Safety Quality Performance Version 2 · MA – evaluation. SA plus the following. eA –...
Transcript of Safety Quality Performance Version 2 · MA – evaluation. SA plus the following. eA –...
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The ACHS EQuIP5 GUIDE
Book 2Accreditation, Standards and Guidelines
Support and Corporate Functions
Safety Quality Performance
The ACHS EQuIP5 Guide: Book 2 – Accreditation, Standards and Guidelines – Support and Corporate Functions
Published by The Australian Council on Healthcare Standards (ACHS)
Copies available from the ACHS Publications Service
Phone: +61 2 9281 9955 Fax: +61 2 9211 9633
Copyright © The Australian Council on Healthcare Standards (ACHS)
This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may be reproduced by any process without prior written permission from The Australian Council on Healthcare Standards. Requests and enquiries concerning reproduction and rights should be addressed to the Chief Executive, The Australian Council on Healthcare Standards, 5 Macarthur Street, ULTIMO NSW 2007 Australia
Recommended citation: The Australian Council on Healthcare Standards (ACHS), The ACHS EQuIP5 Guide: Book 2 – Accreditation, Standards and Guidelines – Support and Corporate Functions. Sydney Australia; ACHS; 2010.
The EQuIP Guide: First published 1996 Second edition 1998 Second edition revised 1999 Third edition 2002 Fourth edition 2006 Fifth edition 2010
5th Edition ISBN-13: 978 1 921806 01 8 (paperback) ISBN-10: 1 921806 01 X (paperback) ISBN-13: 978 1 921806 03 2 (web) ISBN-10: 1 921806 03 6 (web)
October 2010 249
Contents
Foreword� 1
Introduction� 4
Section 1 ACHS�and�accreditation� 5
1.1 About the Australian Council on Healthcare Standards 5
1.2 What is accreditation? 6
Section 2 Overview�of�EQuIP� 7
2.1 The EQuIP cycle 7
2.2 What is EQuIP? 8
2.3 The self assessment 8
2.4 Organisation-Wide Survey (OWS) 8
2.5 Periodic Review (PR) 9
2.6 EQuIP membership 9
2.6.1� ACHS�EQuIP�Certification�Program� 9
Section 3 EQuIP�Surveys� 10
3.1 The EQuIP Self-Assessment process 10
3.1.1� �Benefits�and�objectives�of�the�self�assessment� 10
3.1.2� The�self-assessment�process� 10
3.1.3� �The�EQuIP�Self-Assessment�feedback�report� 11
3.1.4� �Changes�to�the�self-assessment�format�from�EQuIP�4�to�EQuIP5� 11
3.1.5� �Before�starting�a�Pre-Survey��Assessment� 11
3.2 Pre-Survey Assessment (PSA) 12
3.2.1� �How�to�start�a�PSA� 12
3.2.2� The�PSA�format� 12
3.2.3� �Points�to�remember�in��preparing�a�PSA� 15
3.2.4� �The�Electronic�Assessment��Tool�(EAT)� 15
3.3 EQuIP onsite surveys and processes 16
3.3.1� The�survey�schedule� 16
3.3.2� Additional�surveys� 17
3.3.3� �Getting�ready�for�the�survey�−��one�page�summaries� 18
3.3.4� Survey�timetables� 19
3.3.5� �Surveyors’�meeting�with�the�leadership�team� 20
3.3.6� The�survey�presentation� 20
3.3.7� The�survey�process� 20
3.3.8� Verification� 21
3.3.9� The�Summation�Conference� 21
3.4 EQuIP survey reports 22
3.4.1� How�to�use�the�survey�report� 22
3.4.2� �Public�release�of�accreditation��information� 22
3.5 Accreditation levels, survey recommendations and achievement ratings 23
3.5.1� Accreditation�outcomes� 23
3.5.2� Criterion�achievement�ratings� 23
3.5.3� Expectations�for�ratings� 25
3.5.4� �High�Priority�Recommendations��(HPRs)� 26
3.5.5� Achieving�accreditation� 27
3.5.6� Non-accreditation� 27
3.5.7� An�appeals�process� 27
250 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Contents
Section 4 How�to�use�this�EQuIP�Guide� 28
4.1 The EQuIP framework 28
4.2 Key changes in EQuIP5 29
4.2.1� EQuIP5�functions,�standards,�criteria�� 30
4.3 The criteria 32
4.3.1� Structure�of�the�criteria�(an�example)� 32
4.3.2� Mandatory�criteria� 34
4.3.3� Not�applicable�(NA)�criteria�/�elements� 34
4.4 Further information 34
4.4.1� �Aboriginal�and�Torres�Strait�Islander�people� 34
4.4.2� �Policies,�procedures,�protocols,�guidelines�and�by-laws� 35
4.4.3� Jurisdictions� 36
4.4.4� Performance�measures� 36
4.4.5� Clinical�indicators�� 37
4.4.6� �National�E-Health�Transition�Authority�(NEHTA)� 41
4.4.7� �National�Safety�and�Quality�Health�Service�Standards�(Australian�Commission�on�Safety�and�Quality�in�Health�Care)� 41
Section 5 Standards,�criteria,�elements�and�guidelines� 43
Book 1 Clinical Function (Standards 1.1 – 1.6) 43
Book 2 Support Function (Standards 2.1 – 2.5) 251
Corporate Function (Standards 3.1 – 3.2) 375
Section 6�
6.1 Glossary and Acronyms Glossary (Book 1) 229 Glossary (Book 2) 463
Acronyms (Book 1) 245 Acronyms (Book 2) 479
6.2 Acknowledgements (Book 2) 482
October 2010 251
2.1�Quality�Improvement�and�Risk�Management�Standard
The�standard�is:�The governing body leads the organisation in its commitment to improving performance and ensures the effective management of corporate and clinical risks.
The�intent�of�this�standard�is�to�ensure�that�the�organisation:
• effectively�manages�all�corporate�and�clinical�risks�in�an�integrated�way�
• continuously�improves�all�aspects�of�the�organisation�and�the�services�that�the�organisation�provides.
There�are�four�criteria�in�this�standard.�They�are:
2.1.1 Theorganisation’scontinuous quality improvement system demonstratesitscommitmenttoimprovingtheoutcomesofcareandservicedelivery.
2.1.2 Theintegratedorganisation-widerisk management framework ensuresthatcorporate and clinical risksareidentified,minimisedandmanaged.
2.1.3 Healthcareincidentsaremanagedtoensureimprovementstothesystemsofcare.
2.1.4� �Healthcare�complaints and feedback�are�managed�to�ensure�improvements�to�the�systems�of�care.
Risk management�is�intended�to�reduce�the�threat�of�activities�and�processes�going�wrong.�Quality�Improvement�is�the�action�taken�throughout�the�organisation�to�increase�the�effectiveness�of�activities�and�processes�to�provide�added�benefits�to�the�organisation�and�consumers�/�patients.�While�risk�management�and�quality�management�are�distinct�functions,�a�quality�and�risk�management�continuum�exists.�Quality�and�risk�management�programs�must�work�together�to�achieve�organisational�goals�and�quality�outcomes.�Incident and complaints management�is�one�strategy�available�to�healthcare�organisations�for�identifying,�analysing�and�treating�risks.
seCtion 5Standards, criteria, elements and guidelines
seCtion 5Standards, criteria, elements and guidelinesstandard 2.1:�The�governing�body�leads�the�organisation�in�its�commitment�to�improving�performance�and�ensures�the�effective�management�of�corporate�and�clinical�risks
252 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
IntentThe�intent�of�this�criterion�is�to�ensure�that�all�healthcare�organisations�understand�the�importance�of�the�development�of�an�improvement�culture�and�system,�and�are�able�to�demonstrate�their�commitment�to�continuous�quality�improvement�in�all�aspects�of�care�and�service�delivery.
Relationships of 2.1.1 with other criteriaThis�guideline�should�be�read�in�conjunction�with�all�other�criteria.
Organisational commitmentTo�be�effective,�quality�improvement�must�be�fundamental�to�the�way�the�organisation�thinks�about�what�it�does.�It�should�be�embedded�within�the�organisation’s�philosophy,�practices�and�business�processes,�rather�than�viewed�or�practised�as�an�independent�activity.
It�is�important�that�every�employee�is�engaged�in�improvement�efforts�that�are�relevant�and�important�for�their�work.�Organisations�should�build�in�time�for�staff�to�participate�in�quality�improvement�(QI)�as�part�of�their�daily�work,�and�provide�the�necessary�training,�resources,�flexibility�and�authority�for�staff�to�test�processes�and�make�improvements.1
Without�physician�involvement�in�the�process�and�a�focus�on�consumer�/�patient�care,�quality�management�in�clinical�settings�will�remain�difficult�to�achieve.2�Many�doctors�have�clearly�become�leaders�in�this�area.�However,�some�doctors�see�themselves�as�working�for�consumers�/�patients,�and�struggle�to�expand�to�their�‘parallel’�role�in�working�for�an�organisation.3�Clinical�leadership,�arising�from�the�governing�body,�is�needed�if�quality�management�is�to�operate�effectively�amid�the�complexities�of�a�healthcare�environment.
Leadership�faces�two�challenges�in�implementing�quality�improvement�continuously�over�time4:
• When�a�quality�program�is�introduced,�the�major�challenges�will�arise�from�building�the�participatory�review�process�that�is�part�of�quality�improvement.�However,�early�in�a�quality�program,�big�improvements�are�likely�to�be�possible�by�correcting�existing�problems�and�then�by�introducing�preventative�measures.�
• As�the�program�matures,�and�systems�become�established,�recurring�problems�will�gradually�be�resolved�and�areas�of�high�risk�will�be�identified�and�may�be�mitigated.�The�challenge�now�is�to�lift�the�bar�repeatedly�to�generate�further�improvement.�Leadership�remains�imperative,�because�without�ongoing�commitment�there�is�a�tendency�to�forget�the�effort�needed�to�maintain�
Criterion LA – Awareness sA – implementationLA plus the following
MA – evaluationSA plus the following
eA – excellenceMA plus the following
oA – LeadershipEA plus the following
Criterion 2.1.1
Theorganisation’scontinuousqualityimprovementsystemdemonstratesitscommitmenttoimprovingtheoutcomesofcareandservicedelivery.
this is a mandatory criterion
a)� The�governing�body�is�committed�to�continuous�quality�improvement.
b)� A�framework�for�continuous�quality�improvement�exists.�
a)� Quality�improvement�is�planned,�continuous�and�linked�to�the�risk�management�system,�education,�and�the�strategic�plan.
b)� Staff�are�supported�and�participate�in�ongoing�improvement�in�care�and�service�delivery.
c)� Leaders�in�quality�improvement�are�identified�and�developed�across�the�organisation,�and�supported�to�drive�improvement.
a)� The�effectiveness�of�the�improvement�framework�and�its�component�activities�is�evaluated�and�improved�as�required.
b)� Qualitative�and�quantitative�data�are�collected,�analysed�and�used�to�plan�and�drive�improvement.
c)� Clinicians�are�involved�in�the�evaluation�of�the�quality�improvement�system.
a)� Comparison�occurs�with�internal�and�external�systems,�and�improvements�to�practices�and�systems�are�made�to�ensure�better�practice.
and/or
b)� The�evaluation�of�the�effectiveness�of�improvement�activities�demonstrates�excellence�in�improvement�processes.
a)� The�organisation�demonstrates�that�it�is�a�leader�in�continuous�quality�improvement.
October 2010 253
current�levels�of�performance.�This�ongoing�effort�requires�an�embedded�culture�of�striving�for�excellence,�which�is�challenging�to�maintain,�particularly�if�staff�turnover�is�high.�Leadership�is�fundamental�to�building�such�a�culture.
A�‘commitment’�to�quality�improvement�within�the�governing�body�may�appear�somewhat�intangible,�yet�there�are�many�ways�that�an�organisation�can�demonstrate�this.�Consider:�
• the�use�of�key�quality�indicators�by�the�governing�body�within�their�regular�meeting�structure
• inclusion�of�quality�improvement�in�the�strategic�plan
• key�staff�appointments�
• budgetary�decisions
• ways�that�the�organisation�uses�an�accreditation�framework�in�planning�(EQuIP�or�other)
• the�governing�body’s�response�to�ACHS�surveyors’�or�other�external�consultants’�recommendations�
• interactions�with�organisational�councils,�committees,�or�commissions�responsible�for�monitoring�and�ensuring�the�effectiveness�of�quality�improvement�efforts
• participation�by�members�of�the�governing�body�and�support�for�organisational�staff�involvement�in�external�quality�activities,�such�as�training�programs,�EQuIP�surveying,�voluntary�reporting�of�performance�data�to�external�organisations,�training�programs�with�a�quality�focus,�presentations�of�QI�project�outcomes�at�conferences,�etc.
• using�any�(public)�performance�reports�as�opportunities�to�identify�deficiencies�and�improve�care,�health�outcomes,�and�consumer�/�patient�satisfaction.�Performance�reports�may�include�coroner’s�reports,�the�findings�of�a�Royal�/�Special�Commission,�indicator�reports,�consumer�/�patient�survey�or�focus�group�reports.
Prompt points
¼ How does the governing body demonstrate its commitment to continuous quality improvement within the organisation?
¼ How does the governing body monitor and motivate quality improvement efforts and actions within the organisation?
Criterion LA – Awareness sA – implementationLA plus the following
MA – evaluationSA plus the following
eA – excellenceMA plus the following
oA – LeadershipEA plus the following
Criterion 2.1.1
Theorganisation’scontinuousqualityimprovementsystemdemonstratesitscommitmenttoimprovingtheoutcomesofcareandservicedelivery.
this is a mandatory criterion
a)� The�governing�body�is�committed�to�continuous�quality�improvement.
b)� A�framework�for�continuous�quality�improvement�exists.�
a)� Quality�improvement�is�planned,�continuous�and�linked�to�the�risk�management�system,�education,�and�the�strategic�plan.
b)� Staff�are�supported�and�participate�in�ongoing�improvement�in�care�and�service�delivery.
c)� Leaders�in�quality�improvement�are�identified�and�developed�across�the�organisation,�and�supported�to�drive�improvement.
a)� The�effectiveness�of�the�improvement�framework�and�its�component�activities�is�evaluated�and�improved�as�required.
b)� Qualitative�and�quantitative�data�are�collected,�analysed�and�used�to�plan�and�drive�improvement.
c)� Clinicians�are�involved�in�the�evaluation�of�the�quality�improvement�system.
a)� Comparison�occurs�with�internal�and�external�systems,�and�improvements�to�practices�and�systems�are�made�to�ensure�better�practice.
and/or
b)� The�evaluation�of�the�effectiveness�of�improvement�activities�demonstrates�excellence�in�improvement�processes.
a)� The�organisation�demonstrates�that�it�is�a�leader�in�continuous�quality�improvement.
seCtion 5Standards, criteria, elements and guidelinesstandard 2.1:�The�governing�body�leads�the�organisation�in�its�commitment�to�improving�performance�and�ensures�the�effective�management�of�corporate�and�clinical�risks
254 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 2.1.1
Theorganisation’scontinuousqualityimprovementsystemdemonstratesitscommitmenttoimprovingtheoutcomesofcareandservicedelivery.�(continued)
Quality framework, integration and use of data to drive improvement Implementing�processes�that�assist�an�organisation�to�become�a�safe�and�accountable�healthcare�environment�for�consumers�/�patients�and�healthcare�providers�requires�attention�to�systems�and�the�analysis�of�collected�data.
Quality�improvement�and�the�management�of�risks�in�health�care�should�be�part�of�both�strategic�and�operational�planning�in�every�area�and�service�of�healthcare�delivery.�Risk�management�and�quality�improvement�should�be�considered�when�determining�clinical�practice,�equipment�design�and�procurement,�personnel�management�and�financial�planning.5
There�are�some�essentials�that�characterise�a�quality�improvement�program�irrespective�of�the�QI�framework�used�by�the�organisation,�its�size,�type�or�complexity.�It�would�be�expected�that:
• staff�members�accountable�for�taking�action�are�identified�and�informed
• risk�management�and�consumer�/�patient�safety�are�considered�in�all�decision�making
• improvement�teams�are�multidisciplinary
• quality�activities�are�informed�by�appropriate�data�collection
• staff�are�familiar�with�quality�objectives�and�processes,�ideally�through�formal�training,�but�in�the�absence�of�this,�through�orientation�and�mentoring
• there�are�channels�through�which�concerns�about�quality�of�care�and/or�processes�can�be�directed�
• nationally�identified�and�jurisdictional�goals�for�the�healthcare�system�are�considered�and�integrated�into�planning.
Quality�improvement�has�been�widely�integrated�into�Australian�health�care�since�the�1980s.�
Quality�improvement�and�risk�management�systems�are�directed�to�apply�a�structured�framework�for�identification,�analysis,�action,�monitoring�and�review�for�risks,�problems�and/or�opportunities.�Communication�and�consultation�with�stakeholders�are�critical�for�these�processes�to�work�effectively.�
EQuIP�has�been�developed�as�a�framework�for�assessing�organisational�performance�against�wide-reaching�standards�and�criteria.�Member�organisations�may�choose�to�structure�their�QI�activities�around�the�same�framework.�However,�although�the�EQuIP�elements�reflect�the�maturation�of�QI�processes�(awareness��implementation��evaluation�and�further�improvement��excellence��outstanding�achievement),�this�alone�will�not�provide�the�tools�to�undertake�a�QI�project�in�an�area�of�concern.�
ACHS�has�developed�the�RiskManagementandQualityImprovementHandbook5�to�support�members�in�implementing�QI�and�risk�management�within�their�organisation.�The�Guide�is�available�to�members�at�http://www.achs.org.au/RiskMgmtQIHandbook/.�The�handbook�will�introduce�the�many�tools,�skills,�principles�and�frameworks�available�to�conduct�effective�quality�improvement�projects.�
An�organisation�may�be�able�to�show�that�the�words�‘quality�improvement’�appear�within�planning�documents�or�educational�programs.�However,�a�higher�level�of�evidence�would�demonstrate�how�the�quality�system�was�used�to�respond�to�an�issue,�by�investigating�risks�and�mitigating�their�impact.�For�example,�staff�who�undertake�activities�where�there�are�potential�risks�may�benefit�from�an�alternative�approach,�and�this�might�require�education�or�further�training.�If�an�identified�high-risk�practice�were�in�widespread�use,�the�organisation�should�have�structured�processes�to�communicate�the�proposed�solution,�train�staff�in�adopting�the�new�or�altered�practice�and�monitor�the�outcome�of�the�change.
October 2010 255
Evaluating�the�improvement�framework�itself�will�rely�on�a�more�qualitative�examination�undertaken�at�more�than�one�level.�Assuming�the�framework�is�being�widely�used,�consider�whether:
• it�is�used�to�tackle�performance�questions.�If�not,�potential�reasons�may�arise�from�organisational�culture.�Changing�culture�may�be�essential,�but�this�is�likely�to�be�a�long-term�issue�for�senior�managers.�In�the�meantime,�actions�taken�by�the�quality�team�might�reduce�the�impact�of�identifiable�factors�such�as�inadequate�leadership,�inadequate�time�or�resources,�failure�to�gain�multidisciplinary�attendance�at�meetings,�or�to�achieve�outcomes�from�meetings.�
• the�organisation’s�improvement�framework�and�processes�work�effectively�across�different�types�of�quality�issues.�If�not,�organisations�should�consider�the�circumstances�and�reasons�why�the�framework�has�not�been�effective.�Have�any�changes�been�made�in�process,�personnel�or�resources�to�refine�the�improvement�framework�and�its�operations?
