment or investigation is regularly monitored

Results of observational or records audits of patient and procedure, treatment and investigation matching (such as surgical, diagnostics, chemotherapy, renal dialysis, matching and so on)

Risk register or log that includes actions to address identified risks Agenda papers, meeting minutes and reports to relevant committees that include

an analysis of incident data and trends

MM

SM


C 5.5.3 Action is taken to improve the effectiveness of the process for matching patients to their intended procedure, treatment or investigation


SM





Additional information and resourcesAustralian Commission on Safety and Quality in Health Care. Patient Identification Protocols. 2009 [cited 2009]. www.safetyandquality.gov.au

Australian Commission on Safety and Quality in Health Care. Specifications For A Standard National Patient Identification Band. http://www.safetyandquality.gov.au/internet/safety/publishing.nsf/Content/PatientID-Resources-NatStd_Bands

Australian Standard Handbook HB 222–2006 Australian Health Care Client and Provider Identification Handbook. Standards Australia.Standards Australia. Australian Standard AS5017-2006 Health Care Client Identification. 2006, Sydney.

Royal Australasian College of Surgeons Surgical Safety Checklist (Australia And New Zealand) http://www.surgeons.org/media/12661/LST_2009_Surgical_Safety_Check_List_(Australia_and_New_Zealand).pdf

http://www.surgeons.org/media/12661/LST_2009_Surgical_Safety_Check_List_(Australia_and_New_Zealand).pdf



Standard 6: Clinical HandoverClinical leaders and senior managers of a health service organisation implement documented systems for effective and structured clinical

handover. Clinicians and other members of the workforce use the clinical handover systems.


Ensure there is timely, relevant and structured clinical handover that supports safe patient care.

Context



Criteria to achieve the Clinical Handover Standard:

Governance and leadership for effective clinical handover

Clinical handover processes

Patient and carer involvement in clinical handover



Criterion: Governance and leadership for effective clinical handover

Health service organisations implement effective clinical handover systems.




Self assessment

C6.1 Developing and implementing an organisational system for structured clinical handover that is relevant to the healthcare setting and specialities, including: documented policy,

procedures and/or protocols

agreed tools and guides

6.1.1 Clinical handover policies, procedures and/or protocols are used by the workforce and regularly monitored

Policies, procedures and/or protocols on clinical handover that are accessible to the workforce

Patient clinical record shows that clinical handover has occurred Discharge summary that details emergency contact information, post procedure

instructions, appointment times Transfer guidelines and forms for transferring patients to another facility for ongoing

care or investigation Audit of patient clinical records

MM

SM


(i) Policy documents may address clinical handover from area to area and include: process for signing off on a clinical handover when a patient’s care is transferred discharge form that details emergency contact information, post procedure instructions, appointment

times guidelines and forms for transfer to another facility for ongoing care or investigation tools for auditing the clinical pathways and documents reporting mechanism and procedures that include reporting on risk reduction measures details of the evidence-based approach to be adopted and the validated tool(s) for clinical handover patient engagement and/or centred care policy

C6.1.2 Action is taken to maximise the effectiveness of clinical handover policies, procedures and/or protocols

Tools that have been validated and/or are based on the national tools for clinical handover

Observational audit of clinical handover Educational resources and training attendance records related to clinical handover Risk register or log that includes actions to address identified risks Agenda papers, meeting minutes and/or reports of relevant committee(s) that detail

improvement actions taken Quality improvement plan includes actions to address issues identified Examples of improvement activities that have been implemented and evaluated Communication material developed for the workforce and/or patients

MM

SM


C 6.1.3 Tools and guides are periodically reviewed

Schedule of policy, procedures and/or protocols to update in line with best practice or emerging information

Quality improvement plan that includes details of last review and schedule for future reviews

MM

SM




Criterion: Clinical handover processesHealth service organisations have documented and structured clinical handover processes in place.




Self assessment

C6.2 Establishing and maintaining structured and documented processes for clinical handover

6.2.1 The workforce has access to documented structured processes for clinical handover that include:

preparing for handover, including setting the location and time while maintaining continuity of patient care

organising relevant workforce members to participate

being aware of the clinical context and patient needs

participating in effective handover resulting in transfer of responsibility and accountability for care

Clinical handover policies, procedures and/or protocols included in the facility’s orientation guides or manuals

Posting of clinical handover policies, procedures and/or protocols on health service communication board or web site

Educational resources and training attendance records related to clinical handover Patient clinical record shows that clinical handover has occurred Discharge summary that details emergency contact information, post procedure

instructions, appointment times Guidelines and forms for transfer to another facility for ongoing care or investigation Tools and resources associated for structured clinical handover process that are

accessible to the workforce such as ISOBAR, ISBAR, SBAR, SHARED

MM

SM


C6.3 Monitoring and evaluating the agreed structured clinical handover processes, including: regularly reviewing local

processes based on current best practice in collaboration with clinicians, patients and carers

undertaking quality improvement activities and acting on issues identified from clinical handover reviews

reporting the results of clinical handover reviews

6.3.1 Regular evaluation and monitoring of processes for clinical handover are in place.

Reports, investigations and feedback to the workforce on patient incidents involving clinical handover

Risk register or log that includes actions to address identified risks Observational audits of clinical handover Results of patient satisfaction surveys regarding clinical handovers Meeting minutes and/or reports of meetings record actions taken and areas for

future improvement

MM

SM


C6.3.2 Local processes for clinical handover are reviewed in collaboration with clinicians, patients and carers

Audits of clinical handover at patient admission, transfer and discharge and reports on variation from agreed pathways

Patient feedback data such as focus groups, patient satisfaction surveys Agenda papers, meeting minutes and/or reports of relevant committees

MM

SM







Self assessment

at executive level of governance

C6.3.3 Action is taken to increase the effectiveness of clinical handover



MM

SM


C6.3.4 The actions taken and the outcomes of local clinical handover reviews are reported to the executive level of governance

Reports to senior executive on progress and outcomes of actions related to reviews of clinical handover



MM

SM


(i) Executive level of governance may be for a service, facility or broader organisation of a health service, whichever is the most appropriate to take action on the results

C6.4 Implementing a robust organisation-wide system of reporting, investigation and change management to respond to any clinical handover incidents

6.4.1 Regular reporting, investigating and monitoring of clinical handover incidents is in place

Committee terms of reference outline the senior executive responsibilities for clinical handover incidents

Agenda papers, meeting minutes and/or reports of relevant committee(s) include information on clinical handover


Incident reporting forms and processes included in policies, procedures and/or protocols

Reports on trends in clinical handover incidents Feedback provided to the workforce and consumers

MM

SM


Link to 1.2.1(i) An example may include root cause analysis or sentinel event






Self assessment

6.4.2 Action is taken to reduce the risk of an adverse clinical handover incident

Orientation documentation addresses clinical handover policy, procedures and/or protocols

Educational resources and attendance records related to clinical handover Posting of clinical handover policy/guideline on health service communication board

or web site Risk register or log that includes actions to address identified risks Agenda papers, meeting minutes and/or reports of relevant committee(s) that detail


(i) Clinical steps that require handover in a day surgeries procedure service may include: Admission to clinical nurse, clinical admission nurse to anaesthetic staff member, anaesthetic staff member to theatre staff, theatre staff to recovery staff, recovery staff to second stage recovery staff, second stage recovery or discharge staff to responsible patient and/or carer



Criterion: Patient and carer involvement in clinical handover Health service organisations establish mechanisms to include patients and carers in clinical handover processes.




Self assessment

D 6.5 Developing and implementing mechanisms to include patients and carers in the clinical handover process that are relevant to the healthcare setting

6.5.1 Mechanisms to involve a patient and, where relevant, their carer in clinical handover are in use

Information for patients and carers on their roles in handover such as access to a patient charter of rights

Patient experience survey related to clinical handover Forms that patients review, sign and receive as a copy related to their clinical

management and handover at discharge

MM

SM




Australian Commission on Safety and Quality in Health Care. 2010. The OSSIE guide to clinical handover improvement. Sydney: www.safetyandquality.gov.au

Australian Commission on Safety and Quality in Health Care. 2011. The Implementation Toolkit for Clinical Handover Improvement: www.safetyandquality.gov.au

Australian Day Surgery Nurses Association: www.adsna.info




Standard 7: Blood and Blood Products

Clinical leaders and senior managers of a health service organisation implement systems to ensure the safe, appropriate, efficient and effective use

of blood and blood products. Clinicians and other members of the workforce use the blood and blood product safety systems.


Ensure that the patients who receive blood and blood products do so appropriately and safely.

Context



Criteria to achieve the Blood and Blood Products Standard:

Governance and systems for blood and blood product prescribing and clinical use

Documenting patient information

Managing blood and blood product safety

Communicating with patients and carers



Criterion: Governance and systems for blood and blood product prescribing and clinical useHealth service organisations have systems in place for the safe and appropriate prescribing and clinical use of blood and blood products.




Self assessment

C 7.1 Developing governance systems for safe and appropriate prescription, administration and management of blood and blood products

7.1.1 Blood and blood product policies, procedures and/or protocols are consistent with national evidence-based guidelines for pre-transfusion practices, prescribing and clinical use of blood and blood products

Policies, procedures and/or protocols for safe and appropriate prescription, prescription, administration and management of blood and blood products that adhere to national guidelines and best practice, and address areas such as o prescription, administration and management of blood and blood products o pre-transfusion and sampling practices such as specimen collectiono processes that relate to laboratory-hospital interfaceo consent procedure o tools for transfusion that are available o storage and transportation of blood and blood products

Orientation of the workforce including nursing, junior medical officer and consultants which reflect current national guidelines and criteria relating to blood and blood products management.

Education resources related to blood components management Training attendance records. Evaluation reports of education and training

MM

SM


(i) Examples of areas that could be audited to assess appropriateness and administrative practices: clinical audit of fresh frozen plasma clinical audit of red cell use in orthopaedic surgery audit of blood transfusion policy and administration practices blood storage and handling survey

7.1.2 The use of policies, procedures and/or protocols is regularly monitored

Agenda papers, meeting minutes and/or reports of relevant committee(s) that detail monitoring of the use of policies, procedures and/or protocols, such as a clinical review group or transfusion committee

Strategic plan where it relates to blood and blood products Risk register or log that includes actions to address identified risks Documentation on consultation processes in the development and review of

policies, procedures and/or protocols Clinicians checklist for prescribing blood components to ensure blood products

are only released for transfusion when guidelines have been satisfied Audits of the use of forms and tools for prescription, request and administration

of blood products Reports on transfusions provided to clinical units, senior and relevant

committee(s) Reports of vetting of transfusion requests.

MM

SM







Self assessment

Documentation such as request forms or blood administration forms for ordering or administering blood components that adhere to national guidelines

Risk register or log that incorporates blood and blood product risks Reports from clinical data systems Observational audit of accessibility and use of clinical guidelines in clinical areas Audit of patient clinical records for compliance with policy and procedures

(i) Standardised data items collected that are used to assess ‘appropriateness’ rates include: blood component given clinical or laboratory indications reasons for giving blood component if not in accordance with guidelines other relevant medical history of condition number of units required

C 7.1.3 Action is taken to increase the safety and appropriateness of prescribing and clinically using blood and blood products

Audit of patient clinical records that assess compliance with national guidelines such as the rationale for administering blood and blood products

Observational audit of use of policies, procedures and/or protocols Feedback of audit provided to clinical groups Education resources and training attendance records relating to blood and blood

products Peer review and self-audit tools and reports on outcomes Agenda papers, meeting minutes and/or reports of relevant committee(s) that

detail improvement actions Quality improvement plan includes actions to address issues identified Examples of improvement activities that have been implemented and evaluated Communication material developed for the workforce and/or patients

MM

SM


C7.2 Undertaking a regular, comprehensive assessment of blood and blood product systems to identify risks to patient safety and take action to reduce risks

7.2.1 The risks associated with transfusion practices and clinical use of blood and blood products are regularly assessed

Forms or processes included in the policies, procedures and/or protocols to assess blood and blood product risks

Report on incident related to blood and blood products Audit of compliance with policies, procedures and/or protocols Risk register or log that includes actions to address identified risks Process for addressing pathology laboratory documentation that identifies

patient safety risks from the use of blood and blood products Agenda papers, meetings minutes and/or reports that relate to transfusion

practices are routinely reviewed by management

MM

SM







Self assessment

C7.2.2 Action is taken to reduce the risks associated with transfusion practices and the clinical use of blood and blood products

Patients clinical record that shows patients are informed of the risks and benefits of transfusion

Education resources and training attendance records related to the prescription and clinical administration of blood and risk assessment

Agenda papers, meeting minutes and/or reports of relevant committee(s) that detail improvement actions

Examples of modifications to policies, procedures, protocols or work practices to address issues of non-compliance

Communication material developed for the workforce and/or patients

MM

SM


C7.3 Ensuring blood and blood product adverse events are included in the incidents management and investigation system

7.3.1 Reporting on blood and blood product incidents is included in regular incident reports

Policies, procedures and/or protocols for reporting and managing incidents relating to use of blood and blood products

A current register for reporting adverse events with transfusion of blood or blood components and includes actions to address identified risks.