• the�actions�taken�as�part�of�a�QI�project�are�followed�up,�measured,�further�refined,�and�the�outcomes�communicated�to�management.�Where�positive�outcomes�have�been�achieved,�has�the�organisation�initiated�the�same�changes�more�broadly,�or�reported�the�outcome�to�similar�organisations�through�a�presentation,�conference�or�journal?
• the�strengths�and�weaknesses�of�the�organisation’s�approach�to�quality�improvement�are�known.�Has�the�organisation’s�framework�been�compared�to�systems�and�processes�used�by�other�similar�organisations?�
Prompt points
¼ Describe how quality improvement activities are initiated, organised and coordinated. Is there a central framework or committee to coordinate this activity? If so, what roles are played by the component parts?
¼ Describe the links between QI activity and the strategic plan? What links tie QI activity to risk management? When QI activity suggests the need for education, are there any links that would facilitate the provision of training?
¼ What processes / measures are used to monitor the quality of service provision?
¼ How is the QI system itself evaluated and improved?
QI leadership, participation and supportLeaders�are�not�always�‘titled’�personnel�filling�prominent�roles.�Quality�may�be�the�responsibility�of�a�person�with�the�title,�‘Quality�Manager’,�but�achieving�consumer�/�patient�care�that�is�safe�and�excellent�is�the�responsibility�of�all�clinical�personnel,�irrespective�of�their�position�in�an�organisational�hierarchy.�Guiding�genuine�change�in�consumer�/�patient�care�will�require�support�and�commitment�from�people�working�at�an�operational�level.
Among�physicians,�there�are�those�who�have�earned�the�respect�of�their�peers�and�can�influence�others.6�Gaining�‘buy�in’�from�opinion�leaders�will�help�to�build�up�the�momentum�for�change.�Middle�managers�are�key�in�disseminating�and�building�a�quality�conscious�culture.7�They�can�translate�strategy-level�goals�into�actionable�improvement�at�the�department�or�unit�level,�engage�staff�in�safety�and�quality�improvement�efforts,�help�determine�which�care�processes�need�to�be�improved�and�how,�and�establish�processes�for�spreading�and�sustaining�improvement�over�time.7
Organisational�support�may�be�overt�or�be�built�into�a�supportive�culture.�Organisations�and�managers�can�support�identified�leaders�by:
• formally�providing�time�for�the�management�/�coordination�of�QI�teams�/�projects�that�have�been�formally�recognised�by�management
• providing�space�(on�websites,�noticeboards,�etc.)�and�leadership�support�for�any�notices�or�project�recruitment�efforts�associated�with�quality�projects
• recognising�QI�activity�and�outcomes�in�staff�performance�reviews
• supporting�further�education�in�quality�and�leadership�through�conference�attendance,�local�workshops�or�funding�to�support�further�education
• supporting�promotion�of�successful�projects�at�conferences�and�awards
• formally�acknowledging�teams�and�their�leaders�in�newsletters,�staff�meetings,�and�in�other�ways.
The�governing�body�and�senior�management�are�responsible�for�providing�support�for�clinical�staff�to�make�and�execute�good�decisions�and�improve�healthcare�performance.8�Staff,�consumers�and�other�stakeholders�should�be�informed�about,�and�actively�involved�in,�the�organisation’s�safety�and�quality�issues�and�improvement�initiatives.9�
seCtion 5Standards, criteria, elements and guidelinesstandard 2.1:�The�governing�body�leads�the�organisation�in�its�commitment�to�improving�performance�and�ensures�the�effective�management�of�corporate�and�clinical�risks
256 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 2.1.1
Theorganisation’scontinuousqualityimprovementsystemdemonstratesitscommitmenttoimprovingtheoutcomesofcareandservicedelivery.�(continued)
Review�of�the�quality�improvement�system�needs�to�include�clinicians�from�the�range�of�professional�areas�because:
• diverse�training,�consumer�/�patient�pools�and�roles�in�care�bring�different�perspectives�to�problem�solving
• QI�plans�to�resolve�an�identified�issue�may�impact�other�areas�of�care�–�the�web�of�professional�and�systems�linkages�that�facilitate�care�can�be�extensive�and�complex�
• from�the�perspective�of�the�consumer�/�patient,�the�clinicians�are�the�‘public�face’�of�the�organisation.
Most�organisations�have�teams�or�committees�of�clinicians�that�meet�to�consider�outcomes�of�clinical�care.�Where�a�clinician�expresses�concern�about�a�gap�between�desired�outcomes�and�measured�behaviours�or�effects,�there�is�reason�for�further�investigation.�Awareness�of�gaps�may�come�from�internal�or�external�sources,�including:
• complaints�from�consumers�/�patients�
• data�on�incident�types�and�distribution�
• an�internal�review�following�a�serious�incident�or�near�miss�
• external�reviews�such�as�Royal�Commissions,�coroners’�reports�or�ACHS�surveys,�or�clinical�indicator�data.�
The�involvement�of�clinicians2�in�such�investigation�management�and�risk�mitigation�is�central�to�successful�quality�improvement�programs.�Wolff�and�Taylor�have�developed�a�checklist�for�engaging�doctors�in�quality�improvement�and�consumer�/�patient�safety�programs�that�might�provide�some�useful�focus�points�to�improve�engagement�and�participation.2�
Prompt points
¼ How does the organisation develop clinicians who will understand and lead in quality improvement?
¼ How does the organisation support its staff to participate in continuous quality improvement?
¼ What role do clinicians, particularly medical staff, play in quality improvement within the organisation? How are the outcomes of quality improvement reported back to the clinicians?
Evidence commonly presented
Consider whether the following will help to address criterion 2.1.1
¼ Quality council / QI committee / improvement team membership that includes governing body leadership and participation
¼ Governing body agenda and minutes with reports of improvements, clinical and non-clinical performance, sponsoring of key improvement activities
¼ Strategic and operational plans, budgets that include quality improvement
¼ Governing body endorsement of framework for quality improvement
¼ Continuous quality improvement plans, frameworks such as philosophy, policy, improvement processes, performance targets, links to incidents, complaints, risks, education, planning
¼ Strategies for supporting staff to be leaders / participants in improvement activities
¼ By-laws, appointment criteria, position descriptions that include quality improvement responsibilities
¼ System for prioritising improvements to address high-risk, high-volume issues
¼ Reports of quantitative and qualitative performance data, clinical and non-clinical, and communication and distribution channels
¼ Minutes of meetings that discuss and action data
October 2010 257
¼ A list of improvements, clinical and non-clinical
¼ Evaluation of the improvement activities – impact on the consumer / patient, organisation performance targets, cost versus benefit
¼ Evaluation of governing body, management and staff participation such as membership of project teams, number of activities
¼ Evaluation of the continuous quality improvement framework such as understanding and knowledge of the philosophy, policy, improvement processes, performance targets; improvements addressing high-risk, high-volume services; costs versus benefits
¼ Benchmarking activities, improved practices and systems assessment of organisational culture for quality improvement
Performance measurementThis�criterion�states�that:�“The�organisation’s�continuous�quality�improvement�system�demonstrates�its�commitment�to�improving�the�outcomes�of�care�and�service�delivery”.�The�organisation�should�be�able�to�demonstrate�that�a�framework�for�continuous�quality�improvement�is�embedded�in�all�aspects�of�its�operation,�and�that�its�quality�improvement�activities�contribute�to�better�service�provision�for�its�community,�and�better�health�outcomes.
Some�common�suggested�performance�measures�are�as�follows:
Number�of�quality�improvement�activities�that�partially�/�fully�achieve�stated�objectives
Total number of quality improvement activities
Comment:measurableobjectivesandatimeframeshouldbeincludedinQIprojectplansattimeofapprovalbymanagement
Number�of�quality�improvement�meetings�with�executive�/�senior�management�representation�
Total number of quality improvement meetings
Comment:organisationtodefine‘executive/seniormanager’
Number�of�consumers�/�patients�involved�in�formal�quality�improvement�activities
Total number of persons involved in formal quality improvement activities
Comment:organisationtodefine‘involvement’
seCtion 5Standards, criteria, elements and guidelinesstandard 2.1:�The�governing�body�leads�the�organisation�in�its�commitment�to�improving�performance�and�ensures�the�effective�management�of�corporate�and�clinical�risks
258 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 2.1.1
Theorganisation’scontinuousqualityimprovementsystemdemonstratesitscommitmenttoimprovingtheoutcomesofcareandservicedelivery.�(continued)
Number�of�quality�improvement�activities�/�projects�for�which�outcomes�are�currently�monitored��for�the�purposes�of�further�improvement
Total number of quality improvement activities / projects
Number�of�quality�improvement�outcomes�communicated�to�staff�members�not�directly�involved��in�the�quality�activity
Total number of quality improvement activities
Number�of�quality�improvement�activities�formally�acknowledged�by�the�health�service�executive
Total number of quality improvement activities
Comment:dependingontheorganisationanditsgovernance,‘formallyacknowledged’mightinvolvemanagementsignoffonanactivityorareporttoameetingofgoverningbodyorexecutiveteam
Number�of�minutes�of�executive�and�governing�body�meetings�that�record�recommendations�/�outcomes�about�quality�improvement�activities
Total number of executive / governing body meetings held
Number�of�improvements�implemented�in�risk�priority�areas
Total number of potential improvements identified in risk priority areas
Comment:riskpriorityareastobedeterminedbytheorganisation;forexample,riskpriorityareascouldincludeseverityassessmentcode(SAC)1and2,orequivalent
Number�of�clinical�indicators�that�are�better�than�the�national�peer�group�aggregate�rate
Total number of clinical indicators collected by the organisation
October 2010 259
References1.� Riley�WJ,�Parsons�HM,�Duffy�GL�etal.�Realizing�
transformational�change�through�quality�improvement�in�public�health.�JPublicHealthManagPract�2010;�16(1):�72-78.
2.� Wolff�AM�and�Taylor�SA.�Enhancingpatientcare:Apracticalguidetoimprovingqualityandsafetyinhospitals.�Sydney�NSW;�MJA�books;�2009.
3.� Runciman�B,�Merry�A�and�Walton�M.�Safetyandethicsinhealthcare:aguidetogettingitright.�Aldershot�UK;�Ashgate�Publishing�Limited;�2007.
4.� Bishop�A�and�Dougherty�R.Implementingcontinuousqualityimprovementatthehealthcareproviderlevel.Lexington�USA;�Dougherty�Management�Associates;�2004.
5.� Australian�Council�on�Healthcare�Standards�(ACHS).�Riskmanagementandqualityimprovementhandbook.�Sydney�NSW:�ACHS;�2007.�Accessed�from�http://www.achs.org.au/RiskMgmtQIHandbook/�on�27�July�2010.
6.� Reinertsen�J,�Bisognano�M�and�Pugh�M.�Sevenleadershipleveragepointsfororganization-levelimprovementinhealthcare.InnovationSeries.�2nd�edn.�Cambridge�USA;�Institute�for�Healthcare�Improvement�(IHI);�2008.
7.� Federico�F�and�Bonacum�D.�Strengthening�the�core:�Middle�managers�play�a�vital�role�in�improving�safety.�HealthcExec2010; Jan/Feb: 68-70.
8.� Balding�C.�From�quality�assurance�to�clinical�governance.�AustHealthRev�2008;�32(3):�382-391.
9.� Victorian�Quality�Council.�Thehealthcareboard’sroleinclinicalgovernance.Melbourne�VIC;�Dept�of�Human�Services;�2004.
seCtion 5Standards, criteria, elements and guidelinesstandard 2.1:�The�governing�body�leads�the�organisation�in�its�commitment�to�improving�performance�and�ensures�the�effective�management�of�corporate�and�clinical�risks
260 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion LA – Awareness sA – implementationLA plus the following
MA – evaluationSA plus the following
eA – excellenceMA plus the following
oA – LeadershipEA plus the following
Criterion 2.1.2
Theintegratedorganisation-wideriskmanagementframeworkensuresthatcorporateandclinicalrisksareidentified,minimisedandmanaged.
this is a mandatory criterion
a)� There�is�an�organisation-wide�risk�management�policy�/�guideline�for�corporate�and�clinical�risks�that�identifies�specific�strategies�for�managing�risks�and�is�available�to�clinicians,�managers�and�other�staff.
b)� Clinicians,�managers�and�other�staff�are�informed�about�their�responsibilities�for�identifying�and�managing�risks.
a)� There�is�integration�between�quality�improvement,�risk�management�and�strategic�planning�within�the�organisation.
b)� An�integrated,�organisation-wide�risk�management�framework�addressing�corporate�and�clinical�risks�is�developed,�documented�and�implemented.
c)� Systems�are�implemented�to�ensure�clinicians,�managers�and�staff�can�initiate�action�to�prevent�and/or�reduce�the�impact�of�risks.
d)� A�risk�management�approach�is�used�when�considering�and�developing�new�and�modified�services.
a)� The�corporate�and�clinical�risk�management�framework�is�evaluated�and�improved�as�required.
b)� Risk�identification�and�risk�analysis�are�undertaken�using�qualitative�and�quantitative�data.
c)� Data�from�risk�management�processes�are�provided�to�clinicians,�managers�and�other�staff�and�improvements�to�care�and�services�are�planned�and�implemented.
a)� Components�of�the�risk�management�framework�are�compared�with�internal�and�external�systems�and�improvements�are�made�to�ensure�better�practice.
and/or
b)� Evaluation�of�the�risk�management�framework�demonstrates�that�risk�management�is�effective�and�risks�are�minimised.
a)� The�organisation�demonstrates�that�it�is�a�leader�in�corporate�and�clinical�risk�management.
IntentAll�activities�of�all�organisations�involve�risk�that�must�be�managed.�This�is�particularly�true�of�healthcare�organisations,�where�in�addition�to�the�degree�of�risk�inherent�to�the�provision�of�care�there�is�community�expectation�of�safety.�The�intent�of�this�criterion�is�to�ensure�that�the�organisation�identifies,�minimises�and�manages�its�corporate�and�clinical�risks�via�an�integrated,�organisation-wide�risk�management�framework.
Relationships of 2.1.2 with other criteriaThis�guideline�should�be�read�in�conjunction�with�all�other�criteria.
Strategic planning, governance and risk managementRisk�is�defined�as�the�effect�of�uncertainty�on�objectives.1�A�healthcare�organisation’s�objectives�have�different�aspects,�such�as�clinical,�financial,�health�and�safety�or�environmental,�and�they�apply�at�the�strategic,�organisation-wide,�unit,�project�and�process�levels.�In�the�context�of�risk,�uncertainty�is�defined�as�“the�state,�even�partial,�of�deficiency�of�information�related�to�understanding�or�knowledge�of�an�event,�its�consequence,�or�likelihood”.1�Any�deviation�from�the�expected�can�result�in�a�positive�and/or�negative�effect.�Therefore,�any�type�of�risk,�whatever�its�nature,�may�have�either�(or�both)�positive�or�negative�consequences.
Strategic�planning�is�a�continuous�and�systematic�process�whereby�decisions�are�made�by�an�organisation�about�intended�future�outcomes,�how�outcomes�are�to�be�accomplished,�and�how�success�is�measured�and�evaluated.2�A�strategic�plan�should�include�a�mission�statement,�objectives,�goals,�and�an�action�plan.3�Governance�may�be�viewed�as�a�‘guidance�system’�for�the�achievement�of�an�organisation’s�planned�objectives,�as�defined�within�its�
October 2010 261
Criterion LA – Awareness sA – implementationLA plus the following
MA – evaluationSA plus the following
eA – excellenceMA plus the following
oA – LeadershipEA plus the following
Criterion 2.1.2
Theintegratedorganisation-wideriskmanagementframeworkensuresthatcorporateandclinicalrisksareidentified,minimisedandmanaged.
this is a mandatory criterion
a)� There�is�an�organisation-wide�risk�management�policy�/�guideline�for�corporate�and�clinical�risks�that�identifies�specific�strategies�for�managing�risks�and�is�available�to�clinicians,�managers�and�other�staff.
b)� Clinicians,�managers�and�other�staff�are�informed�about�their�responsibilities�for�identifying�and�managing�risks.
a)� There�is�integration�between�quality�improvement,�risk�management�and�strategic�planning�within�the�organisation.
b)� An�integrated,�organisation-wide�risk�management�framework�addressing�corporate�and�clinical�risks�is�developed,�documented�and�implemented.
c)� Systems�are�implemented�to�ensure�clinicians,�managers�and�staff�can�initiate�action�to�prevent�and/or�reduce�the�impact�of�risks.
d)� A�risk�management�approach�is�used�when�considering�and�developing�new�and�modified�services.
a)� The�corporate�and�clinical�risk�management�framework�is�evaluated�and�improved�as�required.
b)� Risk�identification�and�risk�analysis�are�undertaken�using�qualitative�and�quantitative�data.
c)� Data�from�risk�management�processes�are�provided�to�clinicians,�managers�and�other�staff�and�improvements�to�care�and�services�are�planned�and�implemented.
a)� Components�of�the�risk�management�framework�are�compared�with�internal�and�external�systems�and�improvements�are�made�to�ensure�better�practice.
and/or
b)� Evaluation�of�the�risk�management�framework�demonstrates�that�risk�management�is�effective�and�risks�are�minimised.
a)� The�organisation�demonstrates�that�it�is�a�leader�in�corporate�and�clinical�risk�management.
strategic�plan.�Risk�management�is�an�integral�aspect�of�governance,�inasmuch�as�all�objectives,�whether�corporate�or�clinical,�will�contain�an�element�of�risk,�which�must�be�effectively�managed�via�strategies�and�controls,�in�order�for�those�objectives�to�be�achieved.4
Risk�management�is�a�coordinated�activity�that�directs�and�controls�the�organisation�with�regard�to�risk,�while�a�risk�management�framework�is�the�systematic�application�of�management�policies,�procedures�and�practices�to�the�activities�of�communicating,�consulting,�establishing�the�context,�and�identifying,�analysing,�evaluating,�treating,�monitoring�and�reviewing�risk.1�By�associating�the�management�of�risk�with�all�objectives,�of�all�kinds�and�at�all�organisational�levels,�it�becomes�fully�integrated�as�an�organisation-wide�system,�or�risk�management�framework.�This�framework�in�turn�ensures�that�information�about�risk�derived�from�the�risk�management�process�is�satisfactorily�reported�and�used�as�the�basis�for�future�decision�making�and�accountability.1�The�risk�management�framework�should�link�to�strategic�and�business�planning�and�support�assessment�of�new�and/or�altered�services.
For�risk�management�to�be�effective�it�should1:
• create�and�protect�value�by�contributing�to�the�demonstrable�achievement�of�objectives,�and�improvement�of�performance
• be�an�integral�part�of�all�organisational�processes
• be�a�part�of�decision�making
• explicitly�address�uncertainty
• be�systematic,�structured�and�timely
• be�based�on�the�best�available�information
• be�tailored�to�the�organisation
• take�human�and�cultural�factors�into�account
• be�transparent�and�inclusive
• facilitate�continual�improvement�of�the�organisation.
seCtion 5Standards, criteria, elements and guidelinesstandard 2.1:�The�governing�body�leads�the�organisation�in�its�commitment�to�improving�performance�and�ensures�the�effective�management�of�corporate�and�clinical�risks
262 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 2.1.2
Theintegratedorganisation-wideriskmanagementframeworkensuresthatcorporateandclinicalrisksareidentified,minimisedandmanaged.�(continued)
Risk�management�systems�aim�to�support:
• achievement�of�the�organisation’s�strategic�goals
• protection�of�organisational�assets�(financial�and�physical)
• protection�of�human,�and�intangible,�resources�and�property
• prevention�of�injury�to�consumers�/�patients,�employees,�volunteers�and�visitors
• reduction�or�mitigation�of�loss.
Within�the�health�system,�an�integrated�strategy�will�include�the�management�of�both�corporate�and�clinical�risk;�not�only�consumer�/�patient-�and�staff-related�clinical�risk,�but�also�financial,�human�resources,�occupational�health�and�safety,�environmental�and�asset-related�risk.�All�such�risks�must�be�identified�and�integrated�with�the�quality�improvement�system.�
Corporate�risk�management�strategies�may�include:
• audit�processes
• human�resources�planning
• political�risk�management
• implementation�of�financial�management�systems
• fraud�minimisation�schemes
• occupational�health�and�safety�strategies
• effective�use�of�feedback�from�consumers�/�patients�and�staff
• staff�education�and�training�programs
• recruitment�and�retention�strategies
• staff�performance�review�and�development.
Clinical�risk�management�strategies�may�include:
• clinical�audit�processes
• superior�review,�peer�review�and�peer�supervision
• credentialling�and�defining�the�scope�of�clinical�practice�for�all�clinicians�(discussed�within�criterion�3.1.3)
• implementation�of�an�incident�management�system�that�includes�management�of�adverse�and�sentinel�events�(discussed�within�criterion�2.1.3)
• retrospective�consumer�/�patient�health�record�reviews
• effective�use�of�clinical�indicators
• mortality�and�morbidity�reviews
• performance�review�and�professional�development.
No�one�strategy�is�ideal�for�managing�all�risks.�In�order�to�be�effective,�organisations�should�undertake�to�implement�a�‘suite’�of�the�above-mentioned�risk�management�strategies�in�accordance�with�the�size�of�the�organisation�and�the�scope�of�the�services�provided.�As�part�of�this�process,�organisations�should�establish�policy�/�guidelines�and�a�system�that:
• identifies
• analyses
• evaluates
• treats
• continuously�monitors�and�reviews
• communicates
...�all�corporate�and�clinical�risks�that�occur,�or�that�have�the�potential�to�occur,�in�a�healthcare�organisation,�as�well�as�delineating�the�specific�strategies�for�managing�these�risks.
A�governing�body-endorsed�policy�/�guideline�should�be�implemented�that�confirms�the�organisation’s�commitment�to�the�management�of�risk,�defines�its�risk�management�framework,�and�describes�its�principles,�processes�and�specific�strategies�for�achieving�its�objectives,�and�the�responsibility�of�all�staff�for�their�implementation.�This�policy�/�guideline�must�be�made�available�to�all�clinicians,�managers�and�other�staff.
Prompt points
¼ How often is the organisation’s risk management framework evaluated and, if necessary, improved? What prompts this re-evaluation?
¼ What processes does the organisation use to consult with its stakeholders about the management of risk?
¼ How is the organisation’s risk management policy / guideline made available to staff?
October 2010 263
Staff responsibility and involvement in risk managementAll�staff�at�all�levels�have�a�role�to�play�in�the�organisation’s�management�of�risk.�This�accountability�should�be�made�explicit�within�position�descriptions5,�and�discussed�during�performance�reviews.6�Staff�should�be�informed�during�orientation�of�the�organisation’s�processes�for�risk�management,�and�further�educated�according�to�their�role�within�the�organisation�as�to�their�specific�responsibility�for�identifying,�evaluating�and/or�mitigating�risk,�and�the�steps�by�which�any�individual�can�initiate�action�in�order�to�prevent�and/or�reduce�the�impact�of�risks.�It�should�be�emphasised�that�staff�responsibility�extends�to�all�categories�of�risk,�not�clinical�risk�alone.�The�integration�between�quality�and�risk�should�be�made�evident,�with�discussion�of�matters�that�were�initially�raised�as�risk�issues,�but�which�through�proper�management�led�to�improvement�activities�or�to�enhanced�consumer�/�patient�outcomes.�Evaluation�of�the�effectiveness�of�orientation�and�education�programs�should�be�undertaken�to�ensure�that�staff�understand�the�risk�management�framework�and�their�position�within�it,�and�improvements�made�as�required.�The�organisation�should�strive�to�create�a�culture�wherein�active�involvement�of�staff�in�the�risk�management�process�is�encouraged�and�supported.
Clinician�engagement�is�critical�to�the�effective�management�of�clinical�risk.�Involvement�of�clinicians�in�risk�management�programs�should�be�considered�during�credentialling�and�defining�the�scope�of�clinical�practice.�Other�forums�for�clinician�participation,�according�to�the�size�and�scope�of�the�organisation,�may�be�Medical�Advisory�Committees�(MAC)�or�specialist�groups.�Data�from�risk�management�processes�should�be�provided�to�all�relevant�staff,�and�used�as�the�basis�for�improvements�to�care�planning�and�services.
Prompt points
¼ How does the organisation inform and educate its staff about their responsibilities in risk management? How does it determine whether these processes are effective?
¼ What does the organisation do to encourage staff to participate in risk management?
¼ What resources does the organisation provide to facilitate clinician engagement in clinical risk management?
¼ How does the organisation distribute the data gathered from risk management processes? How does it determine to whom the data should be provided?
¼ How does the organisation ensure that necessary changes identified during the risk management process are implemented?
Risk management of new / altered servicesOne�of�the�most�important�aspects�of�an�organisation’s�risk�management�framework�is�the�assessment�of�a�proposed�new�or�modified�service,�for�example,�a�change�to�an�existing�procedure,�or�the�introduction�of�a�new�drug�or�diagnostic�test.7�The�implementation�of�new�or�modified�clinical�interventions�is�governed�at�a�State�/�Territory�level,�and�these�policies�take�a�risk�management�approach�to�the�process,�with�a�view�to�reducing�or�preventing�adverse�events.�The�process�by�which�an�assessment�of�a�new�intervention�is�made,�and�the�identity�of�those�responsible�for�carrying�it�out,�should�be�clearly�delineated�within�the�organisation’s�risk�management�policy�/�guideline;�it�will�also�comprise�an�aspect�of�the�organisation’s�policy�/�guideline�for�managing�credentialling�and�defining�the�scope�of�clinical�practice8,�as�discussed�within�criterion�3.1.3.�The�Royal�Australasian�College�of�Surgeons,�through�its�Research,�Audit�and�Academic�Surgery�Division,�has�issuedGeneralGuidelinesforAssessing,Approving&IntroducingNewSurgicalProceduresintoaHospitalorHealthService7,�which�where�appropriate�should�direct�the�organisation’s�risk�management�of�the�introduction�of�new�surgical�procedures.�The�risk�management�process�for�a�new�or�modified�service�should�consider�its�clinical�effectiveness�and�the�potential�advantages�to�the�consumer�/�patient;�any�known�risks�and�possible�management�strategies�for�them;�how�the�consumer�/�patient�will�be�informed�of�the�advantages�and�risks;�education�and�training�of�staff;�and�costs�and�cost�benefits.9�Upon�introduction,�the�service�must�be�carefully�monitored�and�reviewed,�and�the�gathered�data�used�to�evaluate�and�improve�or�eliminate�it.
seCtion 5Standards, criteria, elements and guidelinesstandard 2.1:�The�governing�body�leads�the�organisation�in�its�commitment�to�improving�performance�and�ensures�the�effective�management�of�corporate�and�clinical�risks
264 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 2.1.2
Theintegratedorganisation-wideriskmanagementframeworkensuresthatcorporateandclinicalrisksareidentified,minimisedandmanaged.�(continued)
Prompt points
¼ What policy / guidelines were consulted in the development of the organisation’s process for managing risk in the introduction of a new or modified service?
¼ How does the organisation assess the effectiveness and safety of a new or modified service?
Evidence commonly presented
Consider whether the following will help to address criterion 2.1.2
¼ Organisation-wide risk management policy / guideline and procedures, endorsed by the governing body, that guide staff in the management and prevention of corporate and clinical risks, and that links with the quality improvement system
¼ Strategic, operational and business plans that consider risks
¼ Minutes of governing body, Medical Advisory Committee, medical staff council and staff meetings where risk issues were reported and actioned
¼ Budget allocation for risk management
¼ Tools for identifying and analysing risks
¼ Quantitative and qualitative data on identified risks such as incidents, Root Cause Analysis findings, clinical outcomes, staff injuries and budget variances
¼ Reports of the data on risks and on the communication and distribution channels used to reach relevant staff
¼ Improvements resulting from the analyses of risks
¼ By-laws, appointment criteria and position descriptions that include risk management responsibilities
¼ Clinician engagement in clinical risk management as an aspect of credentialling and defining the scope of clinical practice
¼ Evaluation of clinician, management and staff understanding of the risk management system
¼ Evaluation of the risk management system – policy, risk identification, system for managing and preventing risks, communication of data on risks, use of data, high-risk, high-volume activities identified and improved, cost versus benefit
October 2010 265
Performance measurementThis�criterion�states�that:�“The�integrated�organisation-wide�risk�management�framework�ensures�that�corporate�and�clinical�risks�are�identified,�minimised�and�managed”.�The�organisation�should�be�able�to�demonstrate�its�commitment�to�the�creation�of�a�culture�in�which�risk�management�is�recognised�as�the�responsibility�of�all�staff,�where�all�aspects�of�the�risk�management�system�are�regularly�evaluated�and�improved�where�necessary,�and�in�which�the�management�of�risk�is�an�aspect�of�the�organisation’s�continuous�quality�improvement�system.�
Some�common�suggested�performance�measures�are�as�follows:
Number�of�improvements�implemented�in�risk�priority�areas
Total number of potential improvements identified in risk priority areas
Comment:riskpriorityareastobedeterminedbytheorganisation;forexample,riskpriorityareascouldincludeseverityassessmentcode(SAC)1and2ratedrisks,orequivalent
Number�of�risk�management�goals�/�targets�met
Total number of risk management goals / targets
Number�of�clinical�indicators�that�are�better�than�the�national�peer�group�aggregate�rate
Total number of clinical indicators collected by the organisation
Number�of�new�interventions�and�treatments�introduced�into�the�organisation
Total number of new interventions and treatments subjected to risk assessment
Number�of�clinicians�actively�engaged�in�clinical�risk�management
Total number of clinicians
Number�of�reviewed�health�records�that�identified�a�preventable�adverse�event
Total number of health records reviewed
Number�of�internal�reviews�of�coroner�cases�/�findings�that�related�to�the�organisation
Total number of cases referred to the coroner
Comment:internalreviewiswheretheorganisationformallyreviewsfindingsrelatedtotheorganisationfromcasesthathavebeenreferredtothecoroner
seCtion 5Standards, criteria, elements and guidelinesstandard 2.1:�The�governing�body�leads�the�organisation�in�its�commitment�to�improving�performance�and�ensures�the�effective�management�of�corporate�and�clinical�risks
266 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 2.1.2
Theintegratedorganisation-wideriskmanagementframeworkensuresthatcorporateandclinicalrisksareidentified,minimisedandmanaged.�(continued)
References1.� AS/NZS�ISO�31000:2010�Riskmanagement–Principlesand
guidelines.
2.� Blackerby�Associates.Learnmoreaboutstrategicplanninginthenot-for-profitandgovernmentsector.�Phoenix�USA.�Accessed�from�http://www.blackerbyassoc.com/SPDefine.html�on�11�August�2010.
3.� Special�Libraries�Association.�Strategicplanninghandbook.�Alexandria�USA;�Special�Libraries�Assoc;�2009.
4.� Dahms�T.�Part�1:�Risk�management�and�corporate�governance:�are�they�the�same?�RiskMagazine2008�(23�January).�Accessed�from�http://www.riskmanagementmagazine.com.au�on�11�August�2010.
5.� Rural�Infection�Control�Practitioners�(RICPRAC).�Infectionpreventionandcontrolmanual:section10.1riskmanagement.�3rd�edn.�Melbourne;�Victorian�Dept�of�Health;�2008.
6.� Maddock�A.�Risk�management�in�practice:�ERM�in�health�care.�RiskMagazine�2006�(14�September).�Accessed�from�http://www.riskmanagementmagazine.com.au�on�11�August�2010.
7.� Royal�Australasian�College�of�Surgeons�(RACS)�and�ASERNIP-S.�Generalguidelinesforassessing,approving&introducingnewproceduresintoahospitalorhealthservice.Stepney�SA;�RACS;�2008.
8.� Australian�Council�for�Safety�and�Quality�in�Health�Care.�Standardforcredentiallinganddefiningscopeofclinicalpractice.Canberra�ACT;�Australian�Council�for�Safety�and�Quality�in�Health�Care;�2004.
9.� Sweeney�J�and�Cimoni�M.�Introducinganewprocedureusingaclinicalgovernanceframework:independentuseofnasendoscopytoassessandmanageswallowingandvoicedisorders.Austin�Health;�Melbourne�VIC;�2005.�Accessed�from�http://www.sapmea.asn.au/conventions/alliedhealth/presentations/Sweeney,%20Joanne%20ah145.ppt�on�12�August�2010.
GuidelinesStandards�Australia.�HB�254-2005:2005�Handbook:Governance,riskmanagementandcontrolassurance.
North�Coast�Area�Health�Service,�NSW�Health.�AnewdirectionfortheNorthCoast:Healthservicesstrategicplan.Towards2010.Lismore;�NSW�Health;�2007.
Further readingDahms�T.�Part�2:�Risk�management�and�corporate�governance:�are�they�the�same?�RiskMagazine2008�(14�February).�Accessed�from�http://www.riskmanagementmagazine.com.au�on�11�August�2010.
Langley�A.�What�does�it�mean�when�the�risk�assessment�says�4.73�x�10-5?�NSWPublicHealthBulletin�2003;�14(8):�166-167.
October 2010 267
seCtion 5Standards, criteria, elements and guidelinesstandard 2.1:�The�governing�body�leads�the�organisation�in�its�commitment�to�improving�performance�and�ensures�the�effective�management�of�corporate�and�clinical�risks
268 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
IntentThe�intent�of�this�criterion�is�to�ensure�that�organisations�have�in�place�effective�systems�for�the�management�of�healthcare�incidents�and�near�misses�as�and�when�they�occur,�so�that�their�causes�may�be�investigated�and�improvements�made�to�processes�and�cultures�in�order�to�prevent�recurrence.
Relationships of 2.1.3 with other criteriaManagement�of�healthcare�incidents�is�a�vital�component�of�the�provision�of�safe�care�and�services�(Standard�1.5)�and�of�the�organisation’s�commitment�to�quality�improvement�(Criterion�2.1.1).�The�organisation’s�risk�management�framework�must�include�processes�for�investigating�and�minimising�the�occurrence�of�incidents�(Criterion�2.1.2),�which�may�employ�an�Information�Technology�system�by�which�incident�data�can�be�recorded�and�analysed�(Criterion�2.3.3).�Failure�to�manage�incidents�correctly�may�lead�to�complaints�(Criterion�2.1.4).�The�management�of�incidents�is�an�aspect�of�the�rights�of�the�consumer�/�patient�(Criterion�1.6.2),�which�include�the�right�to�provide�feedback�and/or�to�lodge�a�formal�complaint,�and�to�have�the�issues�raised�thereby�investigated�and�resolved;�and�the�right�to�privacy�and�confidentiality�throughout�the�management�of�incidents.
Criterion LA – Awareness sA – implementationLA plus the following
MA – evaluationSA plus the following
eA – excellenceMA plus the following
oA – LeadershipEA plus the following
Criterion 2.1.3
Healthcareincidentsaremanagedtoensureimprovementstothesystemsofcare.
this is a mandatory criterion
a)� The�organisation�has�a�process�to�effectively�identify�and�manage�incidents�in�an�integrated�manner,�including�serious�incidents.
b)� The�organisation�is�aware�of�the�principles�for�open�disclosure.
c)� Incident�management�and�open�disclosure�policy�/�guidelines�exist�and�are�communicated�to�staff.
d)� Consumers�/�patients�are�provided�with�information�about�incident�management�processes.
a)� Incidents�are�systematically�managed�in�accordance�with�jurisdictional�policy�/�legislation�and�Australian�standards�including:
� (i)� identification
� (ii)� review
� (iii)� action�on�incidents
� (iv)� communication�
� (v)� �levels�of�responsibility�for�incident�management
� (vi)� �support�for�consumers�/�patients�and�staff�involved�in�incidents
� (vii)� �in-depth�investigations�for�serious�incidents�/�sentinel�events.
b)� Clinicians,�managers�and�staff�are�orientated�/�trained�in�incident�management�and�open�disclosure.
a)� The�incident�management�system�is�evaluated�and�improved�as�required.
b)� The�principles�of�open�disclosure�are�evident�in�the�system�to�manage�incidents.
c)� Incidents�are�trended,�risks�are�identified,�and�improvements�are�made�as�required.
d)� Improvement�strategies�are�evaluated,�communicated�and�implemented�across�the�organisation�to�ensure�the�organisation�is�providing�safe�practice�and�a�safe�environment.
e)� The�support�provided�for�consumers�/�patients�and�staff�involved�in�incidents�is�evaluated,�and�improved�as�required.
a)� The�incident�management�system�is�compared�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.
and/or
b)� The�national�open�disclosure�standard�is�fully�implemented�and�evaluated,�and�improvements�are�made�as�required.�
and/or
c)� Incident�data�is�compared�internally�and�externally�and�improvements�are�made�to�ensure�better�practice.
and/or
d)� Lessons�learned�from�investigations�of�incidents�/�sentinel�events�are�provided�to�other�healthcare�organisations.
and/or
e)� The�organisation�undertakes�research�into�incident�management�and�acts�on�the�results.
a)� The�organisation�demonstrates�it�is�a�leader�in�incident�management�systems�and�processes.
October 2010 269
Management of incidentsA�degree�of�risk�is�an�inherent�component�of�the�provision�of�healthcare,�and�organisations�must�recognise�and�admit�this�while�striving�at�all�times�to�reduce�that�risk.1�The�right�of�the�consumer�/�patient�to�safe,�high�quality�health�care�is�fundamental,�and�a�vital�aspect�of�the�provision�of�safe�services�is�the�management�of�incidents.�Incidents,�including�near�misses,�must�be�identified,�reported�and�investigated,�and�all�appropriate�steps�taken�in�order�to�prevent�their�recurrence.�The�processes�for�the�management�of�clinical�incidents�are�mandated�at�a�State�/�Territory�level,�and�it�is�the�responsibility�of�the�organisation�to�ensure�that�its�systems�meet�the�requirements�of�the�relevant�legislation�and�Australian�standards.