Records of healthcare blood product adverse events Documented incidents are investigated Incident reporting management system, such as a register or log, that

documents analysis and review of incidents relating to use of blood and blood product

Agenda papers, meetings minutes and/or reports of relevant committees that demonstrate incidents relating to use of blood and blood products are routinely reviewed

Root cause analysis of breaches of policies, procedures and/or protocols resulting in a serious breach or sentinel event

Audits of patient clinical records that demonstrate reporting and investigation of incidents relating to use of blood and blood products

Audit of compliance with policies, procedures and/or protocols Data that reports trends in incidents relating to use of blood and blood products

are recorded, such as in meeting minutes or annual reports Information relating to use of blood and blood products presented to the senior

executive and/or relevant committees Peer review processes for transfusion practice such as quality assurance

meetings

MM

SM







Self assessment

C7.3.2 Adverse blood and blood product incidents are reported to and reviewed by the highest level of governance in the health service organisation

Agenda papers, meeting minutes and/or reports of relevant committees or groups with responsibility for management of blood and blood products such as medical advisory and management committee

Reports of adverse blood and blood product incidents provided to relevant committees and senior executive

MM

SM


C7.3.3 Health service organisations participate in relevant haemovigilance activities conducted by the organisation or at state or national level

Policies, procedures and/or protocols identifying all haemovigilance reporting obligations for the organisation

Schedules of haemovigilance reporting Reports provided to organisations monitoring haemovigilance

MM

SM


C 7.4 Undertaking quality improvement activities to improve the safe management of blood and blood products

7.4.1 Quality improvement activities are undertaken to reduce the risks of patient harm from the clinical administration of blood and blood products



MM

SM




Criterion: Documenting patient informationThe clinical workforce accurately records a patient’s blood and blood product transfusion history and indications for use of blood and blood products.




Self assessment

C7.5 As part of the patient treatment plan, the clinical workforce accurately documenting: relevant

medical conditions indications for

transfusion any special

product or transfusion requirements

known patient transfusion history

type and volume of product transfusion

patient response to transfusion

7.5.1 A best possible history of blood product usage and relevant clinical and product information is documented in the patient clinical record

Policies, procedures and/or protocols provide tools, forms and/or specified process for taking a history of blood product usage

Audit of patient clinical records for use of tools, forms and specified process Review of incidents related to poor patient records management Education material and attendance at training related to patient record taking

MM

SM


C7.5.2 The patient clinical records of transfused patients are periodically reviewed to assess the proportion of records completed

Education resources and training attendance records related to patient record taking and auditing of patient records

Audit of patient clinical record and reports on the proportion of patents with complete patient history reviewed by relevant committees

Audit of compliance with policies procedures and/or protocols Agenda papers, meetings minutes and/or reports that relate to transfusion

practices are routinely reviewed by management

MM

SM


C7.5.3 Action is taken to increase the proportion of patient clinical records of transfused patients with a complete patient clinical record

Audit of patient clinical record shows that clinical records for transfused patients are complete

MM

SM


C7.6 The clinical workforce documenting any adverse reactions to blood or blood products

7.6.1 Adverse reactions to blood or blood products are documented in the patient clinical record

Policies, procedures and/or protocols on documentation and reporting of adverse reactions

Record of the clinical workforce attending education on adverse reaction documentation and reporting

Audit of patient clinical records for information on adverse reactions

MM

SM







Self assessment

C7.6.2 Action is taken to reduce the risk of adverse events from administering blood or blood products

Posting of policy, procedures and/or guideline on health service communication board or web site

Education resources and training attendance records related to appropriate prescribing and administration of blood products

Audit results of compliance with policies procedures and/or protocols provided to clinical workforce and relevant committees

Risk register or log that includes actions to address identified risks Agenda papers, meeting minutes and/or reports of relevant committee(s) include the

outcomes of actions taken in response to identified risks Quality improvement plan includes actions to address issues identified Examples of improvement activities that have been implemented and evaluated such as

change to policies or /procedures, publication of medicine information bulletin

MM

SM


C7.6.3 Adverse events are reported internally to the appropriate governance level and externally and as appropriate to the pathology service provider, blood service or product manufacturer whenever appropriate

Adverse reaction reports included in agenda papers, meeting minutes or reports of relevant committees

Agenda papers, meeting minutes and/or reports of relevant committee(s) that detail improvement actions

Reports from incident reporting and management systems that have been sent to external organisations, including pathology service providers and manufacturers

Communication material developed for the workforce and/or patients




Criterion: Managing blood and blood product safetyHealth service organisations have systems to receive, store, transport and monitor wastage of blood and blood products safely and efficiently.




Self

assessment

C7.7 Ensuring the receipt, storage, collection and transport of blood and blood products within the organisation are consistent with best practice and/or guidelines

7.7.1 Regular review of the risks associated with receipt, storage, collection and transport of blood and blood products is undertaken

Audit of transportation and storage of blood and blood products against with policies, procedures and/or protocols

Delegation documentation for access to the secure blood fridge Review of access to secure blood fridge where 24 hour on-site pathology service is

not available Register of current blood components Audit of documentation accompanying blood components Delegation documentation for responding to storage alarms and taking corrective

action Positions descriptions, employment contracts or policies, procedures and/or protocols

specify blood related delegations Observational audit show that labels and dates are checked each time blood

components are handled Records of disposal rates of blood products

MM

SM


(i) Australian Standard for Medical Refrigeration Equipment – For the Storage of Blood and Blood Products (AS3864) is a resource which specifies the requirements for refrigerators and used for the storage of blood and blood products

C7.7.2 Action is taken to reduce the risk of incidents arising from the use of blood or blood product control systems


SM


C 7.8 Minimising unnecessary wastage of blood and blood products

7.8.1 Blood and blood product wastage is regularly monitored

Reports from pathology laboratories regularly reviewed and reconciled by a clinical team

Audit of compliance o f usage and disposal against policy Review of audit results by relevant committees

MM

SM


C 7.8.2 Action is taken to minimise wastage of blood and blood products


SM



http://infostore.saiglobal.com/store/Details.aspx?ProductID=305823



Criterion: Communicating with patients and carersPatients and carers are informed about the risks and benefits of using blood and blood products and about the available alternatives when a plan for treatment is developed.




Self assessment

C7.9 The clinical workforce informing patients and carers about blood and blood product treatment options, and the associated risks and benefits

7.9.1 Patient information relating to blood and blood products, including risks, benefits and alternatives, is available for distribution by the clinical workforce

Materials used in patient education such as brochures, fact sheets, posters Patient information that is available for distribution by the workforce Patients clinical record shows that patients were provided with patient-specific

blood information Patient experience survey shows that patient information was provided


(i) Consumers’ communication tools and education resources may be found at National Blood Authority, Red Cross or resources provided by jurisdictions

C7.9.2 Plans for care that include the use of blood and blood products are developed in partnership with patients and carers

Information available to patients and carers on treatment option and use of blood products

Patient comment on and sign care plan and receive a copy Care plan that patients review, sign and receive as a copy related to the use of

blood and blood products Audits of patient clinical record demonstrate shows that patients are involved in

the development of their care plan Patient and/or carer experience surveys regarding their involvement in the

development of their care plan

MM

SM


C7.10 Providing information to patients about blood and blood product use and possible alternatives in a format that can be understood by patients and carers

7.10.1 Information on blood and blood products is provided to patients and carers in a format that is understood and meaningful

Materials used in patient education such as brochures, fact sheets, posters Patients clinical record shows that patients information is provided Patient feedback shows patient satisfaction with information provided Reports from consumer focus groups on patient information

MM

SM


C7.11 Implementing an informed consent process for all blood and blood product use

7.11.1 Informed consent is undertaken and documented for all transfusions of blood or blood products in accordance with the informed consent policy of the health service organisation

Policies, procedures and/or protocols on informed consent Standardised consent form Materials used in patient education include information on consent Audit of compliance with policy and procedure Reports from patient feedback on informed consent

MM

SM







This Standard may not be applicable to some Day Surgeries but should remain for those places who are involved in blood and blood products.

National Health and Medical Research Council, Clinical Practice Guidelines on the Use of Blood Components, Commonwealth Department of Health and Ageing: www.nhmrc.gov.au

National Blood Authority Australia, Final Report, December 2007, Production Benchmarking and Demand Drivers, Commonwealth of Australia: http://www.nba.gov.au/bptools/index.html

National Blood Authority Australia, Endorsed by AHMC, April 2008, National Blood Supply Contingency Plan, Commonwealth of Australia.

www.nba.gov.au

Australian Standard for Medical Refrigeration Equipment – For the Storage of Blood and Blood Products (AS3864)

Australian and New Zealand Society of Blood Transfusion Blood Product Reference Guidelines: www.anzsbt.org.au

Australian Red Cross Blood Service (ARCBS): http://www.transfusion.com.au/sites/default/files/BloodFridgeRecord.pdf

http://www.transfusion.com.au/sites/default/files/BloodFridgeRecord.pdf


http://www.nba.gov.au/

http://www.nba.gov.au/bptools/index.html


Standards 8: Preventing and Managing Pressure Injuries

Clinical leaders and senior managers of the health service organisation implement evidence-based systems to prevent pressure injuries and

manage them when they do occur. Clinicians and other members of the workforce use the pressure injury prevention and management systems.


Prevent patients from developing pressure injuries and effectively managing pressure injuries when they do occur.

Context



Criteria to achieve the Preventing and Managing Pressure Injuries Standard:

Governance and systems for the prevention and management of pressure injuries

Preventing pressure injuries

Managing pressure injuries




Criterion: Governance and systems for the prevention and management of pressure injuriesHealth service organisations have governance structures and systems in place for the prevention and management of pressure injuries.




Self assessment

C8.1 Developing and implementing policies, procedures and/or protocols that are based on current best practice guidelines

8.1.1 Policies, procedures and/or protocols are in use that are consistent with best practice guidelines and incorporate screening and assessment tools

Policies, procedures and/or protocols that are evidence based and consistent with best practice guidelines and incorporate screening and assessment tools

Audit of clinical practice and the tools and procedures employed to identify individuals at risk

Evaluation reports of the organisations’ pressure injury prevention program that includes the use of policy, procedures and/or protocols and areas that require modification and education requirements

Reports tracking trends over time may benchmark high performing agencies

MM

SM


(i) Evidence-based clinical practice guidelines, such as the Australian Wound Management Association Clinical Practice Guidelines for Pressure Ulcer Prevention and Management are readily available and accessible to the clinical workforce: www.awma.com.au

C8.1.2 The use of policies, procedures and/or protocols are regularly monitored

Policies, procedures and/or protocols are available to the workforce Observation audit of the use of policies, procedures and/or protocols Patient clinical record reviewed against policies, procedures and/or protocols Audits, prevalence surveys and/or incident reporting are conducted and

findings inform organisational prevention and management policies, procedures and/or protocols

Agenda papers, meeting minutes and/or reports of relevant committees that detail improvement actions

MM

SM


(i) A health service where there is a high risk of pressure injuries may routinely undertake a comprehensive assessment of all patients for pressure injuries. Low risk services may undertake a simple screening process and only fully assess patients indentified to be at risk of pressure injuries. This would be reflected in the organisation’s policies, procedures and/or protocols

C8.2 Using a risk-assessment framework and reporting systems to identify, investigate and take action to reduce the frequency and severity of pressure injuries

8.2.1 An organisation-wide system for reporting pressure injuries is in use

Incident reporting forms and processes included in policies, procedures and/or protocols

Reports on pressure injuries and interventions to manage pressure injuries Education resources and training attendance record related to pressure injury

reporting systems Agenda papers, meeting minutes and/or reports of relevant committees

MM

SM


C8.2.2 Administrative and clinical data are used to regularly monitor and investigate the frequency

Process to extract information and regular reports form administration and clinical data on pressure injuries

Quality improvement plans that require routine review of pressure injury incidence, prevalence and management information

Agenda papers, meeting minutes and/or reports of relevant committees with

MM

SM

NM - add to


http://www.awma.com.au/





Self assessment

and severity of pressure injuries

delegated responsibilities for pressure injuries such as clinical risk committees and the senior executive

Reports on trends in pressure injuries External reports to owners, regulators, insurers and departments Feedback to clinical workforce on incidence and prevalence, monitoring proformas,

trends, changes to policy, procedure and/or protocols and review schedules

action plan

(i) Pressure injury data collected may include: number of pressure injuries stage of pressure injuries pressure injury prevention strategies in place at time of injury management strategies implemented

C 8.2.3 Information on pressure injuries is regularly reported to the highest level of governance in the health service organisation

Agenda papers, meeting minutes and/or reports of relevant committees includes information and data on pressure injuries

Pressure injury prevalence and/or incidence reports are routinely tabled at senior executive and clinical governance meetings within the organisation

MM

SM


C 8.2.4 Action is taken to reduce the frequency and severity of pressure injuries

Pressure injury prevention plans describe consultation with relevant stakeholders Data used to track trends over time and changes from actions taken Reports benchmarking performance in the management of preventable pressure

injuries against high performing services Education resources and training attendance records on changes to policies,

procedures and/or protocols following review of pressure injury incidents Risk register or log that includes actions to address identified risks Agenda papers, meeting minutes and/or reports of relevant committee(s) that detail


MM

SM







Self assessment

(i) Educational topics to prevent and manage pressure injuries may include: manual handling to prevent shear and friction aetiology and risk factors for pressure injuries application of risk assessment tools skin assessment selection and/or use of support surfaces development and implementation of an individualised program of skin care repositioning to decrease risk of tissue breakdown documentation pressure injuries assessment and management incident reporting

C 8.3 Undertaking quality improvement activities to address safety risks and monitor the system that prevent and manage pressure injuries

8.3.1 Quality improvement activities are undertaken to prevent pressure injuries and/or improve the management of pressure injuries

Risk register or log that includes actions to address identified risks Amended policies, procedures and/or protocols and guidelines Observational audits of use of screening assessment tools Report on usage rates of specified products and equipment Data collected pre and post interventions Agenda papers, meeting minutes and/or reports of relevant committee(s) that

details improvement actions Quality improvement plan includes actions to address issues identified Examples of improvement activities that have been implemented and evaluated Communication material developed for the workforce and/or patients

MM

SM


C 8.4 Providing or facilitating access to equipment and devices to implement effective prevention strategies and best practice management plans

8.4.1 Equipment and devices are available to effectively implement prevention strategies for patients at risk and plans for the management of patients with pressure injuries

Agenda papers, meeting minutes and/or reports of relevant committee responsible for evaluating the efficacy of products, equipment and devices

Inventories of equipment and audits of clinical use Maintenance log of equipment and devices

MM

SM




Criterion: Preventing pressure injuriesPatients are screened on presentation and pressure injury prevention strategies are implemented when clinically indicated.




Self assessment

C 8.5 Identifying risk factors for pressure injuries using an agreed screening tool for all presenting patients within timeframes set by best practice guidelines

8.5.1 An agreed tool to screen for pressure injury risk is used by the clinical workforce to identify patients at risk of a pressure injury

Pre admission assessment tool Orientation and ongoing education resources on the use of pressure injury

screening for the relevant clinical workforce Schedule of training and attendance records for relevant clinical workforce Audit of patient clinical record for use of screening assessment

MM

SM


(i) Policies, procedures and/or protocols should include criteria that assist the clinical work force determine the need to screening and or assessment. This will be risk based.

C 8.5.2 The use of the screening tool is monitored to identify the proportion of at-risk patients that are screened for pressure injuries on presentation

Audit of patient clinical record for compliance with screening requirement Observational audit of the use of screening tool

MM

SM


C 8.5.3 Action is taken to maximise the proportion of patients who are screened for pressure injury on presentation




MM

SM


C 8.6 Conducting a comprehensive skin inspection in timeframes set by best practice guidelines on patients with a high risk of developing pressure injuries at presentation, regularly as clinically indicated during a patient’s admission, and

8.6.1 Comprehensive skin inspections are undertaken using an agreed assessment tool and documented in the patient clinical record for patients at risk of pressure injuries

Assessment tool is included in policies, procedures and/or protocols Report on use of assessment tool provided to clinical workforce Audit of patient clinical record for completed assessment tool and timing of

assessments

MM

SM


C 8.6.2 Patient clinical Policies, procedures and/or protocols specify the nature and frequency of

patient clinical record audits MM






Self assessment

before discharge records, transfer and discharge documentation are periodically audited to identify at-risk patients with documented skin assessments

Audit of patient clinical record that shows at risk patients with documented skin assessments

Agenda papers, meeting minutes and/or reports of relevant committees include information relating to the audit of patient clinical records

Report to clinical workforce on audit

SM


C 8.6.3 Action is taken to increase the proportion of skin assessments documented on patients at risk of pressure injuries

Provision of infrastructure, instruments, and other equipment necessary to comply with policy, protocol and procedures are accessible to the workforce




MM

SM


C 8.7 Implementing and monitoring pressure injury prevention plans including review when clinically indicated

8.7.1 Prevention plans for all patients at risk of a pressure injury are consistent with best practice guidelines and are documented in the patient clinical record

Policies, procedures and/or protocols reference sources and are consistent with national guidelines

Log of availability and use of pressure injury prevention devices Audit of patient clinical records for compliance with policies, procedures and/or

protocols

MM

SM


C 8.7.2 The effectiveness and appropriateness of pressure injury prevention plans are regularly reviewed

Patient clinical record for review of an individual’s pressure injury prevention plan

Reports on the prevalence and/or incidence of pressure injury within the organisation

Documented review of policies, procedures and/or protocols Agenda papers, meeting minutes and/or reports of relevant committee(s)

MM

SM


D 8.7.3 Patient clinical records are monitored to determine the proportion of at-risk patients that have an implemented pressure injury prevention plan

Audit of patient clinical record identifies patients with documented injury prevention plans

Report on patients with completed pressure injury prevention plans

MM

SM







Self assessment

D 8.7.4 Action is taken to increase the proportion of patients at risk of pressure injuries who have an implemented prevention plan


SM




Criterion: Managing pressure injuriesPatients who have pressure injuries are managed according to best practice guidelines.




Self assessment

C8.8 Implementing best practice management and ongoing monitoring as clinically indicated

8.8.1 An evidence-based wound management system is in place within the health service organisation

Policies, procedures and/or protocols describe the evidence-based wound management system to be used

Agenda papers, meeting minutes and/or reports of relevant committee(s) with responsibilities for implementing and monitoring the wound management system

Education resources and training attendance data managing pressure injuries Observational audit that evidence-based guidelines are accessed by the clinical

workforce Reports from clinical data systems Audits of patient clinical records

MM

SM


(i) Evidence-based clinical practice guidelines are the Australian Wound Management Association: Clinical Practice Guidelines for Pressure Ulcer Prevention and Management; and standards such as the Australian Wound Management Association Standards for Wound Management

C8.8.2 Management plans for patients with pressure injury management plans are consistent with best practice and documented in the patient clinical record

Policies, procedures and/or protocols outline the pressure injury management plan documentation requirements for individuals at risk of pressure injury

A management plan form that specifies the care required, requires the designation of responsibilities for care, and states the frequency of turning, equipment needs, need for referrals and expected outcomes

MM

SM


C8.8.3 Patient clinical records are monitored to determine compliance with evidence-based pressure injury management plans

Audit of patient clinical records for completed pressure injury management plans MM

SM


C8.8.4 Action is taken to increase compliance with evidence-based pressure injury management plans


SM




Criterion: Communicating with patients and carersPatients and carers are informed of the risks, prevention strategies and management of pressure injuries.




Self assessment

D 8.9 Informing patients with a high risk of pressure injury, and their carers, about the risks, prevention strategies and management of pressure injuries

8.9.1 Patient information on prevention and management of pressure injuries is provided to patients and carers in a format that is understood and is meaningful

Materials used in patient education such as brochures, fact sheets, posters Patient information that is available for distribution by the clinical workforce in a

range of formats and language Audit of patient clinical records for patients provided with information on

prevention and management of pressure injuries Report on available patient feedback on information provided

MM

SM


D 8.10 Developing a plan of management in partnership with patients and carers

8.10.1 Pressure injury management plans are developed in partnership with patients and carers

Information and leaflets for patients and/or carers on managing pressure injuries Patient comments on and signs pressure injury management plan and receives

a copy Observational audits of consumers participating in making decisions about their

care Audits of patient clinical record demonstrate the clinical workforce and patients

have collaborated in the development of pressure injury treatment plans and discharge summaries if the individual remains at risk following discharge

Results of patient and/or carer satisfaction surveys regarding re pressure injury management plan

MM

SM


Link to Standard 1.18.1 and Standard 2



Australian Wound Management Association Clinical Practice Guidelines for the Prediction and Prevention of Injuries 2011: http//www.awma.com.au/publications/publications.php#clinical

Australian Wound Management Association Standards for Wound Management 2010: www.awma.com.au

Joanna Briggs Institute, Best Practice Evidence based information sheets for Health Professionals, Pressure Injuries – prevention of pressure related damage. Volume 12, Issue 2, 2008, ISSN: 1329-1874: www.joannabriggs.edu.au

Joanna Briggs Institute, Best Practice Evidence based information sheets for Health Professionals, Pressure Ulcers – management of pressure related tissue damage. Volume 12, Issue 3, 2008, ISSN: 1329-1874: www.joannabriggs.edu.au

Agency for Healthcare Research and Quality, Preventing Pressure Ulcers in Hospitals A Toolkit for Improving Quality of Care. www.ahrq.gov/research/ltc/pressureulcertoolkit/

http://www.awma.com.au/

http://www.awma.com.au/publications/publications.php#clinical


Standard 9: Recognising and Responding to Clinical Deterioration in Acute Health Care

Health service organisations establish and maintain systems for recognising and responding to clinical deterioration. Clinicians and other members

of the workforce use the recognition and response systems.


Ensure a patient’s deterioration is recognised promptly, and appropriate action is taken. #

Context


and ‘Standard 2 Partnering with Consumers’.

Criteria to achieve the Recognising and Responding to Clinical Deterioration in Acute Health Care Standard:

Establishing recognition and response systems

Recognising clinical deterioration and escalating care

Responding to clinical deterioration


# This Standard does not apply to psychiatric deterioration associated with mental disorders.



Criterion: Establishing recognition and response systemsOrganisation-wide systems consistent with the National Consensus Statement are used to support and promote recognition of, and response to, patients whose condition deteriorates in an acute health care facility.




Self assessment

C9.1 Developing, implementing and regularly reviewing the effectiveness of governance arrangements and the policies, procedures and/or protocols that are consistent with the requirements of the National Consensus Statement

9.1.1 Governance arrangements are in place to support the development, implementation and maintenance of organisation-wide recognition and response systems

Committee terms of reference, agenda papers, meeting minutes and/or reports of relevant committee

Position descriptions for workforce with responsibility for developing, implementing, sustaining and monitoring recognition and response systems

Reports on actions arising from review and evaluation of recognition and response systems

MM

SM

NM - add to action

Link to Standard 1

C9.1.2 Policies, procedures and/or protocols for the organisation are implemented in areas such as: measurement

and documentation of observations

escalation of care

establishment of a rapid response system

communication about clinical deterioration

Policies, procedures and/or protocols that are consistent with the requirements of the National Consensus Statement and that cover items listed in 9.1.2

Examples of actions taken to implement policies throughout the organisation Observational and documentation audit of compliance to policies, procedures

and/or protocols

MM

SM

NM - add to action

(i) The recognition and response policy framework should apply across the whole organisation. The policy should address: governance arrangements for overseeing the performance of recognition and response systems roles and responsibilities for key clinical and organisational support activities resources for the recognition and response systems, such as equipment and staff processes to support prompt and effective recognition of and response to clinical deterioration

apply across the organisation, including identification of any areas where variations to these arrangements apply

evaluation, audit and feedback processes and tools arrangements with external organisations that may be part of the rapid response system







Self assessment

C 9.2 Collecting information about the recognition and response systems, providing feedback to the clinical workforce, and tracking outcomes and changes in performance over time

9.2.1 Feedback is actively sought from the clinical workforce on the responsiveness of the recognition and response systems

Report on surveys of the workforce perceptions of recognition and response systems

Feedback mechanisms for the workforce to provide for individual calls for emergency assistance such as debriefing of the workforce involved in individual events, peer review processes

Reports of review of specific event by relevant committee such as Medical Advisory Committee

MM

SM

NM - add to action

C 9.2.2 Deaths or cardiac arrests for a patient without an agreed treatment-limiting order (such as not for resuscitation or do not resuscitate) are reviewed to identify the use of the recognition and response systems, and any failures in these systems

Policies, procedures and/or protocols describe processes for mortality reviews Records of death reviews and reviews of cardiac arrests Mechanism for recording deaths, a mortality review process, and outcomes of

reviews

MM

SM

NM - add to action

9.2.3 Data collected about recognition and response systems are provided to the clinical workforce as soon as practicable

Performance data from routine collections from the recognition and response systems provided to the clinical workforce

Reports or documents containing data about recognition and response systems provided to the clinical workforce

MM

SM

NM - add to action

(i) Data about the performance of recognition and response systems should be collected. This should be reviewed against the planned operation of the system and the effectiveness of the system in improving the recognition of and response to clinical deterioration (outcome measures). Data items that could be collected include: Process measures:

o existence of required policies procedures and/or protocols, such as an escalation protocolo proportion of observation charts completed correctlyo number of calls for emergency assistance o number of calls for emergency assistance within 24 hours of admission to the wardo number of calls for emergency assistance with 24 hours post surgeryo details of each call for emergency assistance, including antecedents to the call, such as whether






Self assessment

calling criteria were triggered with no action taken• Outcome measures:

o number of cardiac arrestso number of deaths, including deaths where the patient does not have a treatment-limiting ordero outcomes of calls for emergency assistanceo number of unplanned admissions to intensive careo number of transfers to units or facilities with a higher level of care

Further information is available from Implementation Guide for the National Consensus Statement: Essential Elements for Recognising and Responding to Clinical Deterioration

C 9.2.4 Action is taken to improve the responsiveness and effectiveness of the recognition and response systems



MM

SM

NM - add to action



Criterion: Recognising clinical deterioration and escalating carePatients whose condition is deteriorating are recognised and appropriate action is taken to escalate care.