An�incident�is�an�event�or�circumstance�that�results�in,�or�could�have�resulted�in,�unintended�or�unnecessary�harm�to�a�person�and/or�a�complaint,�loss�or�damage,�while�a�near�miss�is�an�incident�that�did�not�cause�harm,�loss�or�damage,�but�had�the�potential�to�do�so.2
An�integrated�incident�management�system�must�have�the�capacity�to�record,�examine�and�respond�to�a�diverse�range�of�real�and�potential�outcomes.�Incident�management�itself�is�a�multistep�process,�involving:
• identification�of�incidents,�including�near�misses
• notification�of�identified�incidents�via�the�organisation’s�reporting�system
• prioritisation,�to�ensure�that�a�standardised,�objective�measure�of�severity�is�allocated�to�each�incident
Criterion LA – Awareness sA – implementationLA plus the following
MA – evaluationSA plus the following
eA – excellenceMA plus the following
oA – LeadershipEA plus the following
Criterion 2.1.3
Healthcareincidentsaremanagedtoensureimprovementstothesystemsofcare.
this is a mandatory criterion
a)� The�organisation�has�a�process�to�effectively�identify�and�manage�incidents�in�an�integrated�manner,�including�serious�incidents.
b)� The�organisation�is�aware�of�the�principles�for�open�disclosure.
c)� Incident�management�and�open�disclosure�policy�/�guidelines�exist�and�are�communicated�to�staff.
d)� Consumers�/�patients�are�provided�with�information�about�incident�management�processes.
a)� Incidents�are�systematically�managed�in�accordance�with�jurisdictional�policy�/�legislation�and�Australian�standards�including:
� (i)� identification
� (ii)� review
� (iii)� action�on�incidents
� (iv)� communication�
� (v)� �levels�of�responsibility�for�incident�management
� (vi)� �support�for�consumers�/�patients�and�staff�involved�in�incidents
� (vii)� �in-depth�investigations�for�serious�incidents�/�sentinel�events.
b)� Clinicians,�managers�and�staff�are�orientated�/�trained�in�incident�management�and�open�disclosure.
a)� The�incident�management�system�is�evaluated�and�improved�as�required.
b)� The�principles�of�open�disclosure�are�evident�in�the�system�to�manage�incidents.
c)� Incidents�are�trended,�risks�are�identified,�and�improvements�are�made�as�required.
d)� Improvement�strategies�are�evaluated,�communicated�and�implemented�across�the�organisation�to�ensure�the�organisation�is�providing�safe�practice�and�a�safe�environment.
e)� The�support�provided�for�consumers�/�patients�and�staff�involved�in�incidents�is�evaluated,�and�improved�as�required.
a)� The�incident�management�system�is�compared�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.
and/or
b)� The�national�open�disclosure�standard�is�fully�implemented�and�evaluated,�and�improvements�are�made�as�required.�
and/or
c)� Incident�data�is�compared�internally�and�externally�and�improvements�are�made�to�ensure�better�practice.
and/or
d)� Lessons�learned�from�investigations�of�incidents�/�sentinel�events�are�provided�to�other�healthcare�organisations.
and/or
e)� The�organisation�undertakes�research�into�incident�management�and�acts�on�the�results.
a)� The�organisation�demonstrates�it�is�a�leader�in�incident�management�systems�and�processes.
seCtion 5Standards, criteria, elements and guidelinesstandard 2.1:�The�governing�body�leads�the�organisation�in�its�commitment�to�improving�performance�and�ensures�the�effective�management�of�corporate�and�clinical�risks
270 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 2.1.3
Healthcareincidentsaremanagedtoensureimprovementstothesystemsofcare.(continued)
• investigation�by�the�designated�internal�and,�where�appropriate,�external�authorities
• classification,�which�is�defined�as�the�process�of�capturing�relevant�information�to�ensure�that�the�nature�of�the�incident�is�completely�documented�and�understood
• analysisandaction,to�understand�how�and�why�the�incident�occurred,�and�to�identify�ways�of�preventing�a�recurrence
• feedback,�which�should�include�the�changes�made,�and�the�improvements�achieved�as�a�result�of�the�changes.
Prompt points
¼ What legislation and policies did the organisation draw upon in shaping its incident management policy?
¼ What system of incident reporting does the organisation use?
¼ How does the organisation actively promote incident reporting by staff? How is feedback provided to staff?
¼ Within the organisation, who is responsible for incident investigation?
¼ What changes have been made to the organisation’s systems and processes as a result of incident investigation?
¼ Who is responsible for evaluating the organisation’s system of incident management? How often does this happen? Have any changes been made to the system as a result of this evaluation?
¼ How does the organisation communicate the outcomes of incident investigation to staff? How does it ensure that this communication is effective?
Sentinel events and open disclosureNot�all�incidents�that�occur�during�health�care�cause�harm,�or�could�have�caused�harm,�to�the�consumer�/�patient�involved.�Incidents�that�do�are�known�as�adverse�events.�A�sentinel�event�is�a�rare�but�extremely�serious�form�of�adverse�event,�wherein�the�process�of�health�care�itself�is�unexpectedly�and�unintentionally�responsible�for�harm�to,�or�the�death�of,�a�consumer�/�patient.�In�2003,�the�former�Australian�Council�for�Safety�and�Quality�in�Health�Care,�in�collaboration�with�jurisdictional�authorities,�developed�a�national�list�of�core�sentinel�events3,�which�now�forms�the�basis�of�mandatory�sentinel�event�reporting�by�jurisdictions.�The�national�list�is�as�follows:
1.� Procedures�involving�the�wrong�patient�or�body�part
2.� Suicide�of�a�patient�in�an�in-patient�unit
3.� Retained�instruments�or�other�material�after�surgery�requiring�re-operation�or�further�surgical�procedure
4.� Intravascular�gas�embolism�resulting�in�death�or�neurological�damage
5.� Haemolytic�blood�transfusion�reaction�resulting�from�ABO�incompatibility
6.� Medication�error�leading�to�the�death�of�a�patient�reasonably�believed�to�be�due�to�incorrect�administration�of�drugs
7.� Maternal�death�or�serious�morbidity�associated�with�labour�or�delivery
8.� Infant�discharged�to�the�wrong�family
Some�jurisdictions�have�added�further�categories�to�the�list.�For�example,�the�2008–2009�Sentinel�Event�Report�from�Western�Australia�indicated�that�the�majority�of�sentinel�events�reported�during�that�period�fell�into�the�additional�“other�adverse�event”�category.4
Open�disclosure�is�the�frank�and�transparent�discussion�of�incidents�that�result�in�harm�to�a�consumer�/�patient�while�receiving�health�care.�In�2003,�the�former�ACSQHC�published�theOpenDisclosureStandard:anationalstandardforopencommunicationinpublicandprivatehospitals,followinganadverseeventinhealthcare.1�The�principles�of�open�disclosure�are:
1.� Openness�and�timeliness�of�communication
2.� Acknowledgement�of�the�event
3.� An�expression�of�regret
4.� Recognition�of�the�reasonable�expectations�of�patients�and�their�support�persons
5.� Staff�support
6.� Integrated�risk�management�and�systems�improvement
7.� Good�governance
8.� Confidentiality
October 2010 271
Consumers�/�patients�should�be�informed�about�the�organisation’s�incident�management�processes,�as�well�as�be�notified�about�how�to�contact�support�personnel�such�as�advocates�or�translators.�The�provision�of�feedback�and/or�the�lodging�of�a�formal�complaint�is�one�of�the�consumer�/�patient’s�fundamental�healthcare�rights.�Complaints�investigation�is�an�important�aspect�of�an�integrated�risk�management�system,�as�consumer�/�patient�complaints�provide�an�alternative�viewpoint�on�the�circumstances�under�which�a�particular�incident�occurred,�and�can�also�serve�as�a�‘flag’�for�unreported�incidents.�
The�provision�of�feedback�to�consumers�/�patients�involved�in�an�incident�should�be�timely,�and�updates�should�be�given�throughout�the�investigation,�rather�than�a�final�‘report’�at�the�conclusion�of�what�may�be�a�lengthy�process.�There�should�also�be�reassurance�that�the�consumer�/�patient’s�right�to�privacy�and�the�confidentiality�of�the�health�record�will�be�respected�throughout�the�investigative�process.�If�the�consumer�/�patient’s�care�plan�changes�as�the�result�of�an�adverse�event,�the�new�plan�should�be�developed�in�consultation�with�the�consumer�/�patient�and,�where�appropriate,�his�or�her�carer.
To�be�successful,�the�organisation’s�management�of�open�disclosure�must�also�include�the�provision�of�all�necessary�staff�support,�including�professional�counselling.�Involvement�in�an�adverse�event�can�be�devastating�for�healthcare�providers,�and�organisations�should�work�towards�creating�a�system�that,�while�ensuring�appropriate�accountability,�is�non-punitive,�and�where�the�goal�is�not�the�assignment�of�blame�but�the�improvement�of�processes.�
Prompt points
¼ How are the principles of open disclosure evident in the organisation’s system of incident management?
¼ How does the organisation educate and train staff in the principles and practices of open disclosure? How often are these programs evaluated?
¼ How are adverse events investigated within the organisation? Who is involved in the investigation?
¼ How are consumers / patients provided with information about incident management and complaints?
¼ What support services does the organisation provide for staff involved in an adverse event?
¼ How does the organisation ensure that the support services it provides for consumers / patients and staff involved in an adverse event are appropriate? Who is responsible for evaluating these services? What improvements have been made to these services as a result of their evaluation? – and if none, why not?
Evidence commonly presented
Consider whether the following will help to address criterion 2.1.3
¼ Incident management systems
¼ Policies and procedures, including:
– incidents – open disclosure – how incident management is addressed
during orientation ¼ Participation in programs such as the Australian
Incident Monitoring System (AIMS) or the Incident Information Management System (IIMS)
¼ Evidence of the integration of complaints and feedback in the incident management system
¼ Evidence of staff education and training in incident management and incident reporting
¼ Evidence of staff training in the principles and practice of open disclosure
¼ Evidence of feedback sought from consumers / patients and staff regarding open disclosure support services
seCtion 5Standards, criteria, elements and guidelinesstandard 2.1:�The�governing�body�leads�the�organisation�in�its�commitment�to�improving�performance�and�ensures�the�effective�management�of�corporate�and�clinical�risks
272 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 2.1.3
Healthcareincidentsaremanagedtoensureimprovementstothesystemsofcare.(continued)
Performance measurementThis�criterion�states�that:�“Healthcare�incidents�are�managed�to�ensure�improvements�to�the�systems�of�care”.�Effective�processes�for�investigating�incidents�and�for�making�improvements�to�the�organisation’s�systems�and�processes�as�a�result�are�vital�to�the�provision�of�safe,�high�quality�health�care.�The�organisation�should�be�able�to�demonstrate�that�it�works�to�create�a�culture�in�which�staff�are�encouraged�to�report�incidents,�and�where�incident�reporting�provides�the�basis�for�improvement�of�services�and�processes.
Some�common�suggested�performance�measures�are�as�follows:
Number�of�near�misses�reported
Total number of incidents reported
Number�of�incident�investigations�instigated�by�a�complaint�from�a�consumer�/�patient
Total number of incidents reported
Number�of�incidents�reported�at�each�designated�level�of�severity
Total number of incidents reported
Comment:treateachSACorequivalentasaseparatenumerator
Number�of�sentinel�events�for�which�a�Root�Cause�Analysis�has�been�completed
Total number of sentinel events
Number�of�Root�Cause�Analyses�completed�within�the�required�timeframe
Total number of Root Cause Analyses
Number�of�Root�Cause�Analysis�recommendations�implemented
Total number of Root Cause Analysis recommendations
Number�of�improvements�implemented�from�Root�Cause�Analysis�investigations�that�have�been�sustained�12�months�post-implementation
Total number of improvements from Root Cause Analysis investigations 12 months or more ago
October 2010 273
References1.� Australian�Council�for�Safety�and�Quality�in�Health�Care.�
Opendisclosurestandard:anationalstandardforopencommunicationinpublicandprivatehospitals,followinganadverseeventinhealthcare.Canberra�ACT;�Australian�Council�for�Safety�and�Quality�in�Health�Care;�2003.
2.� Runciman�WB.�Shared�meanings:�preferred�terms�and�definitions�for�safety�and�quality�concepts.�MedJAust2006;�184(10�Suppl):�S41-S43.
3.� Australian�Council�for�Safety�and�Quality�in�Health�Care.�Factsheet:sentinelevents.Canberra�ACT;�Australian�Council�for�Safety�and�Quality�in�Health�Care;�2005.
4.� WA�Department�of�Health.�DeliveringsaferhealthcareinWesternAustralia:WAsentineleventreport2008–2009.Perth;�WA�Dept�of�Health;�2009.
GuidelinesAS/NZS�ISO�31000:2010�Riskmanagement–Principlesandguidelines.
Taylor-Adams�S�and�Vincent�C.�Systems�analysis�of�clinical�incidents:�The�London�protocol.ClinRisk�2004;�10(6):�211-220.
Committee�on�the�Financial�Aspects�of�Corporate�Governance�and�Gee�and�Co�Ltd.�Financialaspectsofcorporategovernance.�London�UK;�Committee�on�the�Financial�Aspects�of�Corporate�Governance;�1992.
NSW�Health.�Easyguidetoclinicalincidentmanagement.Sydney;�NSW�Health.�Accessed�from�http://www.health.nsw.gov.au/quality/incidentmgt/onlineguide/�on�19�August�2010.
NSW�Health.Easyguidetoclinicalpracticeimprovement–aguideforhealthcareprofessionals.�Sydney;�NSW�Health;�2002.
Further readingAustralian�Commission�on�Safety�and�Quality�in�Health�Care�(ACSQHC).�Windowsintosafetyandqualityinhealthcare2009.�Sydney�NSW;�ACSQHC;�2009.
Australian�Commission�on�Safety�and�Quality�in�Health�Care.�Windowsintosafetyandqualityinhealthcare2008.�Sydney�NSW;�ACSQHC;�2008.
NSW�Health�and�Clinical�Excellence�Commission�(CEC).�IncidentmanagementintheNSWpublichealthsystem–looking,learning,acting.July–December2008.Sydney�NSW;�CEC;�2009.
NSW�Health�and�Clinical�Excellence�Commission�(CEC).�Statewideimplementationofopendisclosure:Becauseit’stherightthingtodo.Sydney�NSW;�CEC.�Accessed�from�http://www.health.nsw.gov.au/resources/quality/opendisc/pdf/swide_implementation.pdf�on�19�August�2010.
Victorian�Rural�and�Regional�Health�and�Aged�Care�Services�Division.�Sentineleventprogram.Annualreport2007–08:Buildingfoundationstosupportpatientsafety.Melbourne;�Victorian�Dept�of�Human�Services�(DHS);�2008.
Hughes�C�and�Mackay�P.�Sea�change:�public�reporting�and�the�safety�and�quality�of�the�Australian�health�care�system.��MedJAust�2006;�184(10):�S44-S47.
Wilson�RM�and�van�der�Weyden�MB.�The�safety�of�Australian�healthcare:�10�years�after�QAHCS.MedJAust�2005;�182(6):�260-261.
Rosenthal�M.�Editorial:�The�role�of�information�in�reducing�medical�error.�MedJAust�2004;�181(1):�27-28.
seCtion 5Standards, criteria, elements and guidelinesstandard 2.1:�The�governing�body�leads�the�organisation�in�its�commitment�to�improving�performance�and�ensures�the�effective�management�of�corporate�and�clinical�risks
274 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion LA – Awareness sA – implementationLA plus the following
MA – evaluationSA plus the following
eA – excellenceMA plus the following
oA – LeadershipEA plus the following
Criterion 2.1.4
Healthcare�complaints�and�feedback�are�managed�to�ensure�improvements�to�the�systems�of�care.
a)� The�organisation�has�a�process�for�managing�complaints�and�feedback,�that�is�communicated�to�staff.
b)� The�organisation�has�a�process�for�risk�rating�complaints.
c)� Consumers�/�patients�and�carers�are�informed�of�the�process�for�making�a�complaint�and�providing�feedback.
a)� Complaints�and�feedback�are�managed�in�accordance�with�jurisdictional�policy/�legislation�and�Australian�standards.
b)� The�complaint�management�system�includes:�
� (i)� �registration�of�the�complaint
� (ii)� �review,�including�formal�review�of�serious�complaints�
� (iii)� �response�in�a�timely�manner�
� (iv)� �support�and/or�advocacy�for�consumers�/�patients,�carers�and�staff�involved�in�complaints
� (v)� �communication�of�outcomes.
c)� Clinicians,�managers�and�staff�are�orientated�/�trained�in�complaint�management�and�open�disclosure.
d)� Staff�are�trained�in�relevant�methods�of�conflict�and�complaint�resolution.
e)� Feedback�about�care�and�service�is�communicated�to�staff,�consumers�/�patients�and�management.�
f)� There�is�a�system�to�implement�the�recommendations�from�reviews�of�serious�complaints.
a)� The�principles�of�open�disclosure�of�an�adverse�event�are�evident�in�the�system�to�manage�complaints.
b)� Consumers�/�patients�and�carers�are�involved�in�the�evaluation�of�the�complaint�management�process.
c)� Complaints�are�trended,�risks�are�identified,�and�improvements�are�made�as�required.
d)� The�support�and�access�to�advocacy�provided�for�consumers�/�patients,�carers�and�staff�involved�in�complaints�is�evaluated,�and�improved�as�required.
a)� The�complaint�and�feedback�management�system�is�compared�with�external�systems�and�improvements�are�made�to�ensure�better�practice.
and/or
b)� Complaint�data�are�compared�internally�and�externally,�and�improvements�are�made�to�ensure�better�practice.
and/or
c)� The�organisation�undertakes�research�into�complaint�management�and�acts�on�the�results.
a)� The�organisation�demonstrates�it�is�a�leader�in�complaints�and�feedback�management.
October 2010 275
Criterion LA – Awareness sA – implementationLA plus the following
MA – evaluationSA plus the following
eA – excellenceMA plus the following
oA – LeadershipEA plus the following
Criterion 2.1.4
Healthcare�complaints�and�feedback�are�managed�to�ensure�improvements�to�the�systems�of�care.
a)� The�organisation�has�a�process�for�managing�complaints�and�feedback,�that�is�communicated�to�staff.
b)� The�organisation�has�a�process�for�risk�rating�complaints.
c)� Consumers�/�patients�and�carers�are�informed�of�the�process�for�making�a�complaint�and�providing�feedback.
a)� Complaints�and�feedback�are�managed�in�accordance�with�jurisdictional�policy/�legislation�and�Australian�standards.
b)� The�complaint�management�system�includes:�
� (i)� �registration�of�the�complaint
� (ii)� �review,�including�formal�review�of�serious�complaints�
� (iii)� �response�in�a�timely�manner�
� (iv)� �support�and/or�advocacy�for�consumers�/�patients,�carers�and�staff�involved�in�complaints
� (v)� �communication�of�outcomes.
c)� Clinicians,�managers�and�staff�are�orientated�/�trained�in�complaint�management�and�open�disclosure.
d)� Staff�are�trained�in�relevant�methods�of�conflict�and�complaint�resolution.
e)� Feedback�about�care�and�service�is�communicated�to�staff,�consumers�/�patients�and�management.�
f)� There�is�a�system�to�implement�the�recommendations�from�reviews�of�serious�complaints.
a)� The�principles�of�open�disclosure�of�an�adverse�event�are�evident�in�the�system�to�manage�complaints.
b)� Consumers�/�patients�and�carers�are�involved�in�the�evaluation�of�the�complaint�management�process.
c)� Complaints�are�trended,�risks�are�identified,�and�improvements�are�made�as�required.
d)� The�support�and�access�to�advocacy�provided�for�consumers�/�patients,�carers�and�staff�involved�in�complaints�is�evaluated,�and�improved�as�required.
a)� The�complaint�and�feedback�management�system�is�compared�with�external�systems�and�improvements�are�made�to�ensure�better�practice.
and/or
b)� Complaint�data�are�compared�internally�and�externally,�and�improvements�are�made�to�ensure�better�practice.
and/or
c)� The�organisation�undertakes�research�into�complaint�management�and�acts�on�the�results.
a)� The�organisation�demonstrates�it�is�a�leader�in�complaints�and�feedback�management.
seCtion 5Standards, criteria, elements and guidelinesstandard 2.1:�The�governing�body�leads�the�organisation�in�its�commitment�to�improving�performance�and�ensures�the�effective�management�of�corporate�and�clinical�risks
276 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 2.1.4
Healthcare�complaints�and�feedback�are�managed�to�ensure�improvements�to�the�systems�of�care.�(continued)
IntentFeedback�and�complaints�from�consumers�/�patients�provide�vital�data,�both�positive�and�negative,�about�the�organisation’s�systems�and�processes�and�its�provision�of�services.�The�intent�of�this�criterion�is�to�ensure�that�the�organisation�has�in�place�effective�systems�for�managing�consumer�/�patient�feedback�and�complaints,�so�that�the�information�provided�will�drive�meaningful�and�necessary�quality�improvement,�while�also�identifying�what�the�organisation�and�its�staff�does�well.