Self assessment

D 9.3 Implementing mechanism(s) for recording physiological observations that incorporates triggers to escalate care when deterioration occurs

9.3.1 When using a general observation chart, ensure that it: is designed according to

human factors principles includes the capacity to record

information about respiratory rate, oxygen saturation, heart rate, blood pressure, temperature and level of consciousness graphically over time

includes thresholds for each physiological parameter or combination of parameters that indicate abnormality

specifies the physiological abnormalities and other factors that trigger the escalation of care

includes actions required when care is escalated

Policies, procedures and/or protocols describe the observation chart to be used and reference resources

Patient clinical record shows the use of a general observation chart

MM

SM


(i) ‘Human factors’ is the study of the interactions among humans and other elements of a system, and the profession that applies theory, principles, data and methods to design in order to optimise human well-being and overall system performance. In this context, an observation and response chart that is designed according to human factors principles is designed to optimise the recognition of clinical deterioration, and to prompt an appropriate and timely response.

Key characteristics of observation and response charts that have been designed according to human factors principles include: Having observations listed in order of importance in detecting deterioration and in logical

groups. Because there is good evidence regarding respiratory rate as predictor for clinical deterioration, it should be listed as the first observation to be recorded.

Ensuring that when values for an observation is categorised into discrete ranges, that these categories are mutually exclusive.

Only including information in the main observation recording part of the chart that is critical for recognising clinical deterioration, and responding to it appropriately. Generally this will only include space for recording key observations graphically, the response to be taken when deterioration is identified, and whether there are any modifications to the normal physiological ranges for the patient.

Ensuring that the space on the chart for recording observations is close to the information about the responses that need to be made when deterioration is identified. This reduces the potential for cognitive and memory load and errors occurring.

Design elements that support ease of use of the chart. These include:o recording observations as separate graphs, rather than overlaying them on the same area of

the charto consistent use of abbreviations, labels, fonts and formatting






Self assessment

o font sizes and spaces for recording observations and writing text sufficient to allow easy useo features to support accurate recording of observations such as dual scales within the table for

recording observations, and appropriate use of thicker horizontal and vertical lines Using colour in a meaningful way to support the recognition of deterioration. The density of

colours should relate to the extent to which a patient’s observations are outside normal ranges. This supports of the charts by users who have red–green colour blindness.

For more information see the Developers Guide to Observation and Response Charts.

C 9.3.2 Mechanisms for recording physiological observations are regularly audited to determine the proportion of patients that have complete sets of observations recorded in agreement with their monitoring plan

Policies, procedures and/or protocols that describe the frequency and processes for auditing observations charts

Feedback to the clinical workforce on audits of observations charts Results of audits of observations charts. This could be included as part

of regular documentation audit

MM

SM


C 9.3.3 Action is taken to increase the proportion of patients with complete sets of recorded observations, as specified in the patient’s monitoring plan

Orientation and ongoing education resources and attendance records regarding importance of taking observations

Risk register or log that includes actions to address identified risks Agenda papers, meeting minutes and/or reports of relevant committees



MM

SM


C 9.4 Developing and implementing mechanisms to escalate care and call for emergency assistance where there are concerns that a patient’s condition is deteriorating

9.4.1 Mechanisms are in place to escalate care and call for emergency assistance

Policies, procedures and/or protocols describe the process for escalation of care

Observation of mechanisms such as signs, posters, or stickers on how to call for assistance

Orientation and ongoing education resources and attendance records Record of operational and mechanical call device testing

MM

SM


C 9.4.2 Use of escalation processes, including failure to act on triggers for seeking emergency assistance are regularly audited

Policies, procedures and/or protocols describe the frequency and processes for auditing escalation processes

Feedback to clinical workforce on audit of escalation processes Results of audits of medical records Results of audits of observations charts

MM

SM







Self assessment

C 9.4.3 Action is taken to maximise the appropriate use of escalation processes

Provision of data to relevant committees and clinical workforce Review of escalation processes Reports on the workforce survey relating to escalation of care Education resources and training attendance records related to

escalation processes




MM

SM




Criterion: Responding to clinical deteriorationAppropriate and timely care is provided to patients whose condition is deteriorating.




Self assessment

C 9.5 Using the system in place to ensure that specialised and timely care is available to patients whose condition is deteriorating

9.5.1 Criteria for triggering a call for emergency assistance are included in the escalation policies, procedures and/or protocols

Escalation policies, procedures and/or protocols that include calling criteria

Data on the use of the rapid response system Education resources and training attendance records related to care for

patients whose condition is deteriorating

MM

SM



C 9.5.2 The circumstances and outcome of calls for emergency assistance are regularly reviewed

Records of audits, reviews and routine data collection about calls for emergency assistance

Agenda papers, meeting minutes and/or reports of relevant committees outlining the review and recommended changes

Feedback to the clinical workforce on calls for emergency assistance

MM

SM


C 9.6 Having a clinical workforce that is able to respond appropriately when a patient’s condition is deteriorating

9.6.1 The clinical workforce is trained and proficient in basic life support

Policy, procedures and/or protocols describe the requirements and processes for basic life support

Education resources and attendance records related to competencies in basic life support

Record of audits, reviews and routine data collection about calls for emergency assistance

Agenda papers, meeting minutes and/or reports of relevant committees relating to basic life support competency of the workforce

MM

SM


(i) More information about advanced life support and basic life support is available from the Australian Resuscitation Council

C 9.6.2 A system is in place for ensuring access at all times to at least one clinician, either on-site or in close proximity, who can practise advanced life support

Policies, procedures and/or protocols describe processes for rostering 24 hour access to a clinician or ambulance officer who can practice advanced life support

Delegation of roles and responsibilities to clinicians who can practice advanced life support

Position descriptions, staff duty statements and/or employment contracts that describe an individual clinician’s delegated safety and quality roles and responsibilities

Record of currency of advance life support skills Access to at least one clinicians or ambulance officer who can practise

MM

SM







Self assessment

advanced life support Audit of compliance with policies, procedures and/or protocols policy

(i) Information on calls to the recognition and response system that could be collected about each call for emergency assistance includes: patient demographics date and time of call, response time and stand down time reason for the call treatment or intervention provided outcomes of the call, including the disposition of the patient



Criterion: Communicating with patients and carersPatients, families and carers are informed of recognition and response systems and can contribute to the processes of escalating care.




Self assessment

D 9.7 Ensuring patients, families and carers are informed about, and are supported so that they can participate in, recognition and response systems and processes

9.7.1 Information is provided to patients, families and carers in a format that is understood and meaningful. The information should include:

the importance of communicating concerns and signs and symptoms of deterioration, which are relevant to the patient’s condition, to the clinical workforce

local systems for responding to clinical deterioration, including how they can raise concerns about potential deterioration

Material available for patients about recognition and response systems such as incorporated in an information pack

Documentation that delegates responsibility for informing and orienting patients, families and/or carers

Observation of mechanisms such as signs, posters or stickers on how to participate in recognition and response systems and processes

Audit of patient clinical records shows that information on recognising and responding to clinical deterioration has been provided to patients, families and/or carers

MM

SM


D 9.8 Ensuring that information about advance care plans and treatment-limiting orders is in the patient clinical record, where appropriate

9.8.1 A system is in place for preparing and/or receiving advance care plans in partnership with patients, families and carers

Policies, procedures and/or protocols describe the process for preparing advanced care directives in partnership with patients, families and/or carers

Forms of instructions used to assists with the preparation of advanced care directives in partnership with patients, families and/or carers

Reviews of advanced care directives

MM

SM


(i) A range of different names can be used to describe advanced care directives and limiting treatment orders. These include advanced care plans, living wills, respecting patient choices, not for resuscitation, or do not resuscitate orders.

Information that can be included in an advanced care directive includes: treatment options discussed people involved in the discussion patient’s wishes (if known) specific goals of therapy agreed treatment plan appropriate treatment to be provided






Self assessment

review date of plans specific triggers required to escalate care health professionals to be contacted when triggers are breached

D 9.8.2 Advance care plans and other treatment-limiting orders are documented in the patient clinical record

Audit of patient clinical record for variance between the advanced care directives and treatment provided MM

SM


D 9.9 Enabling patients, families and carers to initiate an escalation of care response

9.9.1 Mechanisms are in place for a patient, family member or carer to initiate an escalation of care response

Policies, procedures and/or protocols describe the process for family escalation

Information provided to families on escalation processes

MM

SM


(i) When developing policies, procedures and/or protocols regarding family escalation, the following issues will need to be considered: the criteria for patient, family, carer to trigger an escalation of care response what defines a ‘critical situation’, and if the family considers the patient is not receiving the medical

attention they believe is necessary, what is sufficient reason to escalate care the method for activating the escalation of care response. This may include an emergency phone

number from all hospital telephones or an emergency call bell the response that will be provided when patients, family or carers escalate care. This may include the

attendance of a medical emergency or rapid response team, an alternative group of clinicians, or one clinician

Further information is available from Implementation Guide for the National Consensus Statement: Essential Elements for Recognising and Responding to Clinical Deterioration

D 9.9.2 Information about the system for family escalation of care is provided to patients, families and carers

Observation of mechanisms such as signs, posters or stickers on how to participate in escalation processes, including information about how to call for assistance

Information broadcast on patient television and audio service Patient feedback on information provided

MM

SM







Self assessment

D 9.9.3 The performance and effectiveness of the system for family escalation of care is periodically reviewed

Agenda papers, meeting minutes and/or reports from relevant committee(s) include safety and quality of care indicators and data

Documentation of outcomes of review of policies, procedures and/or protocols for calls made by families

Audit of calls made by families Qualitative data from communication with families Patient feedback survey on family escalation of care

MM

SM


(i) Key points to consider when evaluating a family escalation system include: level of awareness of the patient, family, carer, and the clinical workforce on the escalation

system the number of times the escalation system is triggered by a patient, family, or carer reason for triggering escalation of care outcome following an escalation of care

D 9.9.4 Action is taken to improve the system performance of the for family escalation of care



MM

SM




Australian Commission on Safety and Quality in Health Care (2011). Implementation Guide for the National Consensus Statement: Essential Elements for Recognising and Responding to Clinical Deterioration: www.safetyandquality.gov.au

Australian Commission on Safety and Quality in Health Care (2010). National Consensus Statement: Essential Elements for Recognising and Responding to Clinical Deterioration, Sydney: www.safetyandquality.gov.au

Australian Commission on Safety and Quality in Health Care (2011). Recognising and Responding to Clinical Deterioration program, including work on observation chart, www.safetyandquality.gov.au/internet/safety/publishing.nsf/Content/prog-patientsrisk-lp

Australian Resuscitation Council website contains information about advanced and basic life support: www.resus.org.au


Standard 10: Preventing Falls and Harm from Falls

Clinical leaders and senior managers of a health service organisation implement systems to prevent patient falls and minimise harm from falls.

Clinicians and other members of the workforce use the falls prevention and harm minimisation systems.


Reduce the incidence of patient falls and minimise harm from falls.

Context



Criteria to achieve the Preventing Falls and Harm from Falls Standard:

Governance and systems for preventing falls

Screening and assessing risks of falls and harm from falling

Preventing falls and harm from falling




Criterion: Governance and systems for preventing fallsHealth service organisations have governance structures and systems in place to reduce falls and minimise harm from falls.




Self assessment

C10.1 Developing, implementing and reviewing policies, procedures and/or protocols, including the associated tools, that are based on the current national guidelines for preventing falls and harm from falls

10.1.1 Policies, procedures and/or protocols are in use that are consistent with best practice guidelines (where available) and incorporate screening and assessment tools

Policies, procedures and/or protocols are evidence-based and consistent with current national Preventing Falls and Harm from Falls Best Practice Guidelines, where available, and incorporate screening and assessment tools

Policies, procedures and/or protocols describe delegated roles and responsibilities of the workforce for falls management

Agenda papers, meeting minutes and/or reports of relevant committee(s) relating to falls and harm form falls

The Preventing Falls and Harm from Falls Best Practice Guidelines are available and accessible to the workforce

MM

SM


C10.1.2 The use of policies, procedures and/or protocols is regularly monitored

Policies, procedures and/or protocols are accessible to the clinical workforce

Observational audit of compliance with policies, procedures and/or protocols

Patient clinical record is reviewed against policies, procedures and/or protocols

Education and attendance at training Reports are made to key committees, such as a Quality Activity

Committee

MM

SM


C10.2 Using a robust, organisation-wide system of reporting, investigation and change management to respond to falls incidents

10.2.1 Regular reporting, investigating and monitoring of falls incidents is in place

Agenda papers, meeting minutes and/or reports of relevant committees or key groups responsible for falls management

Reports on causes of falls incidents across the organisation, including trends in falls incidents and causes, and near misses

Benchmarking of falls incidents Minimum data set for reporting and recording falls

MM

SM







Self assessment

C10.2.2 Administrative and clinical data are used to monitor and investigate regularly the frequency and severity of falls in the health service organisation

Trend analysis reports on falls incident reports, adverse events and near misses

Audit reports on patient clinical records of the frequency and severity of falls

Incidents and accidents register including data on types of injuries sustained

Falls dataset checklists Agenda papers, meeting minutes and/or reports of relevant

committees, such as an occupational health and safety committee Reports to coroners, departments or other authorities

MM

SM


C 10.2.3 Information on falls is reported to the highest level of governance in the health service organisation

Agenda papers, meeting minutes and/or reports of relevant senior executive committees relating to falls and harm form falls

Annual reports containing falls incidents information Clinical indicator reports to jurisdictional bodies, where applicable

MM

SM


C 10.2.4 Action is taken to reduce the frequency and severity of falls in the health service organisation

Audit of patient clinical record for falls risk assessments of patients screened and identified as being at high risk

Information provided to the workforce on falls risks Medication reviews for patients at risk of falls Referrals of at risk patients to services, such as physiotherapist and/or

occupational therapists, where available Educational resources and mandatory education and training sessions

for the workforce related to falls prevention and management Audit of environmental falls risks Register of environmental and equipment falls hazards and actions

taken Risk register or log including actions taken Audit patient clinical records for patients with a falls risk assessment

MM

SM


C 10.3 Undertaking quality improvement activities to address safety risks and ensure the effectiveness of the falls prevention system

10.3.1 Quality improvement activities are undertaken to prevent falls and minimise patient harm

Risk register or log that includes actions to address identified risks Agenda papers, meeting minutes and/or reports of relevant

committee(s) that detail improvement actions taken Quality improvement plan includes actions to address issues identified Examples of improvement activities that have been implemented and


MM

SM







Self assessment

C 10.4 Implementing falls prevention plans and effective management of falls

10.4.1 Equipment and devices are available to implement prevention strategies for patients at risk of falling and management plans to reduce the harm from falls

Agenda papers, meeting minutes and/or reports of relevant committee responsible for evaluating the efficacy of products, equipment and devices

Inventories of equipment and audits of clinical use Maintenance register or log of equipment and devices

MM

SM




Criterion: Screening and assessing risks of falls and harm from fallingPatients on presentation, during admission, and when clinically indicated, are screened for risk of a fall and the potential to be harmed from falls.




Self assessment

C10.5 Using a best practice based tool to screen patients on presentation, during admission and when clinically indicated for the risk of falls

10.5.1 A best practice screening tool is used by the clinical workforce to identify the risk of falls

Pre admission assessment tool Orientation and ongoing education resources on the use of pressure

injury screening for the relevant clinical workforce Schedule of training and attendance records for relevant clinical

workforce Audit of patient clinical records for use of screening assessment on

admission and when clinically indicated

MM

SM


C10.5.2 Use of the screening tool is monitored to identify the proportion of at-risk patients that were screened for falls

Audit of patient clinical records for compliance with screening requirements

Observational audit of the use of screening tool

MM

SM


C10.5.3 Action is taken to increase the proportion of at-risk patients who are screened for falls upon presentation and during admission




MM

SM


C10.6 Conducting a comprehensive risk assessment for patients identified at risk of falling in initial screening processes

10.6.1 A best practice assessment tool is used by the clinical workforce to assess patients at risk of falling

Policies, procedures and/or protocols describe the assessment to be used, that is evidence-based, consistent with national guidelines MM

SM


C10.6.2 The use of the assessment tool is monitored to identify the proportion of at-risk patients with a completed

Audits of patient clinical records that show at risk patients Reports on the number of patients screened and the incidence of falls Observational audit of the use of the assessment tool

MM

SM






Self assessment

falls assessment NM - add to action plan

C10.6.3 Action is taken to increase the proportion of at-risk patients undergoing a comprehensive falls risk assessment


SM




Criterion: Preventing falls and harm from fallingPrevention strategies are in place for patients at risk of falling.




Self assessment

C10.7 Developing and implementing a multifactorial falls prevention plan to address risks identified in the assessment

10.7.1 Use of best practice multifactorial falls prevention and harm minimisation plans is documented in the patient clinical record

Policies, procedures an/or protocols describe best practice multifactorial falls plans and provide tools and resources

Audits of patient clinical records for the use of multifactorial fall prevention plans

Audits of patient clinical records with a multifactorial falls prevention plan against care provided

MM

SM


C10.7.2 The effectiveness and appropriateness of the falls prevention and harm minimisation plan are regularly monitored

Root cause analysis of falls resulting in serious harm Evaluation of patient functional status and incidents of falls and near

misses pre and post implementation of the plan Reports form administration and clinical data that analyse trends in

falls and near misses Agenda papers, meeting minutes and/or reports of relevant

committees or groups responsible for falls management related to falls and harm from falls

Falls indicator data Audits of patient clinical records with a multifactorial falls prevention

plan against care provided

MM

SM


C10.7.3 Action is taken to reduce falls and minimise harm for at-risk patients


SM


C 10.8 Patients at risk of falling are referred to appropriate services, where available, as part of the discharge process

10.8.1 Discharge planning includes referral to appropriate services, where available

Audit of patient clinical records referrals to:o community health serviceso specialist medical practitioners (such as geriatrician,

ophthalmologist) o continence consultant or nurseo allied health professionals such as physiotherapist, occupational

therapist, podiatrist, dietician, optometrist

MM

SM




Criterion: Communicating with patients and carersPatients and carers are informed of the identified risks from falls and are engaged in the development of a falls prevention plan.




Self assessment

D 10.9 Informing patients and carer about the risk of falls, and falls prevention strategies

10.9.1 Patient information on falls risks and prevention strategies is provided to patients and carers in a format that is understood and meaningful

Materials used in patient education such as brochures, fact sheets, posters Patient information that is available for distribution by the clinical workforce

in a range of formats and language Audit of patients’ clinical records for patients provided with information on

falls risks and prevention strategies Report on available patient feedback on information provided

MM

SM


D 10.10 Developing falls prevention plans in partnership with patients and carers

10.10.1 Falls prevention plans are developed in partnership with patients and carers

Information for patients and/or carers on falls risks and prevention strategies Patient comments on and signs falls prevention plans and receives a copy Observational audits of consumers participating in making decisions about

their care Audits of patient clinical records demonstrate the clinical workforce and

patients have collaborated in the development of falls prevention plans and discharge summaries if the individual remains at risk following discharge

Results of patient and/or carer satisfaction surveys regarding in relation to fall prevention plan

MM

SM


Link to Standard 1.18.1 and Standard 2



Australian Commission on Safety and Quality in Healthcare (2009). Preventing Falls and Harm from Falls in Older People. Best Practice Guidelines for Australian Hospitals:. www.safetyandquality.gov.au

World Health Organization. Falls links. Available from: http://www.who.int/violence_injury_prevention/other_injury/falls/links/en/index.html


Action Plan TemplateHealth service organisations may choose to use this template to compile a record of areas requiring improvement strategies to address actions rated as not me during the self assessment.

Action Plan

What needs to be done? What risks and barriers exist?

What strategies can be used to implement changes?

Who is responsible?What are the timeframes?



Glossary

Accreditation: A status that is conferred on an organisation or an individual when they have been assessed as having met particular standards. The two conditions for accreditation are an explicit definition of quality (i.e. standards) and an independent review process aimed at identifying the level of congruence between practices and quality standards. 2

Acute health care facility: A hospital or other health care facility providing healthcare services to patients for short periods of acute illness, injury or recovery. 3

ACSQHC: Australian Commission on Safety and Quality in Health Care (the Commission).

Advance care directive: Instructions that consent to, or refuse the future use of specified medical treatments (also known as a healthcare directive, advance plan or another similar term). 3

Advanced life support: The preservation or restoration of life by the establishment and/or maintenance of airway, breathing and circulation using invasive techniques such as defibrillation, advanced airway management, intravenous access and drug therapy. 3

Adverse drug reaction: A drug response that is noxious and unintended, and which occurs at doses normally used or tested in humans for the prophylaxis, diagnosis or therapy of disease, or for the modification of physiological function.4

Adverse event: An incident in which harm resulted to a person receiving health care.

Adverse medicines event: An adverse event due to a medicine. This includes the harm that results from the medicine itself (an adverse drug reaction) and the potential or actual patient harm that comes from errors or system failures associated with the preparation, prescribing, dispensing, distribution or administration of medicines (medication incident). 5

Antibiotic: A substance that kills or inhibits the growth of bacteria.6

Antimicrobial: A chemical substance that inhibits or destroys bacteria, viruses and fungi, including yeasts or moulds. 6

Antimicrobial stewardship: A program implemented in a health service organisation to reduce the risks associated with increasing microbial resistance and to extend the effectiveness of antimicrobial treatments. Antimicrobial stewardship may incorporate a broad range of strategies including the monitoring and reviews of antimicrobial use.6

Approved patient identifiers: Items of information accepted for use in patient identification, including patient name (family and given names), date of birth, gender, address, medical record number and/or Individual Healthcare Identifier. Health service organisations and clinicians are responsible for specifying the approved items for patient identification. Identifiers such as room or bed number are not to be used.

Basic life support: The preservation of life by the initial establishment of, and/or maintenance of, airway, breathing, circulation and related emergency care, including use of an automated external defibrillator. 7

Blood: Includes homologous and autologous whole blood. Blood includes red blood cells, platelets, fresh frozen plasma, cryoprecipitate and cryodepleted plasma. 8

Blood products: Plasma derivatives and recombinant products excluding medication products.8

Carers: People who provide unpaid care and support to family members and friends who have a disability, mental illness, chronic condition, terminal illness or general frailty.9 Carers include parents and guardians caring for children.



Clinical communication: An exchange of information that occurs between treating clinicians. Communication can be formal (when a message conforms to a predetermined structure for example in a health record or stored electronic data) or informal (when the structure of the message is determined solely by the relevant parties; for example, a face-to-face or telephone conversation.10

Clinical governance: A system through which organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care. This is achieved by creating an environment in which there is transparent responsibility and accountability for maintaining standards and by allowing excellence in clinical care to flourish.11

Clinical handover: The transfer of professional responsibility and accountability for some or all aspects of care for a patient, or group of patients, to another person or professional group on a temporary or permanent basis. 12

Clinical workforce: The nursing, medical and allied health workforce who provide patient care and students who provide patient care under supervision. This may also include laboratory scientists. 13

Clinician: A healthcare provider, trained as a health professional. Clinicians include registered and non-registered practitioners, or a team of health professionals providing health care who spend the majority of their time providing direct clinical care.

Competency-based training: An approach to training that places emphasis on what a person can do in the workplace as a result of training completion.

Complementary healthcare products: Vitamin, mineral, herbal, aromatherapy and homeopathic products, also known as 'traditional' or 'alternative' medicines. 14

Consumer (health): Patients and potential patients, carers and organisations representing consumers’ interests. 15

Consumer medicines information: Brand-specific leaflets produced by a pharmaceutical company, in accordance with the Therapeutic Goods Regulations (Therapeutic Goods Act 1989), to inform patients about prescription and pharmacist-only medicines. These are available from a variety of sources: for example, a leaflet enclosed within the medication package or supplied by a pharmacist; or a computer printout, provided by a doctor, nurse or hospital, and obtained from the pharmaceutical manufacturer or from the internet.4

Continuous improvement: A systematic, ongoing effort to raise an organisation’s performance as measured against a set of standards or indicators. 16

Disease surveillance: An epidemiological practice that involves monitoring the spread of disease to establish progression patterns. The main role of surveillance is to predict, observe and provide a measure for strategies that may minimise the harm caused by outbreak, epidemic and pandemic situations, as well as to increase knowledge of the factors that might contribute to such circumstances.6

Emergency assistance: Clinical advice or assistance provided when a patient’s condition has deteriorated severely. This assistance is provided as part of the rapid response system, and is additional to the care provided by the attending medical officer or team. 3

Environment: The overall surroundings where health care is being delivered, including the building, fixtures, fittings and services such as air and water supply. Environment can also include other patients, visitors and the workforce.

Escalation protocol: The protocol that sets out the organisational response required for different levels of abnormal physiological measurements or other observed deterioration. The protocol applies to the care of all patients at all times. 3

Fall: An event that results in a person coming to rest inadvertently on the ground or floor or another lower level. 17



Guidelines: Clinical practice guidelines are ‘systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific circumstances’.18

Governance: The set of relationships and responsibilities established by a health service organisation between its executive, workforce and stakeholders (including consumers). Governance incorporates the set of processes, customs, policy directives, laws and conventions affecting the way an organisation is directed, administered or controlled. Governance arrangements provide the structure through which the corporate objectives (social, fiscal, legal, human resources) of the organisation are set and the means by which the objectives are to be achieved. They also specify the mechanisms for monitoring performance. Effective governance provides a clear statement of individual accountabilities within the organisation to help in aligning the roles, interests and actions of different participants in the organisation to achieve the organisation’s objectives. In these Standards, governance includes both corporate and clinical governance.