Relationships of 2.1.4 with other criteriaEffective�management�of�healthcare�complaints�and�feedback�is�an�important�aspect�of�the�organisation’s�provision�of�safe�care�and�services�(Standard�1.5)�and�of�its�commitment�to�quality�improvement�(Criterion�2.1.1).�Consumers�/�patients�are�encouraged�to�participate�actively�in�the�planning,�delivery�and�evaluation�of�health�care�(Criterion�1.6.1),�and�an�aspect�of�this�is�the�consumer�/�patient’s�right�to�provide�feedback�or�to�lodge�a�complaint�about�their�health�care,�and�to�have�appropriate�action�taken,�along�with�the�right�to�advocacy�services�and/or�other�support�if�desired�(1.6.2).�
The�process�of�consumer�/�patient�complaints�lodging�and�investigation�should�be�tied�into�the�system�of�incident�management�(Criterion�2.1.3)�within�the�organisation’s�integrated�risk�management�framework�(Criterion�2.1.2).�A�complaint�involving�an�adverse�event�should�be�managed�according�to�the�organisation’s�policy�/�guidelines�on�open�disclosure�(Criterion�2.1.3),�while�a�complaint�lodged�by�either�a�consumer�/�patient�or�another�staff�member�against�a�clinician�may�require�formal�investigation�by�the�relevant�professional�body�(Criterion�2.2.3),�and�impact�upon�credentialling�and�scope�of�practice�(Criterion�3.1.3).�The�organisation�will�have�policy�and�procedures�for�managing�staff�grievances�(Criterion�2.2.5).
Complaints managementA�complaint�is�an�expression�of�dissatisfaction�made�to�an�organisation,�related�to�its�products,�services�or�staff,�or�to�the�complaints-handling�process�itself,�where�a�response�or�resolution�is�explicitly�or�implicitly�expected.1�A�compliment�is�an�expression�or�implication�of�praise�or�satisfaction.2,�3�
In�2004,�the�former�Australian�Council�for�Safety�and�Quality�in�Health�Care�released�the�Better�PracticeGuidelinesonComplaintsManagementforHealthCareServices4,�with�the�stated�aims�of:
• improving�the�responsiveness�of�the�health�system�to�the�needs�and�concerns�of�consumers�/�patients
• placing�consumers�/�patients�at�the�centre�of�the�system�and�harnessing�their�experiences�to�drive�improvements
• helping�healthcare�professionals�to�understand�potential�problems�and�how�to�improve�their�service�to�the�public
• restoring�the�trust�of�consumers�/�patients�and�reducing�the�risk�of�litigation,�through�open�communication�and�a�commitment�to�learn�from�problems�and�prevent�their�recurrence
• promoting�better�complaints�management�practice�by�healthcare�services�and�improving�the�links�between�complaints�management�and�safety�and�quality�improvement.
The�provision�of�feedback�by�consumers�/�patients,�their�families�and/or�carers�can�offer�a�unique�perspective�on�consumer�and�community�needs5,�and�draw�attention�to�both�successes�and�flaws�in�the�systems,�processes�and�services�operating�within�organisations.�Valid�complaints,�properly�managed,�should�lead�to�the�consumer-driven�improvement�of�those�systems,�processes�and�services;�while�positive�feedback�and�compliments�provide�an�opportunity�to�highlight�the�achievements�of�the�organisation’s�operation�and,�in�particular,�its�staff.�
The�management�of�a�complaint�is�a�multistep�process.6�A�complaint�is:
• received�from�a�complainant�either�verbally,�in�writing�or�online
• registered�and�acknowledged,�a�formal�process�that�includes�the�complaint�being�entered�into�the�organisation’s�incident�management�system,�and�the�complainant�being�informed�that�this�has�been�done
• assessed,�an�initial�judgement�of�the�severity�of�the�incident
• investigated�by�the�relevant�internal�and/or�external�authorities
• analysed�and�reviewed�to�determine�the�appropriate�course�of�action
• responded�to,�with�the�recommendations�of�the�investigators�being�acted�upon
• resolved,�in�which,�in�the�event�of�a�valid�complaint,�formal�acknowledgement�is�made�to�the�complainant,�and�all�documentation�finalised.
October 2010 277
Many�complaints�are�received�by�staff�in�a�spontaneous,�verbal�manner,�and�the�appropriate�response�may�include�an�acknowledgement�of�the�complainant’s�concern,�an�explanation�if�the�staff�member(s)�can�give�it,�a�note�of�the�complaint�made�in�the�health�record�of�the�consumer�/�patient�concerned,�facilitation�of�a�discussion�between�the�complainant�and�the�relevant�clinician(s),�an�apology�if�warranted,�and�the�provision�of�information�as�to�how�the�complaint�can�be�formally�lodged,�should�the�complainant�wish�to�proceed.�
There�should�be�a�single,�publicly�recognisable�point�of�contact�within�the�organisation�for�the�receipt�and�management�of�complaints,�and�the�name,�address,�telephone�number�and�website�details�of�the�designated�office�and/or�individual(s)�in�charge�of�the�process�should�be�provided�to�consumers�/�patients�and�their�carers.�The�size�and�nature�of�the�organisation�will�determine�the�number�and�identity�of�those�with�the�authority�to�assess�and�investigate�complaints;�larger�facilities�commonly�employ�professional�complaints�investigators.�
Prompt points
¼ What legislation and policies did the organisation draw upon in shaping its complaint management policy?
¼ How is the complaints management system tied into the organisation’s process for incident management? How are the principles of open disclosure evident within the system?
¼ Within the organisation, who is responsible for receiving complaints? – entering complaints into the incident management system? – investigating complaints?
¼ How does the organisation ensure that recommendations from the investigation of a complaint are implemented?
¼ What changes have been made to the organisation’s systems and processes as a result of complaints investigation?
¼ Who is responsible for evaluating the organisation’s system of complaints management? How often does this happen? Have any changes been made to the system as a result of this evaluation?
¼ How does the organisation communicate the outcomes of complaints investigation to staff? How does it ensure that this communication is effective?
Staff education, training and supportAlthough�the�organisation�will�have�in�place�processes�for�the�lodging�of�a�complaint,�and�designated�staff�to�receive,�report�and�investigate�complaints,�a�complaint�can�be�received�at�any�moment�by�anyone.�It�is�therefore�vital�that�the�organisation�educate�and�train�its�staff�in�the�appropriate�behaviour�and�responses.�With�the�right�approach,�many�complaints�may�be�resolved�without�the�need�for�formal�investigation.
Staff�should�be�made�aware�of�the�organisation’s�processes�for�complaints�management�at�orientation,�and�subsequently�at�regular�education�sessions.�‘Frontline’�staff,�who�are�in�direct�contact�with�consumers�/�patients,�their�families�and/or�their�carers,�are�most�likely�to�receive�a�spontaneous�complaint,�and�should�receive�formal�training�not�only�in�the�correct�procedure�for�reporting�a�complaint,�but�in�conflict�and�complaint�resolution.�Appropriate�training�courses�are�offered�by�the�various�State�/�Territory�health�departments.�Standards�Australia�also�offers�a�good�practice�guide�called�TheHowAndWhyOfComplaintsHandling7,�which�is�intended�to�assist�those�involved�in�complaints�handling,�and�should�be�referred�to�when�organisations�are�developing�or�reviewing�complaints�management�systems�and/or�training�programs.�
Prompt points
¼ What information about complaints management is provided to staff during orientation? How often are ‘refresher’ sessions in this information provided?
¼ What training does the organisation provide or facilitate to assist staff in the handling of complaints? For what staff is this training offered?
¼ How does the organisation provide feedback to staff concerning the outcomes of complaints investigation?
¼ What support services are available to staff affected by a complaint?
seCtion 5Standards, criteria, elements and guidelinesstandard 2.1:�The�governing�body�leads�the�organisation�in�its�commitment�to�improving�performance�and�ensures�the�effective�management�of�corporate�and�clinical�risks
278 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 2.1.4
Healthcare�complaints�and�feedback�are�managed�to�ensure�improvements�to�the�systems�of�care.�(continued)
Consumer awareness and supportThe�right�to�comment�about�any�aspect�of�their�experience�while�receiving�health�care�is�guaranteed�to�consumers�/�patients�under�the�Australian�Charter�Of�Healthcare�Rights8,�which�supports�the�view�that�all�participants�in�the�healthcare�system�benefit�from�processes�that�encourage�feedback�about�the�services�received�by�consumers�/�patients,�and�which�ensure�that�any�concerns�are�resolved�in�an�open,�fair�and�timely�manner.�
Information�about�giving�feedback�should�be�provided�to�consumers�/�patients�prior�to�or�at�admission,�and�staff�should�offer�periodic�reminders.�Further�reminders�can�be�displayed�in�appropriate�areas�such�as�waiting-rooms�and�at�reception,�and�should�be�prominent�upon�the�organisation’s�website.�
Correct�complaints�management�also�requires�the�provision�and/or�facilitation�of�consumer�/�patient�support.�Information�about�giving�feedback�or�lodging�a�complaint�should�be�made�available�in�a�range�of�languages�drawn�from�the�organisation’s�knowledge�of�the�community�it�serves,�and�in�Braille�and/or�audio�format,�if�appropriate.�
Another�vital�form�of�consumer�/�patient�support�is�that�of�advocacy.�Professional�advocates�may�represent�the�consumer�/�patient�throughout�the�complaints�process.�Some�large�organisations�employ�Patient�Representatives�or�Consumer�Advocates�to�listen�to�consumer�/�patient�concerns,�offer�advice�and,�if�requested,�take�direct�action�in�the�complaints�process�on�the�consumer�/�patient’s�behalf.�While�it�is�not�mandatory�to�provide�this�form�of�support,�the�organisation�should�make�consumers�/�patients�aware�that�external�advocacy�services�exist,�what�they�do,�and�that�they�have�a�right�to�access�these�services�if�they�wish.�They�should�also�supply�all�necessary�information�for�doing�so,�such�as�contact�details.�This�information�should�be�provided�in�an�appropriate�range�of�languages.
Information�on�advocacy�can�be�found�at:�http://www.healthinsite.gov.au/topics/Consumer_Advocacy
Prompt points
¼ How are consumers / patients informed of their right to provide feedback? When and where does this happen?
¼ By what different means may a complaint be lodged within the organisation by consumers / patients or their representatives?
¼ Does the organisation provide Patient Representatives or Consumer Advocates to support consumers / patients and/or their carers through the complaints process? If not, what advocacy groups does the organisation provide contact details for?
FeedbackThe�provision�of�feedback�by�the�organisation�throughout�the�investigation�process,�with�a�formal�acknowledgement�at�the�end,�lets�the�consumer�know�that�his�or�her�concerns�are�being�taken�seriously�and�true�resolution�sought.�The�processes�by�which�feedback�is�provided�to�the�complainant�should�be�detailed�within�the�organisation’s�complaints�management�policy,�and�any�failure�or�breakdown�in�the�system�rigorously�investigated.
Another�necessary�aspect�of�complaints�management�is�feedback�to�staff,�including�managers.�Where�the�investigation�of�a�complaint�concludes�with�the�recommendation�of�changes�to�systems�and�processes,�this�must�be�acknowledged�and�acted�upon�at�the�managerial�level,�and�the�changes�communicated�to�staff.�
It�is�vital�that�changes�made�either�to�the�complaints�management�system�or�to�organisation�processes�are�communicated,�as�well�as�the�reasons�for�them,�so�that�all�relevant�staff�are�aware�of�any�new�procedures,�and�that�all�staff�are�reminded�of�the�importance�of�consumer�complaints.�The�effectiveness�of�the�communication�process�should�be�regularly�evaluated.
October 2010 279
Prompt points
¼ How often is feedback provided to the complainant during the complaints investigation process? How is the complainant informed that a complaint has been resolved?
¼ How does the organisation communicate to staff any changes made as a result of a complaint investigation?
¼ How are compliments from consumers / patients disseminated within the organisation?
¼ How does the organisation obtain feedback about its complaints management system?
¼ How does the organisation ensure that its provision of support services to consumers / patients and staff are appropriate and effective?
Evidence commonly presented
Consider whether the following will help to address criterion 2.1.4
¼ Complaints management system ¼ Policies and procedures, including:
– complaints – open disclosure – how complaints management is addressed
during orientation ¼ Integration of incident and complaints
management systems ¼ Information available to consumers / patients on
how to provide feedback or lodge a complaint ¼ Evidence of staff training in complaints handling,
conflict resolution and open disclosure ¼ Evidence that the organisation facilitates the
access of consumers / patients to support personnel including translators and advocates
Performance measurementThis�criterion�states�that:�“Healthcare�complaints�and�feedback�are�managed�to�ensure�improvements�to�the�systems�of�care”.�Effective�processes�for�responding�to�feedback,�for�resolving�and/or�investigating�complaints,�and�for�making�improvements�to�the�organisation’s�systems�and�processes�as�a�result�are�vital�to�the�provision�of�safe,�high�quality�healthcare.�The�organisation�should�be�able�to�demonstrate�that�it�has�systems�to�receive�and�act�upon�consumer�feedback�and�complaints,�and�that,�where�necessary,�improvements�are�made�to�its�services�and�processes�as�a�consequence.
Some�common�suggested�performance�measures�are�as�follows:
Number�of�complaints�lodged�by�consumers�/�patients
Total number of consumers / patients seen / admitted
Number�of�complaints�resolved�without�formal�investigation
Total number of complaints received
Number�of�complaints�lodged�about�the�complaints�management�system
Total number of complaints lodged
Number�of�complaints�by�specialty�/�category
Total number of complaints
Comment:organisationtodefine‘specialty/category’
seCtion 5Standards, criteria, elements and guidelinesstandard 2.1:�The�governing�body�leads�the�organisation�in�its�commitment�to�improving�performance�and�ensures�the�effective�management�of�corporate�and�clinical�risks
280 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
1.� AS�ISO�10002—2006�Customersatisfaction–Guidelinesforcomplaintshandlinginorganizations.
2.� Tasmanian�Department�of�Health�and�Human�Services.�ComplimentsandcomplaintspolicyforTasmania’sagencyfundedcommunitysectororganisations.Hobart�TAS;�Government�of�Tasmania;�2009.
3.� Department�of�Veterans’�Affairs.�Complaints,complimentsandfeedback.�Canberra�ACT;�Australian�Government.�Accessed�from�http://www.dva.gov.au/contact_us/Pages/index.aspx�on�13�August�2010.
4.� Australian�Council�for�Safety�and�Quality�in�Health�Care.�Betterpracticeguidelinesoncomplaintsmanagementforhealthcareservices.Canberra�ACT;�Australian�Council�for�Safety�and�Quality�in�Health�Care;�2004.
5.� Australian�Council�for�Safety�and�Quality�in�Health�Care.�Complaintsmanagementhandbookforhealthcareservices.Canberra�ACT;�Australian�Council�for�Safety�and�Quality�in�Health�Care;�2005.
6.� NSW�Health.�Policydirective:Complaintmanagementpolicy.�Sydney;�NSW�Health;�2006.
7.� Standards�Australia.�HB�229:2006Handbook:Thewhyandhowofcomplaintshandling.
8.� Australian�Commission�on�Safety�and�Quality�in�Health�Care�(ACSQHC).�Australiancharterofhealthcarerights(forconsumers).�Sydney�NSW;�ACSQHC;�2008.
Guidelines1.� AS�4608:2004�Disputemanagementsystems.�Second�edn.
2.� WA�Office�of�Safety�and�Quality�in�Healthcare.�WesternAustralianhealthcomplaintmanagementtoolkit2009.Perth;�WA�Department�of�Health;�2009.
Further readingRomios�P,�Newby�L,�Wohlers�M�etal.Turningwrongsintorights:learningfromconsumerreportedincidents–anannotatedliteraturereview.�Melbourne�VIC;�Health�Issues�Centre,�La�Trobe�University;�2003.
Criterion 2.1.4
Healthcare�complaints�and�feedback�are�managed�to�ensure�improvements��to�the�systems�of�care.�(continued)
Number�of�consumers�/�patients�informed�about�the�complaints�process
Total number of consumers / patients seen / admitted
Number�of�consumers�/�patients�satisfied�with�access�to�support�personnel
Total number of consumers / patients surveyed
Number�of�staff�members�satisfied�with�the�support�services�provided
Total number of staff members surveyed
Number�of�complaint�investigations�resolved�within�the�designated�timeframe
Total number of complaints investigated
References
October 2010 281
2.2�Human�Resources�Management�Standard
The�standard�is:�Human resources management supports quality health care, a competent workforce and a satisfying working environment for staff.
The�intent�of�this�standard�is�to�ensure�the�organisation’s�workforce�is�recruited�and�managed�in�a�manner�that�supports�the�provision�of�quality�and�safe�care�and�services.�Human�resources�management�practices�should�also�support�the�organisation’s�goals�and�objectives.�
The�standard�for�the�workforce�management�contains�five�criteria.�These�are:�
2.2.1� Workforce planning supports�the�organisation’s�current�and�future�ability�to�address�needs.
2.2.2� �The�recruitment, selection and appointment system�ensures�that�the�skill�mix�and�competence�of�staff,�and�mix�of�volunteers,�meet�the�needs�of�the�organisation.
2.2.3�� �The�continuing employment and performance development system ensures�the�competence�of�staff�and�volunteers.
2.2.4� �The�learning and development system ensures�the�skill�and�competence�of�staff�and�volunteers.�
2.2.5� Employee support systems�and�workplace�relations�assist�the�organisation�to�achieve�its�goals
Human resources management�is�the�policies,�practices�and�systems�that�influence�employees’�behaviours,�attitudes�and�performance1.
seCtion 5Standards, criteria, elements and guidelines
1.� de�Cieri�H�and�Kramer�R.�(Adapted�from�Noe,�Hollenbeck,�Gerhart�&�Wright.)�HumanResourceManagementinAustralia:strategy,people,performance.Sydney�NSW;�McGraw-Hill�Australia;�2003.
seCtion 5Standards, criteria, elements and guidelinesstandard 2.2:�Human�resources�management�supports�quality�health�care,�a�competent�workforce�and�a�satisfying�working�environment�for�staff
282 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
IntentThe�health�workforce�ranges�from�workers�with�no�formal�qualifications�providing�support�services�through�to�highly�qualified�specialists�working�in�technology-intensive�positions,�and�also�includes��non-clinical�staff.�It�is�acknowledged�that�the�workforce�is�supported�by�volunteers�and�carers.
The�intent�of�this�criterion�is�to�ensure�that�the�organisation�has�plans�to�meet�its�current�and�future�needs�within�each�segment�of�its�workforce.
Relationships of 2.2.1 with other criteriaWorkforce�planning�provides�a�vision�for,�and�responds�to,�all�aspects�of�workforce�management�(Standard�2.2).�Workforce�planning�should�reflect�the�organisation’s�strategic�and�planning�goals�(Criterion�3.1.1).