Hand hygiene: A general term referring to any action of hand cleansing.

Healthcare associated infections: Infections that are acquired in healthcare facilities (nosocomial infections) or that occur as a result of healthcare interventions (iatrogenic infections). Healthcare associated infections may manifest after people leave the healthcare facility. 19

Health outcome: The health status of an individual, a group of people or a population that is wholly or partially attributable to an action, agent or circumstance.

Health service organisation: A separately constituted health service that is responsible for the clinical governance, administration and financial management of a service unit(s) providing health care. A service unit involves a grouping of clinicians and others working in a systematic way to deliver health care to patients and can be in any location or setting, including pharmacies, clinics, outpatient facilities, hospitals, patients’ homes, community settings, practices and clinicians’ rooms.

Health service record: Information about a patient held in hard or soft copy. The health service record may comprise of clinical records (such as medical history, treatment notes, observations, correspondence, investigations, test results, photographs, prescription records, medication charts), administrative records (such as contact and demographic information, legal and occupational health and safety reports) and financial records (such as invoices, payments and insurance information).

High-risk medicines: Medicines that have a high risk of causing serious injury or death to a patient if they are misused. Errors with these products are not necessarily more common, but the effects can be more devastating. Examples of high-risk medicines include anticoagulants, opioids and chemotherapy.20

Hospital: A healthcare facility licensed by the respective regulator as a hospital or declared as a hospital.

Human factors: Study of the interactions between humans and other elements of a system, and the profession that applies theory, principles, data and methods to design in order to optimise human wellbeing and overall system performance.21

Incident: An event or circumstance that resulted, or could have resulted, in unintended and/or unnecessary harm to a person and/or a complaint, loss or damage.

Infection: The invasion and reproduction of pathogenic or disease causing organisms inside the body. This may cause tissue injury and disease.6

Infection control or infection control measures: Actions to prevent the spread of pathogens between people in a healthcare setting. Examples of infection control measures include targeted healthcare associated infection surveillance, infectious disease monitoring, hand hygiene and personal protective equipment.6

Informed consent: A process of communication between a patient and their medical officer that results in the patient’s authorisation or agreement to undergo a specific medical intervention.22 This communication should ensure the patient has an understanding of all the available options and the expected outcomes such as the success rates and/or side effects for each option.23



Interventional procedures: Any procedure used for diagnosis or treatment that penetrates the body. These procedures involve incision, puncture, or entry into a body cavity.

Invasive devices: Devices inserted through skin, mucosal barrier or internal cavity, including central lines, peripheral lines, urinary catheters, chest drains, peripherally inserted central catheters and endotracheal tubes.

Medication: The use of medicine for therapy or for diagnosis, its interaction with the patient and its effect.

Medication authorities: An organisation’s formal authorisation of an individual, or group of individuals, to prescribe, dispense or administer medicines or categories of medicine consistent with their scope of practice.

Medication error: Any preventable event that may cause or lead to inappropriate medication use or patient harm while the medication is in the control of the healthcare professional, patient or consumer.24

Medication history: An accurate recording of a patient’s medicines. It comprises a list of all current medicines including all current prescription and non-prescription medicines, complementary healthcare products and medicines used intermittently; recent changes to medicines; past history of adverse drug reactions including allergies; and recreational drug use.25

Medication incident: See Adverse medicines event.

Medication management system: The system used to manage the provision of medicines to patients. This system includes dispensing, prescribing, storing, administering, manufacturing, compounding and monitoring the effects of medicines as well as the rules, guidelines, decision-making and support tools, policies and procedures in place to direct the use of medicines. These are specific to a healthcare setting.

Medications reconciliation: The process of obtaining, verifying and documenting an accurate list of a patient’s current medications on admission and comparing this list to the admission, transfer, and/or discharge medication orders to identify and resolve discrepancies. At the end of the episode of care the verified information is transferred to the next care provider.

Medicine: A chemical substance given with the intention of preventing, diagnosing, curing, controlling or alleviating disease, or otherwise improving the physical or mental welfare of people. Prescription, non-prescription and complementary medicines, irrespective of their administration route, are included.26

Monitoring plan: A written plan that documents the type and frequency of observations to be recorded as referred to in Standard 9, ‘Recognising and Responding to Clinical Deterioration in Acute Health Care’.3

Near miss: An incident that did not cause harm, but had the potential to do so.27

Non-clinical workforce: The workforce engaged in a health service organisation who do not provide direct clinical care but support the business of health service delivery through administration, hotel service and corporate record management, management support or volunteering.

Non-prescription medicines: Medicines available without a prescription. Some non-prescription medicines can be sold only by pharmacists or in a pharmacy; others can be sold through non-pharmacy outlets. Examples of non-prescription medicines include simple analgesics, cough medicines and antacids.26

Open disclosure: An open discussion with a patient about an incident(s) that resulted in harm to that patient while receiving health care. The criteria of open disclosure are an expression of regret and a factual explanation of what happened, the potential consequences and the steps taken to manage the event and prevent recurrence.28



Orientation: A formal process of informing and training workforce upon entry into a position or organisation, which covers the policies, processes and procedures applicable to the organisation.

Patient: A person receiving health care. Synonyms for ‘patient’ include consumer and client.

Patient-care mismatching events: Events where a patient receives the incorrect procedure, therapy, medication, implant, device or diagnostic test. This may be as a result of the wrong patient receiving the correct treatment (such as the wrong patient receiving an X-ray) or as a result of the correct patient receiving the wrong care (such as a surgical procedure performed on the wrong side of the body or the provision of an incorrect meal, resulting in an adverse event).

Patient-centred care: The delivery of health care that is responsive to the needs and preferences of patients. Patient-centred care is a dimension of safety and quality.

Patient clinical record: Consists of, but is not limited to, a record of the patient’s medical history, treatment notes, observations, correspondence, investigations, test results, photographs, prescription records and medication charts for an episode of care.

Patient information: Formal information that is provided by health services to a patient. Patient information to ensures the patient is informed before making decisions about their health care.

Patient blood management: Involves a precautionary approach and aims to improve clinical outcomes by avoiding unnecessary exposure to blood components. It includes the three pillars of blood management: optimisation of blood volume and red cell mass

minimisation of blood loss

optimisation of the patient’s tolerance of anaemia.29

Patient master index: An organisation’s permanent listing or register of health information on patients who have received or are scheduled to receive services.30

Periodic review: Infrequent review, the frequency of which is determined by the subject, risk, scale and nature of the review.

Point of care: The time and location where an interaction between a patient and clinician occurs for the purpose of delivering care.

Policy: A set of principles that reflect the organisation’s mission and direction. All procedures and protocols are linked to a policy statement.

Prescription medicine: A prescription medicine is any medicine that requires a prescription before it can be supplied. A prescription must be authorised by an appropriately registered practitioner.31

Pressure injuries: These are localised to the skin and/or underlying tissue, usually over a bony prominence and caused by unrelieved pressure, friction or shearing. Pressure injuries occur most commonly on the sacrum and heel but can develop anywhere on the body. Pressure injury is a synonymous term for pressure ulcer.

Procedure: The set of instructions to make policies and protocols operational and are specific to an organisation.

Protocol: An established set of rules used for the completion of tasks or a set of tasks.

Rapid response system: The system for providing emergency assistance to patients whose condition is deteriorating. The system includes the clinical team or individual providing emergency assistance, and may include on-site and off-site personnel. 3



Recognition and response systems: Formal systems that help workforce promptly and reliably recognise patients who are clinically deteriorating, and appropriately respond to stabilise the patient. 3

Regular: Performed at recurring intervals. The specific interval for regular review, evaluation, audit or monitoring and so on needs to be determined for each case. In these Standards, the time period should be consistent with best practice, be risk based, and be determined by the subject and nature of the review.

Risk: The chance of something happening that will have a negative impact. It is measured by consequences and likelihood.

Risk management: The design and implementation of a program to identify and avoid or minimise risks to patients, employees, volunteers, visitors and the institution.

Senior level of governance: The most senior committee or individual with the delegated authority to act or influence change to bring about improvement is care or processes.

System: The resources, policies, processes and procedures that are organised, integrated, regulated and administered to accomplish the objective of the Standard. The system:

interfaces risk management, governance, operational processes and procedures, including education, training and orientation

deploys an active implementation plan and feedback mechanisms

includes agreed protocols and guidelines, decision support tools and other resource material

employs a range of incentives and sanctions to influence behaviours and encourage compliance with policy, protocol, regulation and procedures.

Training: The development of knowledge and skills.

Treatment-limiting orders: Orders, instructions or decisions that involve the reduction, withdrawal or withholding of life-sustaining treatment. These may include ‘no cardiopulmonary resuscitation’ or ‘not for resuscitation’.3

Workforce: All those people employed by a health service organisation.



References

1. Paterson R, The Review Team for the Review of Future Governance Arrangements for Safety and Quality in Health Care. National arrangements for safety & quality of health care in Australia: the report of the review of future governance arrangements for safety and quality in health care. Canberra: Australian Health Ministers' Conference, 2005.

2. Australian Council for Safety and Quality in Health Care. Standard for Credentialling and Defining the Scope of Clinical Practice: A National Standard for credentialling and defining the scope of clinical practice of medical practitioners, for use in public and private hospitals, 2004.

3. Australian Commission on Safety and Quality in Health Care. National Consensus Statement: Essential Elements for Recognising and Responding to Clinical Deterioration. Sydney: ACSQHC, 2010.

4. Australian Commission on Safety and Quality in Health Care. The National Medication Safety and Quality Scoping Study Committee Report. Sydney: ACSQHC, 2009.

5. Australian Council for Safety and Quality in Healthcare. Second National Report on Patient Safety - Improving Medication Safety. Canberra: Australian Council for Safety and Quality in Healthcare, 2002.

6. Cruickshank M, Ferguson J, editors. Reducing Harm to Patients from Health Care Associated Infection: The Role of Surveillance. Sydney: Australian Commission on Safety and Quality in Health Care, 2008.

7. Any Attempt at Resusitation is Better Than no Attempt, Forward to Guidelines: Glossary of Terms. Australian Resuscitation Council, 2010 (Accessed 27/04/2011, at http://www.resus.org.au/policy/guidelines/admin/glossary_of_terms.htm.)

8. Factsheets, Blood and Blood Products in Australia. National Blood Authority Australia, 2009. (Accessed 29 March 2011, at http://www.nba.gov.au/pubs/factsheets-blood-products.html.)

9. About Carers. (Accessed 28 March, 2011, at http://national.carersaustralia.com.au/?/national/section/2:about-carers.)

10. Coiera EW, Jayasuriya RA, Hardy J, Bannan A, Thorpe MEC. Communication loads on clinical the workforce in the emergency department. Medical Journal of Australia 2002;176:415-418.

11. Scally G, Donaldson LJ. Clinical governance and the drive for quality improvement in the new NHS in England BMJ 1998;317 61.

12. National Patient Safety Agency. Seven steps to patient safety. London: National Patient Safety Agency, 2004.

13. Department of Health and Ageing. National Mental Health Report 2007: Summary of Twelve Years of Reform in Australia's Mental Health Services under the National Mental Health Strategy 1993-2005. Canberra, 2007.

14. Different Types of Medicines, MSD. 2007. (Accessed 20 April 2011, at http://www.msd-australia.com.au/content/corporate/products/TypesMed.html.)

15. Consumer representative program policy. Consumers Health Forum of Australia, 2011. (Accessed 24 March 2011, at https://www.chf.org.au/consumer-representatives-program-policy.php#link11.)

16. Aged Care Standards and Accreditation Agency Ltd. Audit Handbook. Paramatta: ACSAA, June 2009.

17. Falls, Fact Sheet No 344. WHO, 2010. (Accessed 14 April 2011, at http://www.who.int/mediacentre/factsheets/fs344/en/.)

18. Field M, Lohr K, editors. Guidelines for clinical practice: from development to use. Washington DC.: National Academy Press, 1992.

19. National Health & Medical Research Council. Australian Guidelines for the Prevention and Control of Infection in Healthcare. Canberra: NHMRC, 2010:260.

20. ISMP's List of High- Alert Medications. Institute for Safe Medication Practices, 2008. (Accessed 20 April 2011, at http://www.ismp.org/Tools/highalertmedications.pdf.)

21. Carayon P, editor. Handbook of Human Factors and Ergonomics in Health Care and Patient Safety. Hillsdale, NJ: Lawrence Erlbaum Associates, 2007.

22. Patient Physician Relationship Topics: Informed Consent. American Medical Association. (Accessed 22 March 2011, at http://www.ama-assn.org/ama/pub/physician-resources/legal-topics/patient-physician-relationship-topics/informed-consent.page.)


http://www.ama-assn.org/ama/pub/physician-resources/legal-topics/patient-physician-relationship-topics/informed-consent.page.

http://www.ama-assn.org/ama/pub/physician-resources/legal-topics/patient-physician-relationship-topics/informed-consent.page.

http://www.ismp.org/Tools/highalertmedications.pdf.

http://www.who.int/mediacentre/factsheets/fs344/en/.

http://www.chf.org.au/consumer-representatives-program-policy.php#link11.

http://www.msd-australia.com.au/content/corporate/products/TypesMed.html.

http://national.carersaustralia.com.au/?/national/section/2:about-carers.

http://national.carersaustralia.com.au/?/national/section/2:about-carers.

http://www.nba.gov.au/pubs/factsheets-blood-products.html.

http://www.resus.org.au/policy/guidelines/admin/glossary_of_terms.htm.


23. Carey-Hazell Karen. Improving patient information and decision making. The Australian Health Consumer Issue 1: Consumers Health Forum of Australia, 2005.

24. What is a medication error? National Coordinating Council for Medication Error Reporting and Prevention. (Accessed 28 March 2011, at http://www.nccmerp.org/aboutMedErrors.html.)

25. Explanatory Notes, Completing Medication History Form. WA Department of Health. (Accessed 30 March 2011, at http://www.watag.org.au/wamsg/docs/Explantory_Notes_Medication_History_Form.pdf.)

26. Australian Pharmaceutical Advisory Council. Guiding principles for medication management in the community. Canberra: Commonwealth of Australia, 2006.

27. Barach P, Small SD. Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems. BMJ 2000;320(7237):759-763.

28. Australian Commission on Safety and Quality in Health Care. Open Disclosure Standard, 2008.

29. National Blood Authority. Patient Blood Management Guidelines: Module 1. Canberra: Commonwealth of Australia, 2011:11.

30. New South Wales Department of Health. Patient Matters Manual. Chapter 9. Sydney: New South Wales Department of Health, 2008.

31. Perscription medicines, Fact Sheet 1-3. Victorian Government. (Accessed 28 March 2011, at www.betterhealth.gov.au.)

32. Australian Commission on Safety and Quality in Health Care. Windows into Safety and Quality in Health Care 2010. Sydney: Australian Commission on Safety and Quality in Health Care, 2010.

33. Elshaug A, Moss J, Littlejohns P, Karnon J, Merlin T, J. H. Identifying existing health care services that do not provide value for money. Medical Journal of Australia 2009;190(5):269-273.

34. Australian Commission on Safety and Quality in Health Care. Australian Charter for Health Care Rights. Sydney: Australian Commission on Safety and Quality in Health Care, 2008.

35. Meterko M, Wright S, Lin H, Lowy E, Cleary PD. Mortality among patients with acute myocardial infarction: The influences of patient-centered care and evidence-based medicine. Health Services Research 2010;In press.

36. Boulding W, Glickman S, Manary M, Schulman K, R. S. Relationship between patient satisfaction with inpatient care and hospital readmission within 30 days. . The American Journal of Managed Care 2011;17(1):41-48.

37. Edgcumbe D. Patients' perceptions of hospital cleanliness are correlated with rates of methicillin-resistant Staphylococcus aureus bacteraemia. Journal of Hospital Infection 2009;71(1):99-101.

38. DiGioia AI, Greenhouse PK, Levison TJ. Patient and family-centered collaborative care: An orthopaedic model. Clinical Orthopaedics and Related Research 2007;463(13-19).

39. Arbuthnott A, Sharpe D. The effect of physician-patient collaboration on patient adherence in non-psychiatric medicine. Patient Education and Counseling 2009;77(1):60-67.

40. Charmel P, Frampton S. Building the business case for patient-centred care. Healthcare Financial Management 2008;March 62 (3):80-85.

41. Institute of Medicine. Crossing The Quality Chasm: A New Health System for the 21st Century. Washington DC: National Academy Press, 2001.

42. Australian Commission on Safety and Quality in Health Care. Australian Safety and Quality Framework for Health Care. Sydney: Australian Commission on Safety and Quality in Health Care, 2010.

43. The National Hand Hygiene Initiative. Hand Hygiene Australia, 2011. (Accessed 9 May 2011, 2011, at http://www.hha.org.au/.)

44. National Health & Medical Research Council. The Australian Immunisation Handbook 9th Edition Canberra, ACT: Australian Government 2008.

45. Duguid M, Cruickshank M, editors. Antimicrobial Stewardship in Australian Hospitals. Sydney: ACSHQC, 2011.

46. Roughead EE, Lexchin J. Adverse Drug Events: counting is not enough, action is needed. Medical Journal of Australia 2006;184(7):315-316.

47. Roughead EE, Semple SJ. Medication safety in acute care in Australia: where are we now? Part 1: a review of the extent and causes of medication problems 2002–2008. Australia and New Zealand Health Policy 2009;6(18).

48. Roughead EE, Semple S. Literature review:medication safety in acute care in Australia. Sydney: ACSQHC, 2008.


http://www.hha.org.au/.

http://www.betterhealth.gov.au./

http://www.watag.org.au/wamsg/docs/Explantory_Notes_Medication_History_Form.pdf.

http://www.nccmerp.org/aboutMedErrors.html.


49. Australian Commission on Safety and Quality in Health Care. Windows into safety and quality in health care 2008. Sydney: Australian Commission on Safety and Quality in Health Care, 2008.

50. Gosbee J. Human factors engineering and patient safety. Quality and Safety in Health Care 2002;11:352-354.

51. Karsh B-T, Holden RJ, Alper SJ, Or CKL. A human factors engineering paradigm for patient safety: Designing to support the performance of the healthcare professional. Quality and Safety in Health Care 2006;15:59-65.

52. Surgical Safety Checklist. Royal Australasian College of Surgeons, 2009. (Accessed 19 April 2011, at http://www.surgeons.org/racs/fellows/resources-for-surgeons#WHO.)

53. Ensuring Correct Patient, Correct Site, Correct Procedure Protocols Australian Commission on Safety and Quality in Health Care, 2008. (Accessed 19 April 2011, at http://www.safetyandquality.gov.au/internet/safety/publishing.nsf/Content/PatientID-Resources-Exp_Correct-Pat-Site-Proc.)

54. A national standard for patient identification bands in Australia. ACSQHC, 2009. (Accessed 17 May 2011, at http://www.safetyandquality.gov.au/internet/safety/publishing.nsf/Content/PriorityProgram-04_Initiatives#std.)

55. Australian Medical Association. Safe Handover: Safe Patients. Guidance on clinical handover for clinicians and managers, 2006.

56. Australian Institute of Health and Welfare. Australia's Health 2006. Canberra, 2006.

57. Wong MC, Yee KC, Turner P. Clinical Handover Literature Review, eHealth Services Research Group, University of Tasmania Australia: Australian Commission on Safety and Quality in Health Care, 2008.

58. Clark E, Squire S, Heyme A, Mickle MA, Petrie E. The PACT Project: improving communication at handover. Medical Journal of Australia 2009;190(11):S125-S127.

59. Hatten-Masterton S, Griffiths M. SHARED maternity care: enhancing clinical communication in a private maternity setting. Medical Journal of Australia 2009;190(11):S150-S151.

60. Aldrich R, Duggan A, Lane K, Nair K, Hill K. ISBAR revisited: identifying and solving barriers to effective clinical handover in inter-hospital transfer – public report on pilot study. Newcastle: Hunter New England Health 2009.

61. Wong MC, Yee KC, Turner P. Nursing and medical handover in general surgery, emergency medicine and general medicine at the Royal Hobart Hospital - public report on pilot study. Hobart: University of Tasmania, 2008.

62. Graves N, Birrell FA, Whitby M. Modeling the economic losses from pressure ulcers among hospitalized patients in Australia. Wound Repair and Regeneration 2005;13(5):462-467.

63. Van Den Bos J, Rustagi K, Gray T, Halford M, Ziemkiewicz E, Shreve J. The $17.1 Billion Problem: The Annual Cost Of Measurable Medical Errors. Health Affairs 2011;30(4):596-603.

64. Buist M, Bernard S, Nguyen TV, Moore G, Anderson J. Association between clinical abnormal observations and subsequent in-hospital mortality: a prospective study. Resuscitation 2004;62:137-141.

65. Calzavacca P, Licari E, Tee A, Egi M, Downey A, Quach J, et al. The impact of rapid response system on delayed emergency team activation patient characteristics and outcomes - A follow-up study. Resuscitation 2010;81:31-35.

66. MERIT Study Investigators. Introduction of the medical emergency team (MET) system: a cluster-randomised controlled trial. Lancet 2005;365:2091-2097.

67. Cioffi J, Salter C, Wilkes L, Vonu-Boriceanu O, Scott J. Clinicians' responses to abnormal vital signs in an emergency department. Australian critical care 2006;19(2):66-72.

68. Endacott R, Kidd T, Chaboyer W, Edington J. Recognition and communication of patient deterioration in a regional hospital: A multi-methods study. Australian critical care 2007;20:100-105.

69. McQuillan P, Pilkington S, Allan A, Taylor B, Short A, Morgan G, et al. Confidential inquiry into quality of care before admission to intensive care. British Medical Journal 1998;316:1853-1858.

70. Australian Commission on Safety and Quality in Health Care. Preventing Falls and Harm From Falls in Older People: Best Practice Guidelines for Australian Residential Aged Care Facilities 2009. Sydney: ACSQHC, 2009.

71. Australian Commission on Safety and Quality in Health Care. Preventing Falls and Harm From Falls in Older People: Best Practice Guidelines for Australian Community Care 2009. Sydney: ACSQHC, 2009.

72. Australian Commission on Safety and Quality in Health Care. Preventing Falls and Harm From Falls in Older People: Best Practice Guidelines for Australian Hospitals 2009. Sydney: ACSQHC, 2009.


http://www.safetyandquality.gov.au/internet/safety/publishing.nsf/Content/PriorityProgram-04_Initiatives#std.

http://www.safetyandquality.gov.au/internet/safety/publishing.nsf/Content/PatientID-Resources-Exp_Correct-Pat-Site-Proc.

http://www.safetyandquality.gov.au/internet/safety/publishing.nsf/Content/PatientID-Resources-Exp_Correct-Pat-Site-Proc.

http://www.surgeons.org/racs/fellows/resources-for-surgeons#WHO.


Appendix 1 - Decision Support Tool for determining the level of performance to meet the NSQHS StandardsIssue Satisfactory Performance Unsatisfactory PerformancePolicies, procedures and/or protocols are in use

Documents details the date they become effective and the date of the next revision

Source documents are referenced, particularly where they are represented as best practice

Documents may reference the consultation processes undertaken or collaborative group involved in their development

The documents are adapted to the specific context and setting in which they are used by the health service

The workforce know the documents exist, can access them, and know and use the contents

Include the tolls, forms and processes refaced in the Standards

Documentation is: Outdated Incomplete Either overly complex and detailed or lacking in specificity Not related to the organisation, for example policy developed by

another organisation or body and not adapted for use by the health services, and/or

Not accessible or unknown to users

Monitor and report Data sampling or collection occurs across the health service Quality of data is known Processes exist to test and improve the quality of the data Feedback is provided to targeted areas and/or available across

the health service Data presented in reports is meaningful and relevant Data collection and reporting informs a problem area or an area

of specific risk Timeliness of the collection and review of the data is consistent

with the issue being examined

Data is not sufficiently proximal to the issue being examined to provide meaningful information

No feedback is provided or the feedback provided is not sufficiently specific to be of use

Feedback is not available to, individuals, the workforce, units, governance committees or areas that can make improvements, and/or

Data is not sufficiently recent to be relevant to the current provisioning of service

Action is taken to improve The action being taken:o is applicable broadly across the health service, and/oro is readily transferable across the organisation, and/oro focuses on key risks or priority areas identified by the

health service Action outcomes will inform future improvement plans across the

health service or target specific risks Action outcomes are, or will be, communicated to the workforce,

patients, and governance committees Action is timely and responsive to issues as they arise, and/or Action is coordinated

Action claims to be organisation wide, but relates to a localised issue, process or situation and there is no clear outcome with the transfer of lessons learned across the health service

Action is limited to an area of interest rather than an organisational priority or risk

Significant delays exist between the identification of an issue and action being taken, and/or

Action is disparate and not coordinated, duplicated across the organisation



Issue Satisfactory Performance Unsatisfactory Performance

Training Training provided or accessed is matched to workforce training needs;

A system, such as a register, is in place to track workforce participation in training and qualifications, and/or

Training programs are evaluated

Training does not address safety and quality of care needs, or workforce training needs

The workforce are not aware of training The workforce are not able to access training, and/or The workforce are not given the opportunity to provide feedback

on trainingRisk Assessment Clear and agreed processes exist to identify risks for the

organisation and for individual service areas A scale to rate risk is consistently applied The risks are reviewed on a regular basis, and/or Risks are assessed at all levels of an organisation

There is no formal process for identifying and rating of risk, or where risk exists, the formal process is not applied, and/or

Risks are identified and rated at an organisational level, not at an individual service level

Regular review Review occurs across the relevant organisation or a representative sample that is appropriate for the issue under review;

Risk assessment is used as the basis to determine the location and size of the sample, and/or

Frequency and timing of the review is both organisationally appropriate and consistent with the level of risk of the issue.