The�availability,�quality�and�fallibility�of�staff�presents�a�risk�factor�for�all�organisations,�but�even�more�so�for�service�organisations�with�a�responsibility�to�ensure�the�safety�of�the�public,�such�as�healthcare�organisations.�The�control�of�safety�factors�associated�with�workforce�planning�is�an�aspect�of�the�organisation’s�integrated�risk�management�framework�(Criterion�2.1.2),�and�failure�in�this�area�may�lead�to�incidents�(Criterion�2.1.3)�and�complaints�(Criterion�2.1.4).
Workforce planning Forward�planning�is�needed�to�ensure�that�the�organisation�can�respond�to�the�changing�needs�of�communities,�governments,�health�services�and�employees�now�and�into�the�future.�Comprehensive�workforce�planning�takes�time,�meaningful�stakeholder�engagement,�and�collaboration.�Good�planning�ensures�that�the�longer-term�and�broader�goals�of�the�organisation�can�be�met�despite�the�urgency�of�immediate�demands.
The�approach�to�workforce�planning�will�differ�depending�on�whether�it�aims�to�address�immediate�needs�(the�next�shift),�short-term�needs�(less�than�one�year)�or�longer-term�goals�(three�to�five�years).�
Criterion LA – Awareness sA – implementationLA plus the following
MA – evaluationSA plus the following
eA – excellenceMA plus the following
oA – LeadershipEA plus the following
Criterion 2.2.1
Workforce�planning�supports�the�organisation’s�current�and�future�ability�to�address�needs.
a)� Systems�exist�to�ensure�that�the�skill�mix�of�clinical�and�support�staff�meets�consumer�/�patient�needs.
b)� Documented�policy�and�procedures�for�workforce�planning�and�management�are�available�to�staff.
c)� Policy�/�guidelines�for�safe�working�hours�exist.�
d)� Strategies�are�in�place�to�ensure�safe,�quality�treatment�and�care�if�prescribed�levels�of�skill�mix�of�clinical�and�support�staff�are�not�available.
a)� The�workforce�strategic�plan�is�clearly�linked�to�the�organisation’s�strategic�direction�and�goals.
b)� The�organisation’s�workforce�planning�reflects�current�and�future�needs�of�consumers�/�patients�and�staff.
c)� Workforce�management�functions�and�responsibilities�are�clearly�identified.
d)� Fatigue�prevention�and�management�strategies�are�implemented.
e)� Staff�members�are�advised�of,�and�have�access�to,�workforce�policies�and�procedures.
f)� There�are�contingency�plans�to�manage�workforce�shortages.
a)� The�workforce�policy,�plan,�goals�and�strategic�direction�are�regularly�reviewed,�evaluated�and�improvements�are�made�as�required.
b)� Performance�measures�are�used�on�a�regular�basis�to�evaluate�employee�fatigue,�and�improvements�are�made�as�required.
a)� Performance�measures�and�processes�for�workforce�planning�are�compared�internally�and�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.
and/or
b)� The�organisation�conducts�research�and�develops�innovative�ways�to�improve�workforce�management.
a)� The�organisation�demonstrates�it�is�a�leader�in�planning�for�current�and�future�workforce�requirements.
October 2010 283
A�number�of�external�changes�that�will�affect�workforce�planning�in�healthcare�organisations�in�upcoming�years�have�been�identified.�The�potential�impact�of�these�and�other�environmental�factors�should�be�considered�by�the�organisation.�They�include:
• the�need�to�provide�more�flexible�working�arrangements
• changes�from�State�/�Territory-based�to�national�professional�registration�and�continuing�education
• new�clinical�schools�with�larger�numbers�of�trainees�requiring�clinical�experience�
• expanding�roles�for�nurses�and�midwives
• changing�gender�balance�in�some�health�professions
• the�ageing�of�the�nursing�workforce
• demand�exceeding�supply�in�many�health�professions,�and�the�associated�reliance�on�overseas-trained�professionals.
Organisations�may�benefit�from�considering�these�principal�steps�in�a�workforce�planning�process1:
• review�the�environment�in�which�the�organisation�operates
• forecast�workforce�demand
• forecast�workforce�supply
• analyse�gaps�and�generate�strategies
• monitor�and�evaluate.
A�process�was�developed�by�Victoria’s�Department�of�Human�Services�to�assist�rural�planners�to�evaluate�workforce�needs�without�requiring�sophisticated�computer�tools.�A�description�of�this�process,�which�may�also�be�useful�in�other�settings,�is�available�online1�at:�http://www.health.vic.gov.au/ruralhealth/downloads/rural_health_workforce_planning_guidelines.pdf�
Good�planning�should�involve�organisational�managers,�not�because�this�will�meet�EQuIP�requirements,�but�because�those�working�within�the�organisation�understand�its�current�needs�and�can�consider�future�challenges.�To�assist�the�process1:
• make�available�the�best�possible�information�for�planning,�including�the�work�already�undertaken�in�environmental�review
• encourage�a�consultative�process�in�which�the�manager�involves�others�with�relevant�knowledge
• use�a�structured�approach�to�prompt�consideration�of�different�factors�that�may�impact�on�staffing�needs.
Criterion LA – Awareness sA – implementationLA plus the following
MA – evaluationSA plus the following
eA – excellenceMA plus the following
oA – LeadershipEA plus the following
Criterion 2.2.1
Workforce�planning�supports�the�organisation’s�current�and�future�ability�to�address�needs.
a)� Systems�exist�to�ensure�that�the�skill�mix�of�clinical�and�support�staff�meets�consumer�/�patient�needs.
b)� Documented�policy�and�procedures�for�workforce�planning�and�management�are�available�to�staff.
c)� Policy�/�guidelines�for�safe�working�hours�exist.�
d)� Strategies�are�in�place�to�ensure�safe,�quality�treatment�and�care�if�prescribed�levels�of�skill�mix�of�clinical�and�support�staff�are�not�available.
a)� The�workforce�strategic�plan�is�clearly�linked�to�the�organisation’s�strategic�direction�and�goals.
b)� The�organisation’s�workforce�planning�reflects�current�and�future�needs�of�consumers�/�patients�and�staff.
c)� Workforce�management�functions�and�responsibilities�are�clearly�identified.
d)� Fatigue�prevention�and�management�strategies�are�implemented.
e)� Staff�members�are�advised�of,�and�have�access�to,�workforce�policies�and�procedures.
f)� There�are�contingency�plans�to�manage�workforce�shortages.
a)� The�workforce�policy,�plan,�goals�and�strategic�direction�are�regularly�reviewed,�evaluated�and�improvements�are�made�as�required.
b)� Performance�measures�are�used�on�a�regular�basis�to�evaluate�employee�fatigue,�and�improvements�are�made�as�required.
a)� Performance�measures�and�processes�for�workforce�planning�are�compared�internally�and�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.
and/or
b)� The�organisation�conducts�research�and�develops�innovative�ways�to�improve�workforce�management.
a)� The�organisation�demonstrates�it�is�a�leader�in�planning�for�current�and�future�workforce�requirements.
seCtion 5Standards, criteria, elements and guidelinesstandard 2.2:�Human�resources�management�supports�quality�health�care,�a�competent�workforce�and�a�satisfying�working�environment�for�staff
284 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 2.2.1
Workforce�planning�supports�the�organisation’s�current�and�future�ability�to�address�needs.�(continued)
Prompt points
¼ How does the workforce plan address the goals and objectives outlined in the organisation’s strategic plan?
¼ What are the key factors affecting workforce supply?
¼ What characteristics of the workforce and labour supply have been considered when developing the workforce plan?
¼ Who is responsible for preparing and implementing the workforce plan?
Contingency planning for workforce shortages Workforce�shortages�can�occur�on�a�short-term,�shift-by-shift�basis.�Available�staff�crises�can�be�managed�using�a�contingency�plan,�which�may�include�strategies�such�as�reprioritising�tasks,�allocating�tasks�to�different�staff�members,�and�relying�on�a�pool�of�filler�staff,�which�may�consist�mostly�of�previous�employees,�and�sourcing�casual�staff�from�agencies.2
Ongoing�skill�shortages�should�be�addressed�through�longer-term�planning.�Considerable�research�has�demonstrated�that�targeted�programs�can�lead�to�cultural�change�with�subsequent�positive�outcomes�for�business�performance.3
Attracting�good�people�and�retaining�them�is�clearly�an�important�goal.�Magnet�hospitals�are�those�able�to�recruit�the�best�qualified�nurses�and�then�retain�these�staff.�US�research�undertaken�in�the�1990s�suggested�that�participatory�management,�effective�leadership,�professional�practice�environments�(illustrated�by�the�existence�of�quality�care,�positive�staffing�relationships�and�autonomy�of�practice�amongst�nursing�staff)�and�clearly�defined�career�development�pathways�are�key�issues�in�the�recruitment�and�retention�of�nursing�staff.4�Among�the�most�important�workplace�features�for�nurses�who�participated�in�a�review�of�‘magnet�characteristics’�in�an�Australian�context5�were:
• working�in�clinical�environments�characterised�by�good�levels�of�consumer�/�patient�care
• being�supervised�by�credible,�effective�managers
• positive�professional�relationships�with�medical�colleagues.
Prompt points
¼ How does the organisation ensure that the right people with the required skills and behaviours are available when and where they are needed on a day-to-day basis?
¼ How are short-term labour shortages managed to maintain quality, safe care? What patterns of skill shortages exist? What improvements have been made?
¼ How are day-to-day shortages being minimised by strategic planning?
Responsibilities for workforce managementLine�managers�and�supervisors�have�a�responsibility�for�staff�employed�below�them.�Because�workforce�management�can�be�challenging�and�time�consuming�for�individuals,�and�is�extremely�important�for�the�organisation,�all�managers�should�be�aware�of�their�specific�responsibilities�as�a�supervisor�of�their�staff.�
Depending�on�organisational�size�and�structure,�line�managers�will�carry�different�degrees�of�responsibility�for�the�following�aspects�of�workforce�management6:
• appointments�–�placing�the�right�person�in�the�right�job
• induction�–�starting�new�employees�in�their�roles
• training�–�teaching�employees�tasks�that�are�new�to�them
• staff�development�–�improving�the�job�performance�of�each�person�and�developing�skills�so�that�staff�are�prepared�for�internal�advancement
• team�building�–�gaining�creative�cooperation�and�developing�smooth�working�relationships
• interpreting�the�company’s�employment�policies�and�procedures
• fiscal�control�–�managing�labour�costs
• culture�–�creating�and�maintaining�departmental�morale
• OH&S�–�protecting�employees’�health�and�physical�safety.
October 2010 285
The�manager’s�human�resources�(HR)�responsibilities�and�organisational�key�performance�indicators�(KPIs)�in�workforce�management�should�be�clearly�documented�within�his�or�her�position�description,�and�signed�off.
It�is�particularly�important�that�those�responsibilities�borne�by�line�managers�are�differentiated�from�those�of�the�HR�department.�When�HR�responsibilities�are�outsourced,�the�differentiating�of�responsibilities�should�be�specifically�outlined�in�contracts�/�other�agreements�and�communicated�to�line�managers,�so�that�no�steps�in�the�recruiting�and�staff�support�processes�are�neglected.
Human�resource�department�responsibilities�generally�fall�into�three�specific�areas:
• line�management�within�their�own�department�–�supervising�activities�of�their�own�staff
• coordinating�HR�policy�and�actions�–�to�ensure�that�workforce�decisions�are�adopted�and�executed,�particularly�in�OH&S,�health�(including�records�of�immunity�testing,�vaccinations,�allergies),�credentialling�(e.g.�ensuring�professional�staff�have�current�registrations�and�are�abiding�by�scopes�of�practice),�liaison�with�unions,�scheduling�shift�personnel
• staff�(service�and�transactional�functions)�–�hiring,�training,�evaluating,�rewarding,�counselling,�promoting�and�terminating�employment.
Relative�responsibilities�of�internal�or�outsourced�HR�providers�for�the�different�tasks�listed�above�must�be�clearly�defined�to�enable�cooperative�management�of�staff�issues�between�line�managers�and�the�HR�department.�Without�due�care,�there�is�potential�for�duplication�and/or�for�omission�of�important�tasks.
Prompt points
¼ Within the organisation, who or which department takes responsibility for appointments, induction, training, staff development, HR policies and procedures, HR budgeting and fiscal control, organisational culture and OH&S? Where are these responsibilities recorded?
Skill mix of clinical and support staffThe�term�‘skill�mix’�is�used�to�describe�the�mix�of�positions,�grades�or�occupations�within�a�unit�/�organisation.7�Skill�mix�can�also�refer�to�the�combinations�of�activities�or�skills�needed�for�each�position�within�the�organisation.�
Planning�for�future�requirements,�particularly�in�an�under-resourced�labour�market,�requires�visionary�management�by�line�managers�in�order�to�meet�current�needs�while�allowing�skills�development.�Where�there�are�shortages�of�staff�and�an�inadequate�mix�of�skills,�a�problem�that�particularly�confronts�regional�and�remote�organisations,�flexible�and�creative�management�may�be�required�to�provide�services�to�meet�consumer�/�patient�demand.�
Creative�workforce�management�may�be�needed�to�overcome�a�skills�shortage�or�improve�the�cost-effectiveness�of�the�health�workforce;�this�may�involve�staff�travelling�between�facilities,�job�sharing,�dual�role�timetabling�or�provision�of�supervised�activities�for�staff�being�upskilled.�
Education�and�recruitment�can�change�the�skill�mix�within�a�team.�A�more�flexible�workforce�achieved�by�upskilling�and�reskilling�health�professionals�can�assist�in�meeting�evolving�needs.8�Clinical�staff�can�acquire�new�skills�and�be�authorised�to�undertake�additional�tasks.�Upskilling�has�the�potential�to�improve�continuity�of�care�and�quality,�especially�in�chronic�disease�management.8
Increasingly,�nurses�and�allied�health�professionals�are�being�upskilled�to�relieve�highly-qualified�physicians�so�that�they�can�focus�their�attentions�elsewhere.�For�example,�diabetes�educators�and�dietitians�assist�endocrinologists�in�managing�the�care�of�people�with�diabetes,�freeing�physicians�to�focus�on�clinical�aspects�of�care.�Pathologists�are�freed�to�support�physicians�in�interpreting�test�results�when�they�work�in�collaboration�with�colleagues�trained�in�medical�laboratory�science.
seCtion 5Standards, criteria, elements and guidelinesstandard 2.2:�Human�resources�management�supports�quality�health�care,�a�competent�workforce�and�a�satisfying�working�environment�for�staff
286 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 2.2.1
Workforce�planning�supports�the�organisation’s�current�and�future�ability�to�address�needs.�(continued)
Prompt points
¼ How well is recruitment coordinated in this organisation? Who is responsible for recruiting decisions? How are recruiting responsibilities documented to avoid duplication or omission of tasks?
¼ How well does the skill mix for the organisation / department meet the service requirements?
¼ How does the organisation make sure the skill mix is still suitable when there are changes such as service requirements, casemix, cost containment, new processes and procedures? How does workforce planning reflect the organisation’s longer-term strategic plan? How are learnings from workforce planning incorporated into the strategic planning process?
¼ How have changes to the skill mix been identified, solved and implemented?
¼ What is the role of recruitment, selection and appointment, and of learning and development, in enhancing the skill mix?
Policies and proceduresWorkplace�policies�and�procedures�should�communicate�at�least�the�minimum�performance�level�required�and�reflect�legal�aspects�of�workforce�management,�so�that�the�workforce�can�contribute�to�meeting�the�goals�and�objectives�of�the�organisation.�Policies�and�procedures�should�cover�aspects�relevant�to�the�organisation.�For�example:
• legal�and�ethical�aspects�such�as�agreements,�awards�and�contracts
• job�design
• recruitment
• selection�and�appointment
• orientation�and�integration
• code�of�conduct
• performance�management
• pay,�leave�and�conditions
• learning�and�development
• managing�diversity
• workplace�relations.
Prompt points
¼ How are staff made aware of workforce policies and procedures?
¼ How well do these policies and procedures assist staff with understanding the system and supporting them to perform well?
¼ How does the organisation know that the workforce policies and procedures are current and relevant?
Safe working hours and fatigue managementFatigue�caused�by�long�working�hours�can�impair�judgement�and�competence.9�There�is�a�risk�of�diminished�quality�of�care,�and�a�risk�to�the�health�and�safety�of�the�individual.10�
Policy�and/or�guidelines�on�safe�working�hours�and�fatigue�management�should�be�developed�with�staff�input�and�made�readily�available�to�the�entire�workforce,�including�non-employee�workers�such�as�visiting�medical�officers�(VMOs)�and�students.�University�departments�that�send�trainees�to�the�organisation�should�also�be�informed.�
Safe�working�hours�can�be�used�to�manage�fatigue�risks�which�can�be�planned�through�better�rostering.11�If�a�potential�risk�is�identified,�the�use�of�risk�identification�tools�such�as�the�FatigueAssessmentTool,�accessible�from�the�Australian�Medical�Association’s�website,�and�management�according�to�the�Australian�Medical�Association’s10�or�other�professional�bodies’�codes�of�practice12,�can�assist.�Nursing�unions�hold�seminars�to�assist�their�members�to�manage�shift�work�and�fatigue.
Fatigue�risk�management�includes�eliminating�or�minimising�risks�arising�from�the�hazards�associated�with�shift�work�and�extended�working�hours.10�It�is�important�that�staff�have�time�to�eat�and�drink�even�when�their�workloads�are�heavy�or�access�to�dining�facilities�limited:�hypovolaemia�and�hypoglycaemia�may�extend�reaction�times�or�impair�psychomotor�performance.13
October 2010 287
Fatigue�represents�a�serious�risk�to�consumers�/�patients�and�staff�alike,�and�must�be�proactively�managed�to�avoid�incidents.�Depending�on�the�records�available,�a�measure�of�continuous�hours�worked�by�individuals�is�a�reliable�guide�to�the�potential�for�fatigue.�Organisations�should�consider�what�data�are�already�being�collected�that�might�give�an�indication�of�continuous�hours�being�worked;�for�instance,�in�a�surgical�setting,�the�theatre�scheduling�database�(often�known�as�an�Operating�Room�Management�Information�System�or�ORMIS)�may�provide�insights�into�hours�being�worked.�Vehicle�logs�may�give�insights�into�hours�worked�by�staff�who�see�consumers�/�patients�in�their�homes.�
Fatigue�may�play�a�role�in�adverse�events,�so�time�of�day�and�overtime�hours�should�be�considered�in�any�evaluation,�such�as�a�Root�Cause�Analysis�of�an�incident.�Where�fatigue�may�be�an�issue,�a�team�approach�that�considers�the�unique�demands�and�resources�of�the�workplace�will�be�key�to�finding�ways�to�minimise�these�risks.�Ideas�for�managing�these�challenges�that�have�been�trialled�successfully�should�be�shared�between�teams�or�organisations.
Prompt points
¼ What strategies / practices are used to minimise errors and incidents when someone is fatigued? How effective are these strategies?
¼ How is fatigue risk systematically identified? Which staff groups are at most risk? What controls are in place to manage risk?
¼ What aspects of organisational culture may lead people to work long hours even when fatigued?
¼ What longer-term planning is being conducted to minimise risks associated with fatigue?
¼ How is fatigue, or the potential for fatigue, managed in employees / casual staff who may be engaged in other employment?
Evidence commonly presented
Consider whether the following will help to address criterion 2.2.1
¼ Evaluation of the achievement of workforce plans
¼ Evaluation of the workforce planning process
¼ Review of policies and procedures documentation
¼ Fatigue risk policy
¼ Fatigue risk assessment and management plans
¼ Evaluation of skill mix against service requirements
¼ Minutes of meetings relating to workforce planning, skills shortages, fatigue management and whether actions have been addressed
seCtion 5Standards, criteria, elements and guidelinesstandard 2.2:�Human�resources�management�supports�quality�health�care,�a�competent�workforce�and�a�satisfying�working�environment�for�staff
288 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 2.2.1
Workforce�planning�supports�the�organisation’s�current�and�future��ability�to�address�needs.�(continued)
Performance measurementThis�criterion�states�that:�“Workforce�planning�supports�the�organisation’s�current�and�future�ability�to�address�needs.”�The�organisation�should�have�clearly�defined�processes�and�responsibilities�for�the�recruitment�and�retention�of�staff,�both�clinical�and�non-clinical,�so�that�both�current�and�future�workplace�needs�are�met.
Some�common�suggested�performance�measures�are�as�follows:
Number�of�FTE�staff�resigning�from�the�organisation�/�area�/�department�within�the�previous�year
Total number of FTE positions defined within the organisation / area / department
Comment:FTE=full-timeequivalent
Number�of�overtime�hours�worked
Total number of FTE staff
Number�of�sick�days�taken
Total number of FTE staff
Number�of�nursing�hours�worked
Total number of consumer / patient bed days by specialty / unit
Comment:thismeasuremightbemonitoredforotherprofessionalgroupsasappropriateforthespecificneedsoftheorganisation/department
Agency�nurse�hours�worked�in�the�specified�time�frame
Total nurse hours worked in the specified time frame
Number�of�workforce�plan�key�performance�indicators�(KPIs)�met�within�specified�timeframe
Total number of workforce plan KPIs
October 2010 289
References 1.� Victorian�Rural�and�Regional�Health�and�Aged�Care�
Services.�Ruralhealthworkforceplanningguidelines.Melbourne�VIC;�Dept�of�Human�Services;�2006.
2.� Blythe�J,�Baumann�A,�Zeytinoglu�I�etal.Full-time�or�part-time�work�in�nursing:�Preferences,�tradeoffs�and�choices.�Healthcare�Quarterly�2005;�8(3):�69-77.
3.� Sanders�EJ�and�Cooke�RA.�Translating“soft”changesinto“hard”dollars:Financialreturnsfromorganisationalcultureimprovement.�Arlington�Heights�USA;�Human�Synergistics;�2005.�Accessed�from�http://www.humansynergistics.com.au/content/articles/papers/financial-roi-culture-rob-cooke-jun-05/default.asp�on�14�April�2010.
4.� Upenieks�V.�Recruitment�and�retention�strategies�literature�review.�MedscapeToday(30�March�2010).�Accessed�from�http://www.medscape.com/viewarticle/449690_3�on�1�September�2010.
5.� Joyce�J�and�Crookes�P.�Developing�a�tool�to�measure�‘magnetism’�in�Australian�nursing�environments.��AustJAdvNurs�2007;�25(1):�17-23.
6.� Dessler�G,�Griffiths�J�and�Lloyd-Walker�B.�Humanresourcemanagement.�2nd�edn.�Sydney�NSW;�Pearson�Education�Australia;�2004.
7.� Buchan�J�and�Dal�Poz�MR.�Skill�mix�in�the�health�care�workforce:�reviewing�the�evidence.�BullWorldHealthOrgan�2002;�80(7):�575-580.
8.� Duckett�SJ.�Interventions�to�facilitate�health�workforce�restructure.�AustNZHealthPolicy�2005;�2(1):�14.
9.� Nocera�A�and�Khursandi�DS.�Doctors’�working�hours:�can�the�medical�profession�afford�to�let�the�courts�decide�what�is�reasonable?�MedJAust�1998;�168(12):�616-618.
10.� Australian�Medical�Association�(AMA).�Nationalcodeofpractice–hoursofwork,shiftworkandrosteringforhospitaldoctors.Canberra�ACT;�AMA;�2005.
11.� Australian�Medical�Association.�Safehourscampaignfatigueriskassessmenttool.Accessed�from�http://safehours.ama.com.au/�on�31�August�2010.
12.� Royal�Australasian�College�of�Surgeons�(RACS).�Standardsforsafeworkinghoursandconditionsforfellows,surgicaltraineesandinternationalmedicalgraduates.�Melbourne�VIC;�RACS;�2007.
13.� Association�of�Anaesthetists�of�Great�Britain�and�Ireland�(AAGBI).�Fatigueandanaesthetists.London�UK;�AAGBI;�2005�
seCtion 5Standards, criteria, elements and guidelinesstandard 2.2:�Human�resources�management�supports�quality�health�care,�a�competent�workforce�and�a�satisfying�working�environment�for�staff
290 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
IntentRecruitment�involves�targeting�suitable�applicants�and�receiving�applications,�and�is�followed�by�a�selection�process�to�rank�candidates�and�determine�the�most�suitable�person�to�fill�a�position.�
Following�reference�checking,�credentialling,�criminal�record�/�working�with�children�checks�and�any�other�relevant�checks,�the�chosen�applicant�is�offered�a�position�and�appointed.�These�processes�and�their�associated�documentation�will�provide�much�of�the�evidence�for�this�criterion.
The�intent�of�this�criterion�is�to�ensure�that�all�aspects�of�recruitment,�selection�and�appointment�meet�the�needs�of�the�organisation.
Relationships of 2.2.2 with other criteriaComprehensive�workforce�planning�(Criterion�2.2.1)�identifies�the�staff�needed�to�allow�the�organisation�to�achieve�the�goals�outlined�in�its�strategic�and�operational�plans�(Criterion�3.1.1).�If�recruitment�is�subcontracted�to�external�service�providers,�this�arrangement�must�be�managed�so�as�to�ensure�the�quality�of�the�service�delivery,�assessed�against�the�terms�of�agreement�(Criterion�3.1.4).�Failures�in�the�processes�for�recruiting�appropriately�qualified�staff�may�lead�to�incidents�(Criterion�2.1.3)�and�complaints�(Criterion�2.1.4).
Organisational�need�will�determine�the�recruitment�of�clinicians,�whose�suitability�for�available�positions�will�be�managed�via�the�processes�of�credentialling�and�defining�the�scope�of�clinical�practice�(Criterion�3.1.3).�
Recruitment, selection and appointmentRecruitment,�selection�and�appointment�processes�must�meet�legislated�obligations.�Equal�opportunity�and�anti-discrimination�legislation�requires�that�the�recruitment�process,�including�the�selection�criteria,�is�consistent�with�the�position�specifications.�Employers�should�operate�in�accordance�with�the�Commonwealth�Acts�covering�fair�work�and�work�relations,�OH&S�and�privacy.�In�addition,�there�are�different�Acts�operating�within�each�State�/�Territory�jurisdiction,�with�detailed�regulations�pertaining�particularly�to�OH&S�and�industrial�relations�issues.�A�range�of�Commonwealth�and�State�/�Territory�legislation�protects�against�discrimination�based�on�stated�criteria,�such�as�race,�age�and�gender.
Criterion LA – Awareness sA – implementationLA plus the following
MA – evaluationSA plus the following
eA – excellenceMA plus the following
oA – LeadershipEA plus the following
Criterion 2.2.2
The�recruitment,�selection�and�appointment�system�ensures�that�the�skill�mix�and�competence�of�staff,�and�mix�of�volunteers,�meets�the�needs�of�the�organisation.
a)� Recruitment,�selection�and�appointment�are�undertaken�in�accordance�with�legislative�requirements,�jurisdictional�policy�/�regulations�and�organisational�policy�/�guidelines.
b)� Recruitment�processes�ensure�staff�and�volunteers�have�the�necessary�licences,�registration,�qualifications,�skills�and�experience�to�perform�their�work.
a)� The�recruitment�system�ensures�an�adequate�number�and�skill�mix�of�staff�to�provide�the�organisation’s�services.
b)� All�departments�/�units�comply�with�the�organisation’s�recruitment,�selection�and�appointment�requirements.
c)� The�volunteer�recruitment�system�supports�an�adequate�number�and�mix�of�volunteers�to�provide�applicable�services.
d)� There�is�a�system�and�program�for�the�orientation�and�integration�of�all�staff�and�volunteers.
a)� Performance�measures�are�used�to�evaluate�and�improve�recruitment,�selection�and�appointment�systems,�and�adapt�them�to�changing�service�requirements,�where�required.
b)� The�orientation�and�integration�system�is�evaluated�and�improved�on�a�regular�basis.
a)� Performance�measures�and�processes�for�recruitment,�selection,�appointment,�orientation�and�integration�are�compared�internally�and�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.
and/or
b)� Developments�in�research�inform�the�recruitment,�selection,�appointment,�orientation�and�integration�systems.
a)� The�organisation�demonstrates�it�is�a�leader�in�recruitment,�selection,�appointment,�orientation�and�integration�systems.
October 2010 291
From�2010,�the�‘Modern�Awards’�program�will�move�a�number�of�professions,�including�nursing�and�aged�care,�onto�nationally�negotiated�awards,�through�a�phased�transition�over�five�years.1�Administration�of�legislation�covering�the�professional�practice�of�medical�doctors,�nurses�and�other�health�professionals�in�all�Australian�States�and�Territories�falls�under�the�remit�of�the�National�Registration�and�Accreditation�Scheme2,�and�is�administered�by�the�Australian�Health�Practitioner�Regulation�Agency�(AHPRA).�Information�is�available�at:�http://www.ahpra.gov.au�
Types�of�workforce�agreements�undertaken�between�organisations�and�their�health�professionals�may�vary,�with�marked�differences�in�the�contracted�agreements�used�within�the�private�and�public�sector.�Private�hospital�policy�in�relation�to�staff�/�contractors�may�be�covered�in�organisational�by-laws�which�themselves�must�reflect�legislation�governing�the�operation�of�private�healthcare�facilities�in�the�relevant�State�/�Territory.
Volunteers�are�not�covered�by�the�legislation�referenced�above.�State�/�Territory-based�laws�generally�include�clauses�to�protect�volunteers�from�personal�liability.�However,�specific�conditions�may�preclude�cover�for�volunteers�/�the�organisation.�Both�the�organisation�and�volunteers�should�be�fully�aware�of�the�terms�and�conditions�of�any�Volunteer�Protection�clauses�operating�in�their�State�/�Territory�and�understand�their�rights�and�responsibilities�in�relation�to�this�legislation.�Volunteer�appointments�may�also�be�conditional�on�police�and/or�working�with�children�checks.
Organisations�need�to�be�aware�of�the�legislated�obligations�that�apply�to�them�and�monitor�any�changes�to�legislation.�These�requirements�should�be�reflected�in�their�policies.�
Details�covered�by�employment�contracts�include:
• hours�of�employment�and�full-time,�part-time�or�casual�employment�status�–�permanent�or�stated�temporary�duration
• salary�and�benefits
• start�date�and�probation�period
• any�other�conditions�of�employment;�this�may�include�signed�agreements�relating�to�position�description,�confidentiality,�workplace�safety.�
Criterion LA – Awareness sA – implementationLA plus the following
MA – evaluationSA plus the following
eA – excellenceMA plus the following
oA – LeadershipEA plus the following
Criterion 2.2.2
The�recruitment,�selection�and�appointment�system�ensures�that�the�skill�mix�and�competence�of�staff,�and�mix�of�volunteers,�meets�the�needs�of�the�organisation.
a)� Recruitment,�selection�and�appointment�are�undertaken�in�accordance�with�legislative�requirements,�jurisdictional�policy�/�regulations�and�organisational�policy�/�guidelines.
b)� Recruitment�processes�ensure�staff�and�volunteers�have�the�necessary�licences,�registration,�qualifications,�skills�and�experience�to�perform�their�work.
a)� The�recruitment�system�ensures�an�adequate�number�and�skill�mix�of�staff�to�provide�the�organisation’s�services.
b)� All�departments�/�units�comply�with�the�organisation’s�recruitment,�selection�and�appointment�requirements.
c)� The�volunteer�recruitment�system�supports�an�adequate�number�and�mix�of�volunteers�to�provide�applicable�services.
d)� There�is�a�system�and�program�for�the�orientation�and�integration�of�all�staff�and�volunteers.
a)� Performance�measures�are�used�to�evaluate�and�improve�recruitment,�selection�and�appointment�systems,�and�adapt�them�to�changing�service�requirements,�where�required.
b)� The�orientation�and�integration�system�is�evaluated�and�improved�on�a�regular�basis.
a)� Performance�measures�and�processes�for�recruitment,�selection,�appointment,�orientation�and�integration�are�compared�internally�and�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.
and/or
b)� Developments�in�research�inform�the�recruitment,�selection,�appointment,�orientation�and�integration�systems.
a)� The�organisation�demonstrates�it�is�a�leader�in�recruitment,�selection,�appointment,�orientation�and�integration�systems.
seCtion 5Standards, criteria, elements and guidelinesstandard 2.2:�Human�resources�management�supports�quality�health�care,�a�competent�workforce�and�a�satisfying�working�environment�for�staff
292 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 2.2.2
The�recruitment,�selection�and�appointment�system�ensures�that�the�skill�mix�and�competence�of�staff,�and�mix�of�volunteers,�meets�the�needs�of�the�organisation.�(continued)
All�employment�contracts�should�be�signed�by�both�parties�to�demonstrate�mutual�agreement.
Various�performance�measures�may�be�used�to�evaluate�and�improve�recruitment,�selection,�and�appointment�systems�within�the�organisation.�For�example,�outcomes�of�three�monthly�probationary�performance�reviews�may�provide�guidance�as�to�the�effectiveness�of�the�existing�programs.�Monitoring�departures�of�new�staff�within�the�probationary�period,�and�analysing�trends�detected�through�conducting�exit�interviews�for�all�departing�staff,�may�also�identify�system�issues.
Prompt points
¼ How does the recruitment process support the organisation to ensure the best person is recruited to a position? How is the process evaluated?
¼ Which sections of legislation and regulations inform the policies that govern recruitment, selection and appointment? How does the organisation ensure that relevant sections of legislation and regulations are met?
¼ What are the legal and other risks that may impact upon the organisation if recruitment, selection and appointment policies and procedures are not followed? How is non-compliance with policy managed?
¼ If the recruitment process is outsourced, what documentation from the external provider indicates that it meets legislative and regulatory requirements?
Service provisionRecruitment�goals�should�align�with�broader�strategic�and�operational�goals�as�identified�through�workforce�planning,�which�is�addressed�within�criterion�2.2.1.�The�recruitment�system�requires�access�to�records�of�departmental�staff,�position�titles�/�roles�and�their�position�descriptions.�
It�may�be�a�challenge�to�fill�all�positions�full�time�and�permanently.�In�situations�of�workforce�shortage,�managers�should�have�processes�that�allow�them�to�consider�alternative�approaches�to�recruitment�and�appointment,�to�adapt�to�the�challenges�of�service�provision.�Examples�of�processes�to�cover�staff�shortages�might�include�job-sharing�arrangements,�restructuring�of�team�responsibilities,�conditional�appointments,�or�short-term,�casual�appointments�linked�to�specific�projects.
Prompt points
¼ How are strategic planning, operational planning and workforce planning linked to recruiting?
¼ What recruitment responses can support departmental needs for particular skills or staff availability?
¼ How is the skill mix within the relevant team reviewed before a new position or replacement is recruited? How are future service needs considered as part of this process?
Checking credentials Pre-employment�screening�is�an�essential�risk�management�process�for�organisations,�particularly�for�recruited�senior�staff.�Screening�is�mandatory�in�some�States�/�Territories�for�certain�positions,�such�as�those�involving�working�with�children,�or�Responsible�Officer�roles�within�the�financial�services�sector.�Where�casual�staff�are�sourced�from�agencies,�it�is�important�to�confirm�that�all�agency�staff�have�themselves�been�screened�and�have�met�the�standards�of�the�contracting�healthcare�facility.�These�standards�may�be�more�specific,�or�higher,�than�the�standards�of�the�agency.
It�is�important�that�claimed�qualifications�and�experience�are�verified.�Academic�and�professional�qualifications�should�be�checked�with�the�appropriate�universities�and�colleges3,�dates�of�employment�with�payroll�departments,�and�reference�checks�sought�from�past�line�managers.�Other�checks�include�criminal�history�checks,�checks�with�professional�Boards�and�Colleges,�and�directorships�and�company�affiliations.�Large�organisations�may�subcontract�this�work.�
The�Australian�Medical�Council�(AMC)�assesses�international�medical�graduates�(IMGs)�who�wish�to�practise�specialty�medicine�in�Australia,�and�makes�recommendations�to�the�Medical�Board�of�Australia.4�Since�mid-2007,�a�national�process�has�ensured�that�all�IMGs�are�assessed�through�one�of�
October 2010 293
four�different�pathways�before�they�are�registered�to�practise�medicine�in�Australia.5�Organisations�must�ensure�that�their�overseas-trained�doctors�have�met�the�requirements�of�the�AMC�and�have�a�legitimate�Australian�registration�to�practise.
If�formal�qualifications�are�required�to�fulfil�a�position,�whether�clinical�or�non-clinical,�a�system�for�verifying�and�recording�a�copy�of�the�qualification�is�suggested.�Methods�for�verifying�skills�include�conducting�referee�checks,�skills�testing�by�peers�and�viewing�samples�of�written�work.�
Prompt points
¼ Describe the pre-employment screening process undertaken for a managerial staff member. How does the process change when the staff member will occupy a clinical role?
¼ What processes are in place to check staff who will be working with children?
Volunteer recruitmentConsiderable�planning,�management,�feedback�and�review�are�required�to�achieve�an�effective�management�program�for�volunteers.�It�is�important�that�the�volunteer�program�complements�the�work�undertaken�by�paid�staff,�and�that�there�is�no�perceived�threat�to�existing�positions.
The�organisation�needs�to�provide�a�clear�explanation�of�the�reasons�for�using�volunteers�instead�of�employing�staff�to�undertake�those�roles.�
Prompt points
¼ What organisational structures and/or processes support volunteers to perform a volunteer role to the best of their ability?
¼ What volunteer recruitment and retention strategies are in place?
¼ What new ways of using volunteers has the organisation considered?
¼ How do you monitor satisfaction of volunteers in their role?
Orientation and integrationOrientation�provides�new�staff�or�volunteers�with�a�background�to�the�organisation,�for�example�the�mission,�vision�and�values�and�introduction�to�the�organisational�culture.5�Orientation�programs�vary�greatly�between�organisations,�and�should�be�developed�to�meet�the�specific�needs�of�the�organisation�and�in�response�to�characteristics�or�the�identity�of�the�participants.�Formal�orientation�programs�involving�presentations�may�be�used�when�large�numbers�of�staff�require�an�introduction�to�an�organisation.�This�approach�is�commonly�used�for�junior�clinicians�in�large�teaching�hospitals,�although�alternative�options�are�emerging�that�utilise�improved�telecommunications.�
New�staff�should�receive�orientation�covering�the�organisation�and�key�staff�members,�and�more�specific�information�about�the�department�/�unit�in�which�the�staff�member�will�be�based.�Formal�orientation�programs�that�allocate�delivery�of�specific�content�to�a�single�person�will�reduce�the�risk�that�key�information�is�omitted.�
Volunteers�should�also�receive�orientation�to�facilitate�integration�with�the�organisation.�Effective�integration�of�volunteers�can�maximise�volunteer�contribution,�reduce�risks�to�the�organisation�and�minimise�issues�or�tension�developing�between�paid�and�volunteer�staff.6�
Staff�surveys�and�performance�reviews�provide�opportunities�to�assess�the�effectiveness�of�orientation�and�integration�processes.�Information�gained�by�individual�managers�highlighting�system�flaws�should�be�acted�on�if�local,�or�if�reflecting�broader�system�issues,�used�to�improve�the�existing�orientation�and�integration�program.