Frequency of review is insufficient in providing information that can be used to introduce change

Size of the review is too small or limited to provide meaningful information

Data collected is not current, incomplete and/or poor quality Reviewed data is not representative of all areas where the issue

occurs The review inappropriately excludes consumers

Evidence base or best practice

Reference is current and source is accepted as reputable and authoritative, and may include professional body, published articles, published research

May be peer reviewed, and/or Where possible or appropriate, are consistent with national

specifications or standards.

Material or resources are not referenced, or source is not clear, Reference material is out of date, and/or Inconsistencies are apparent in the material or resources.

Processes and/or systems are in place

Processes/systems:o are responsive in their ability to address issueso clearly delineate roles and responsibilitieso interface with risk management, governance, operational

processes and procedures for each Standard

Workforce are not aware of the processes/systems, and/or Processes/systems are cumbersome and/or not adhered to

Communication Format of communication (for example email, posters or website updates) is appropriate to the purpose

Language is clear and concise Workforce are aware of the communication Processes in place for routinely distributing relevant

Format is inappropriate for purpose Communication is not adapted for the target audience, and/or Key pieces of communication do not reach the target audience Communication strategies are rarely or not evaluated



Issue Satisfactory Performance Unsatisfactory Performancecommunication materials are in place;

The effectiveness of the communication strategy is evaluated and/or

The needs of culturally and linguistically diverse populations are taken into consideration

Communication strategies are evaluated and modified accordingly

Equipment Workforce are trained in use of equipment and/or Records are kept of equipment maintenance

Workforce do not know how to use the available equipment appropriately

Equipment is not available and/or Equipment is not maintained



Appendix 2 - Summary of items and actions that require auditing or review by health services

Number Item or actionAudit of clinical

informationReview of process Completed

Standard 1: Governance for safety and quality in health service organisations Yes No

1.1.1An organisation-wide management system is in place for the development, implementation and regular review of policies, procedures and/or protocols

1.6.1 An organisation wide quality management system is in use and regularly monitored.

1.10.1 A system is in place to defined and regularly review the scope of practice for the clinical workforce

1.11.2 The clinical workforce participates in regular performance reviews that support individual development and improvement

1.13.1 Feedback from the workforce on their understanding and use of safety and quality systems is analysed.

1.15.3 Feedback is provided to the workforce on the analysis of reported complaints.

1.15.4 Patient feedback and complaints are reviewed by the highest level of governance in the organisation.

1.18.2 Mechanisms are in place to monitor and improve documentation of informed consent

Standard 2: Partnering with consumers Yes No

2.4.1 Consumers and/or carers provide feedback on patient information publications prepared by the health service organisation

2.9.2 Consumers and/or carers participate in the implementation of quality activities relating to patient feedback data

Standard 3: Preventing and controlling healthcare associated infections Yes No

3.1.2 The use of policies, protocols and procedures is regularly monitored

3.1.3 The effectiveness of the infection prevention and control systems is regularly reviewed at the highest level of governance in the organisation





3.5 Developing, implementing and auditing a hand hygiene program consistent with the current national hand hygiene initiative

3.8.1 Compliance with the system for the use and management of invasive devices is monitored

3.10.2 Compliance with aseptic non-touch technique is regularly audited

3.11.2 Compliance with standard precautions is monitored

3.11.4 Compliance with transmission-based precautions is monitored

3.14 Developing, implementing and regularly reviewing the effectiveness of the antimicrobial stewardship system

3.15.2 Policies, procedures and/or protocols for environmental cleaning are regularly reviewed

3.15.3 An established environmental cleaning schedule is in place and environmental cleaning audits are undertaken regularly

3.16.1 Compliance with relevant national or international standards and manufacturer’s instructions for cleaning, disinfection and sterilisation of reusable instruments and devices is regularly monitored

Standard 4: Medication safety Yes No

4.2 Undertaking a regular, comprehensive assessment of medication use systems to identify risks to patient safety and implementing system changes to address the identified risks

4.3.2 The use of the medication authorisation system is regularly monitored

4.4.1 Adverse medicines incidents are regularly monitored, reported and investigated

4.5.1 The performance of the medication safety system is regularly assessed

4.9.2 The use of the information and decision support tools is regularly reviewed

4.10.1 Risks associated with secure storage and safe distribution of medicines are regularly reviewed

4.10.3 The storage of temperature-sensitive medicines is monitored





4.10.5 The system for disposal of unused, unwanted or expired medications is regularly monitored

4.11.1 The risks for storing, prescribing, dispensing and administration of high-risk medicines are regularly reviewed

Standard 5: Patient identification and procedure matching Yes No

5.1.1 Use of an organisation-wide patient identification system is regularly monitored

5.2.1 The system for reporting, investigation and analysis of patient care mismatching events is regularly monitored

5.4. Developing, implementing and regularly reviewing the effectiveness of the patient identification and matching system at patient handover, transfer and discharge

5.5.2 The process to match patients to any intended procedure, treatment or investigation is regularly monitored

Standard 6 Clinical handover Yes No

6.1.1 Clinical handover policies, procedures and/or protocols are used by the workforce and regularly monitored

6.1.3 Tools and guides are periodically reviewed

6.3 Monitoring and evaluating the agreed structured clinical handover processes, including

-regularly reviewing local processes based on current best practice in collaboration with clinicians, patients and carers

-undertaking quality improvement activities and acting on issues identified from clinical handover reviews

-reviewing the results of clinical handover reviews at executive level of governance

6.4.1 Regular reporting, investigating and monitoring of clinical handover incidents is in place

Standard 7: Blood and Blood Products Yes No

7.1.2 The use of policies, procedures and/or protocols is regularly monitored

7.2.1 The risks associated with transfusion practices and clinical use of blood and blood products are regularly assessed





7.5.2 The patient clinical records of transfused patients are periodically reviewed to assess the proportion of records completed

7.7.1 Regular review of the risks associated with receipt, storage and transport of blood and blood products is undertaken

7.8.1 Blood and blood product wastage is regularly monitored

Standard 8: Preventing and managing pressure injuries Yes No

8.1.2 The use of policies, procedures and/or protocols are regularly monitored.

8.2.2 Administrative and clinical data are used to regularly monitor and investigate the frequency and severity of pressure injuries

8.3 Undertaking quality improvement activities to address safety risks and monitor the systems that prevent and manage pressure injuries

8.5.2 The use of the screening tool is monitored to identify the proportion of at risk patients that are screened for pressure injuries on presentation

8.6.2 Patient clinical records, transfer and discharge documentation are periodically audited to identify the proportion of at risk patients with documented skin assessments

8.7 Implementing and monitoring pressure injury prevention plans and reviewing when clinically indicated

8.8.3 Patient clinical records are monitored to determine compliance with evidence-based pressure injury management plans

Standard 9: Recognising and responding to clinical deterioration in acute health care Yes No

9.2.2 Deaths or cardiac arrests for a patient without an agreed treatment-limiting order (such as not for resuscitation or do not resuscitate) are reviewed to identify the use of the recognition and response systems, and any failures in these systems

9.3.2 Mechanisms for recording physiological observations are regularly audited to determine the proportion of patients with complete sets of observations recorded in accordance with the monitoring plan for that patient





9.5.2 The circumstances and outcome of calls for emergency assistance are regularly reviewed

9.9.3 The performance and effectiveness of the system for family escalation of care is periodically reviewed

Standard 10: Preventing falls and harm from falls Yes No

10.1 Developing, implementing and reviewing policies, procedures and/or protocols, including the associated tools, are based on the current national guidelines for preventing falls and harm from falls

10.2.1 Regular reporting, investigation and monitoring of falls incidents is in place

10.5.2 Use of the screening tool is monitored to identify the proportion of at risk patients that were screened for falls

10.6.2 The use of the assessment tool is monitored to identify the proportion of at risk patients with a completed falls assessment

10.7.2 The effectiveness and appropriateness of the falls prevention and harm minimisation plan are regularly monitored



Appendix 3 - Summary of actions that require workforce trainingItem or Action Standard Completed

Standard 1: Governance Yes No

1.4.2 Annual mandatory training programs to meet the requirements of these Standards 2 - 10

1.4.4 Competency-based training is provided to the clinical workforce to improve safety and quality

1.12 Ensuring that systems are in place for ongoing safety and quality education and training

1.16.2 The clinical workforce are trained in open disclosure processes

Standard 2: Partnering with Consumers Yes No

2.3 Facilitating access to relevant orientation and training for consumers and/or carers partnering with the organisation

2.6.2 Consumers and/or carers are involved in training the clinical workforce

Standard 3: Health Associated Infection Yes No

3.9.1 Education and competency-based training in invasive devices protocols and use is provided for the workforce who perform procedures with invasive devices

3.10.1 The clinical workforce is trained in aseptic non-touch technique

3.18.1 Action is taken to maximise coverage of the relevant workforce trained in a competency-based program to decontaminate reusable medical devices

Standard 9: Recognising and Responding to Clinical Deterioration in Acute Health Care Yes No

9.6.1 The clinical workforce is trained and proficient in basic life support



Appendix 4 - Summary of not applicable actions by day procedure type

Health Service Type Definition Standards1 2 3 4 5 6 7 8 9 10

Day Procedure Services/ Independent stand-alone unit funded by a private enterpriseDay surgery hospitals Facilities providing general and specialist

surgical procedures performed under general, spinal, or sedation.

All Items applicable


Item 3.14.3 may not be applicable




May not be applicable if blood not in use

Items 8.5 -8.8 may not be applicable

Items 9.7 - 9.9may not beapplicable

Items 10.5-10.8may not beapplicable

Gynaecology Specialist gynaecological facilities providing surgical procedures performed under general, spinal, or sedation.







May not be applicable if blood not in use




Endoscopy Specialist facilities providing procedures performed primarily under sedation.





Item 5.3 may not be applicable


Notapplicable




Haemotology / Oncology

Facilities providing care and treatment for cancer and blood disorders including: chemotherapy, radiotherapy, pain management, bone marrow biopsies, blood/blood products transfusion.







All items applicable




In Vitro Fertilisation Specialist facilities for treatment of infertility including collection of eggs under sedation







Notapplicable



Items 10.5- 10.8may not beapplicable

Plastics / Cosmetic surgery

Facilities providing elective care including procedures performed under a general anaesthetic or sedation.







Notapplicable




Haemodialysis Unit

Specialist facility providing treatment for kidney failure. Sedation is not generally required.







All itemsapplicable




Opthamology Unit

Specialist facility providing treatment of eye conditions, including minor surgery under IV sedation or local anaesthetic







Notapplicable




Dental Practice Practice providing dental care including minor surgery under local anaesthetic or sedation







Notapplicable




Dermotology Practice Specialist practice providing care of skin conditions including minor surgery under local anaesthetic







Notapplicable




Primary Health Care Centre

Diverse range of services eg Aboriginal and Torres Strait Islander services, community health. May undertake high risk procedures in areas that are remote or have limited access to higher level services







Notapplicable






Appendix 5 - Steps in determining additional not applicable actions

During the accreditation process, there may be instances where individual organisations consider that a Standard or action is ‘not applicable’ to the operation of their health service. The proposed process for identifying additional ‘not applicable’ actions is as follows:

1. A health service assesses an action as ‘not applicable’ and applies to the accrediting agency providing evidence / arguments for the action to be rated as not applicable.

2. The accrediting agency confirms that an action is ‘not applicable’ for the purpose of accreditation of that facility based on the evidence, context and precedence.

Assessment of submissions for ‘not applicable’ actions will be against agreed criteria. The decisions of an Accrediting Agency can be appealed by health services.

All actions that are confirmed as ‘not applicable’ and the basis for the decision is provided to the surveyor, regulator and national coordinator.

3. The surveyor assesses the evidence and makes a recommendation to the accrediting agency making the decision on compliance.

4. The national coordinator assesses ‘not applicable’ actions to determine national trends with a view to:

Clarifying the requirements of the action Providing additional tools and resources for health services to met the Standard Makes amendment to the Guides Considers amendments to the Standards.

Draft criteria for determining not applicable items

The health service organisation demonstrates an action, criteria or Standard is not applicable because a particular service or product is not provided by the health service organisation for example, Blood and blood products, wrist bands.

The health service demonstrates an action, criteria or Standards has limited applicability to the health service organisation eg Standard 9 Recognising and responding to clinical deterioration is not be applicable in non-acute health care setting.

If a health service organisation changes the types of services offered and an action, criteria or Standard that was previously assessed is no longer applicable.

Return to front


Date€¦ · Web viewNM - add to action plan D 2.3 Facilitating access to relevant orientation...

Documents

Transcript of Date€¦ · Web viewNM - add to action plan D 2.3 Facilitating access to relevant orientation...