Prompt points
¼ What skills / knowledge / values are imparted to new employees during orientation and integration?
¼ How does the organisation know the orientation and integration system has helped new employees with starting to become productive on the job?
¼ How is the orientation and integration adapted for different groups of personnel, including casual and contract staff, and volunteers?
¼ How has the organisation used feedback about the orientation and integration program to continuously improve the program?
seCtion 5Standards, criteria, elements and guidelinesstandard 2.2:�Human�resources�management�supports�quality�health�care,�a�competent�workforce�and�a�satisfying�working�environment�for�staff
294 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 2.2.2
The�recruitment,�selection�and�appointment�system�ensures�that�the�skill�mix�and�competence�of�staff,�and�mix�of�volunteers,�meets�the�needs�of�the�organisation.�(continued)
Evidence commonly presented
Consider whether the following will help to address criterion 2.2.2
¼ Evaluation of recruitment and selection policies, procedures and processes
¼ Review of orientation and integration with policies and procedures
¼ Manager training / knowledge of recruitment and selection in line with organisational policies and procedures
¼ Audits of recruitment and selection records for compliance with the policy or procedure to be followed for the positions filled
¼ Audits of orientation and integration records for completion by new staff / volunteers
¼ Review of agreements with external recruitment agencies such as recruitment firms and government suppliers including any performance indicators and performance evaluation and feedback
¼ Feedback from orientation and integration sessions
October 2010 295
Performance measurementThis�criterion�states�that:�“The�recruitment,�selection�and�appointment�system�ensures�that�the�skill�mix�and�competence�of�staff,�and�mix�of�volunteers,�meets�the�needs�of�the�organisation”.�The�organisation’s�processes�for�the�recruitment,�appointment�and�orientation�of�staff�and�volunteers�should�meet�all�legislative�requirements�and�organisational�needs.
Some�common�suggested�performance�measures�are�as�follows:
Number�of�interview�selection�panels�constituted�according�to�organisational�policy
Total number of interview selection panels
Number�of�staff�on�interview�selection�panels�educated�in�recruitment�procedure�and�policy
Total number of staff on interview selection panels
Number�of�vacancies�filled�within�X�weeks�of�incumbent�vacating�position
Total number of vacancies
Comment:organisationtodefine‘X’
Number�of�new�staff�who�complete�a�departmental�orientation�session�within�1�week�of�commencement�of�employment
Total number of new staff employed
Number�of�staff�who�participated�in�an�orientation�and�integration�program�within�1�month�of�commencing�work
Total number of new staff employed
Number�of�casual�/�agency�staff�provided�with�orientation
Total number of casual / agency staff contracted
Number�of�days�where�services�are�closed�due�to�staff�shortages
Total number of days where services are closed (due to any reason)
seCtion 5Standards, criteria, elements and guidelinesstandard 2.2:�Human�resources�management�supports�quality�health�care,�a�competent�workforce�and�a�satisfying�working�environment�for�staff
296 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 2.2.2
The�recruitment,�selection�and�appointment�system�ensures�that�the�skill�mix�and�competence�of�staff,�and�mix�of�volunteers,�meets�the�needs�of�the�organisation.�(continued)
Number�of�inappropriate�staffing�levels�through�inappropriate�planning
Total number of inappropriate staffing levels
Comment:‘inappropriatestaffinglevels’and‘inappropriateplanning’tobedefinedinadvancebytheorganisation
Number�of�staff�satisfied�with�their�workload
Total number of staff surveyed
Number�of�new�employees�that�stay�for�at�least�X�months
Total number of new employees
Comment:organisationtodefine‘X’;Xshouldbegreaterthantheprobationaryperiod
Number�of�interviews�conducted
Total number of job applications received
Number�of�applicants�interviewed
Total number of vacancies
Number�of�terminations�after�short�service
Total number of terminations
Comment:organisationtodefine‘shortservice’
October 2010 297
References1.� Fair�Work�Australia�and�Fair�Work�Ombudsman.�Fairwork
online.�Canberra�ACT.�Accessed�from�http://www.fairwork.gov.au/Pages/default.aspx�on�17�March�2010.
2.� National�Health�Workforce�Taskforce�(NHWT).�Intergovernmentalagreementforanationalregistrationandaccreditationschemeforthehealthprofessions.�Canberra�ACT;�NHWT;�2008.
3.� Medical�Board�of�Queensland.�Policystatementfortheverificationofqualification.Brisbane�QLD;�Medical�Board�of�Queensland;�undated.
4.� Australian�Health�Practitioner�Regulation�Agency�(AHPRA).�Specialistregistration.�Canberra�ACT;�AHPRA.�Accessed�from�http://www.ahpra.gov.au/Registration/Registration-Process/Specialist-Registration.aspx�on�16�July�2010.
5.� Dessler�G,�Griffiths�J�and�Lloyd-Walker�B.�Humanresourcemanagement.2nd�edn.�Sydney�NSW;�Pearson�Education�Australia;�2004.
6.� National�Health�and�Medical�Research�Council�(NHMRC).�Workingwithvolunteersandmanagingvolunteerprogramsinhealthcaresettings.�Melbourne�VIC;�NHMRC;�2003.
seCtion 5Standards, criteria, elements and guidelinesstandard 2.2:�Human�resources�management�supports�quality�health�care,�a�competent�workforce�and�a�satisfying�working�environment�for�staff
298 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion LA – Awareness sA – implementationLA plus the following
MA – evaluationSA plus the following
eA – excellenceMA plus the following
oA – LeadershipEA plus the following
Criterion 2.2.3
The�continuing�employment�and�performance�development�system�ensures�the�competence�of�staff�and�volunteers.
a)� Staff�and�volunteers�are�provided�with�a�written�position�description�outlining�their�role,�responsibilities�and�accountabilities.
b)� Staff�and�volunteers�are�provided�with�appropriate�supervision�by�experienced,�trained�and�qualified�staff.
c)� Performance�of�staff,�including�contracted�staff�and�volunteers,�is�reviewed�in�accordance�with�organisation-wide�requirements.
d)� Accurate�and�complete�personnel�records,�including�training�records,�are�maintained�and�kept�confidential.
e)� The�organisation�has�policy�/�guidelines�for�the�process�of�managing�a�complaint�or�concern�about�a�clinician.
f)� The�organisation�has�policy�/�guidelines�for�the�process�of�managing�a�complaint�or�concern�about�a�member�of�staff,�including�contracted�staff�and�volunteers.
a)� There�is�a�performance�development�system�that�ensures:
� (i)� �clinical,�non-clinical�staff�and�volunteers�are�competent�and�accountable�for�their�work
� (ii)� �there�is�active�participation�of�both�the�manager�and�employee�in�performance�review
� (iii)� �areas�for�improvement�and�additional�educational�and�development�needs�are�identified.
b)� There�is�a�system�that�ensures�professional�and�other�licensed�staff�provide�verified�documentary�evidence�to�demonstrate�their�continuing�registration�with�the�relevant�regulatory�body.
c)� Staff�comply�with�published�codes�of�professional�practice,�relevant�to�their�professional�role.
d)� Position�descriptions,�including�accountabilities�and�responsibilities,�are�regularly�reviewed.
e)� There�is�a�process�for�managing�a�complaint�or�a�concern�about�a�clinician.�
f)� There�is�a�process�for�managing�a�complaint�or�concern�about�a�member�of�staff,�including�contracted�staff�and�volunteers.
a)� The�performance�development�system�is�integrated�with�any�relevant�service�plans�or�changing�service�requirements.
b)� Evaluation�is�undertaken�to�ensure�staff,�including�contracted�staff,�and�when�appropriate�volunteers,�have�participated�in�performance�review�and�development.
c)� Performance�measures�are�used�to�evaluate�and�improve�the�performance�development�system.�
d)� Staff�participate�in�evaluating�the�performance�development�system.
e)� The�process�for�managing�a�complaint�or�concern�about�a�clinician�is�evaluated,�and�improved�as�required.
f)� The�process�for�managing�a�complaint�or�concern�about�a�staff�member,�including�contracted�staff�member�or�volunteer,�is�evaluated,�and�improved�as�required.
a)� Performance�development�measures�and�processes�are�compared�internally�and�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.�
and/or
b)� The�evaluation�of�the�continuing�employment�and�performance�development�system�demonstrates�that�the�system�is�effective�in�staff�development.
a)� The�organisation�demonstrates�it�is�a�leader�in�continuing�employment�and�performance�development�systems.
October 2010 299
Criterion LA – Awareness sA – implementationLA plus the following
MA – evaluationSA plus the following
eA – excellenceMA plus the following
oA – LeadershipEA plus the following
Criterion 2.2.3
The�continuing�employment�and�performance�development�system�ensures�the�competence�of�staff�and�volunteers.
a)� Staff�and�volunteers�are�provided�with�a�written�position�description�outlining�their�role,�responsibilities�and�accountabilities.
b)� Staff�and�volunteers�are�provided�with�appropriate�supervision�by�experienced,�trained�and�qualified�staff.
c)� Performance�of�staff,�including�contracted�staff�and�volunteers,�is�reviewed�in�accordance�with�organisation-wide�requirements.
d)� Accurate�and�complete�personnel�records,�including�training�records,�are�maintained�and�kept�confidential.
e)� The�organisation�has�policy�/�guidelines�for�the�process�of�managing�a�complaint�or�concern�about�a�clinician.
f)� The�organisation�has�policy�/�guidelines�for�the�process�of�managing�a�complaint�or�concern�about�a�member�of�staff,�including�contracted�staff�and�volunteers.
a)� There�is�a�performance�development�system�that�ensures:
� (i)� �clinical,�non-clinical�staff�and�volunteers�are�competent�and�accountable�for�their�work
� (ii)� �there�is�active�participation�of�both�the�manager�and�employee�in�performance�review
� (iii)� �areas�for�improvement�and�additional�educational�and�development�needs�are�identified.
b)� There�is�a�system�that�ensures�professional�and�other�licensed�staff�provide�verified�documentary�evidence�to�demonstrate�their�continuing�registration�with�the�relevant�regulatory�body.
c)� Staff�comply�with�published�codes�of�professional�practice,�relevant�to�their�professional�role.
d)� Position�descriptions,�including�accountabilities�and�responsibilities,�are�regularly�reviewed.
e)� There�is�a�process�for�managing�a�complaint�or�a�concern�about�a�clinician.�
f)� There�is�a�process�for�managing�a�complaint�or�concern�about�a�member�of�staff,�including�contracted�staff�and�volunteers.
a)� The�performance�development�system�is�integrated�with�any�relevant�service�plans�or�changing�service�requirements.
b)� Evaluation�is�undertaken�to�ensure�staff,�including�contracted�staff,�and�when�appropriate�volunteers,�have�participated�in�performance�review�and�development.
c)� Performance�measures�are�used�to�evaluate�and�improve�the�performance�development�system.�
d)� Staff�participate�in�evaluating�the�performance�development�system.
e)� The�process�for�managing�a�complaint�or�concern�about�a�clinician�is�evaluated,�and�improved�as�required.
f)� The�process�for�managing�a�complaint�or�concern�about�a�staff�member,�including�contracted�staff�member�or�volunteer,�is�evaluated,�and�improved�as�required.
a)� Performance�development�measures�and�processes�are�compared�internally�and�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.�
and/or
b)� The�evaluation�of�the�continuing�employment�and�performance�development�system�demonstrates�that�the�system�is�effective�in�staff�development.
a)� The�organisation�demonstrates�it�is�a�leader�in�continuing�employment�and�performance�development�systems.
seCtion 5Standards, criteria, elements and guidelinesstandard 2.2:�Human�resources�management�supports�quality�health�care,�a�competent�workforce�and�a�satisfying�working�environment�for�staff
300 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 2.2.3
The�continuing�employment�and�performance�development�system�ensures�the�competence�of�staff�and�volunteers.�(continued)
IntentThe�intent�of�this�criterion�is�to�ensure�that�the�healthcare�organisation�and�the�individual�staff�member�take�equal�responsibility�for�maintaining�the�skills,�performance�and�competence�required�to�provide�quality�health�care.�
Throughout�this�criterion,�wherever�the�terms�‘staff’�and�‘staff�members’�are�not�further�clarified,�it�should�be�assumed�that�‘staff’�includes�employed�staff�and�contracted�staff,�seconded�staff�and�visiting�clinicians�while�working�within�the�organisation,�and�volunteers,�regardless�of�their�working�hours.
Relationships of 2.2.3 with other criteriaManagement�of�a�staff�member’s�performance�and�facilitating�their�ongoing�development�follows�on�from�their�appointment,�orientation�and�integration�(Criterion�2.2.1).�With�respect�to�clinicians,�this�will�further�involve�credentialling�and�delineation�of�the�scope�of�clinical�practice�(Criterion�3.1.3).
The�organisation’s�learning�and�development�system�provides�opportunities�for�employees�and�volunteers�to�develop�their�skills�and�improve�their�performance�(Criterion�2.2.4).�Effective�implementation�and�management�of�support�systems�and�workplace�relations�should�facilitate�long-term�employment�and�positive�employee�relations�(Criterion�2.2.5).
Position descriptions All�staff�should�have�a�documented,�dated�position�description,�which�is�kept�current�and�includes�specification�of�responsibilities,�accountabilities,�functions�and�activities�(including�scope�of�clinical�practice)�and�the�frequency�and�process�of�performance�appraisal.�
Position�descriptions�should�be�kept�up-to-date�to�support�high�productivity�and�to�focus�communications�between�employees�and�supervisors.�The�descriptions�should�be�dynamic�and�reflect�any�changes�in�duties�and�responsibilities�over�time.�A�joint�review�of�the�position�description�should�be�made�regularly�by�the�employee�and�the�supervisor,�and�changes�in�duties�and�responsibilities�discussed.�Updates�are�required�following�significant�changes�to�employment�structures�or�duties.�Review�of�the�position�description�could�be�undertaken�in�conjunction�with�the�performance�review,�which�is�usually�an�annual�event.
The�date�of�the�review�should�be�recorded�on�the�document.�If�there�are�changes�to�the�position�description,�the�body�responsible�for�employment�records�should�be�notified.�
Accountability�and�responsibility�are�not�the�same�thing,�although�a�single�person�may�be�both�responsible�for�something�and�as�a�result�may�be�held�accountable�for�a�failure�in�respect�of�it.�However,�multiple�people�may�be�responsible�for�the�same�thing,�so�the�person�held�‘accountable’�should�be�clearly�identified.
Preparing�position�descriptions�for�volunteers�aims�to�formalise�the�relationship�between�the�organisation�and�its�helpers.�It�will�emphasise�the�rights�and�responsibilities�of�both�parties.�Conducting�a�support�task�audit�will�highlight�the�type�and�amount�of�work�that�needs�to�be�done�to�enable�paid�staff�to�concentrate�on�core�activities.�It�is�preferable�that�paid�staff�members�play�an�active�role�in�the�volunteer�employment�process.�This�will�ensure�that�all�volunteer�work�complements�rather�than�duplicates�the�work�of�paid�staff.1�Clear�position�descriptions�may�also�focus�volunteer�recruitment�activities.
Prompt points
¼ Where does the organisation hold its centralised file of all position descriptions? Who is responsible for ensuring that all current positions have relevant position descriptions? How frequently is this process undertaken?
¼ How are roles and responsibilities of volunteers defined and managed by the organisation?
¼ How is senior management kept updated on the status of position descriptions for all personnel? What reporting mechanisms monitor the currency and coverage of position descriptions?
October 2010 301
Personnel records and training recordsPersonnel�records�should�be�accurate,�complete,�confidential�and�only�available�to�authorised�personnel�as�outlined�in�the�organisation’s�policy�and�procedures.�The�personnel�records�system�will�contain�personal�information�and�should�be�managed�in�accordance�with�the�National�Privacy�Principles�and�jurisdictional�legislation.�Access�of�employees�to�their�own�personnel�records�should�be�according�to�legal�regulations�and�organisational�policy.�Policy�and�procedures�should�protect�personnel�information�through�internal�systems�such�as:
• specifying�staff�with�limited�and�unlimited�access�to�specific�files
• restricting�physical�movement�of�staff�files�or�specifying�the�computer�terminals�through�which�information�is�accessed
• defining�the�circumstances�in�which�specified�information�may�be�disclosed.
Information�commonly�included�on�personnel�files�or�stored�in�a�Human�Resources�Information�System�includes:�
• personal�details,�employment�details,�position�description,�terms�and�conditions�of�employment,�relevant�educational�and�professional�qualifications�
• the�employment�contract�and�records�of�referee�and�other�validation�checks
• AHPRA�registration�number�(where�applicable),�and�dates�of�any�professional�registration�checks
• scope�of�practice�(where�applicable)
• designated�financial�authority
• record�of�staff�orientation
• record�of�attendance�at�fire�/�emergency�management�training
• record�of�education�and�training,�including�mandatory�training�such�as�child�protection�systems
• record�of�annual�performance�reviews
• records�of�leave
• record�of�any�compensable�injuries
• records�of�vaccinations
• disclosed�health�information,�such�as�allergies�or�carer�responsibilities
• record�of�any�formal�disciplinary�action.
The�management�system�for�personnel�records�should�abide�by�relevant�jurisdictional�legislation�and�organisational�policy�/�by-laws.�Most�jurisdictions�have�legislation�relating�to�privacy�of�the�records�and�their�retention�and�disposal.�
Prompt points
¼ What systems ensure that confidential information recorded on personnel records is restricted so that it is reviewed only under relevant circumstances by authorised staff?
¼ What processes help to ensure that personnel records are complete and regularly updated?
Professional registration and codes of professional practiceOrganisations�should�be�aware�of�the�requirements�for�registration�for�the�different�classes�of�healthcare�professionals�that�it�employs�or�who�deliver�care�from�their�premises�or�under�their�masthead.�Where�licences�/�registration�require�renewal,�there�should�be�an�alert�system�primed�to�the�expiry�date�for�all�staff�licences�to�ensure�that�where�the�organisation�does�not�administer�the�renewal�process,�renewal�details�are�confirmed.�National�registration�of�many�healthcare�professions�will�make�it�easier�to�confirm�the�registration�of�clinicians�through�an�online�database.�Information�is�available�at:�http://www.ahpra.gov.au/Registration/Registers%20of%20Practitioners.aspx�
In�addition�to�ensuring�that�clinical�staff�meet�their�obligations�for�registration,�the�organisation�should�also�monitor�whether�staff�are�meeting�their�professional�obligations�for�ongoing�professional�development�(CPD).�In�particular,�regular�updating�of�achievement�for�nurses�will�be�necessary,�as�their�scope�of�practice�may�be�expanded�following�completion�of�training�modules�and/or�advanced�skills�competency�checks.�The�review�/�updating�process,�and�particularly�any�associated�renumeration�implications,�should�be�understood�by�all�relevant�staff.
From�1�July�2010,�the�HealthPractitionerRegulationNationalLawAct2009�(Cth)�defines�registration�and�other�professional�obligations�for�the�majority�of�clinical�professions.�Under�this�Act,�specified�health�professions�and�their�titles�are�limited�to�use�by�those�registered�in�the�profession.�Professional�boards�coordinate�national�registration�under�the�umbrella�of�the�Australian�Health�Practitioner�Regulation�Agency�(AHPRA).
Under�AHPRA,�each�national�professional�board�ensures�that�registered�professionals�meet�requirements�for�professional�indemnity�insurance,�continuing�professional�development�standards,�English�language�skills,�and�requirements�in�relation�to�previous�practice�and�criminal�history.�
seCtion 5Standards, criteria, elements and guidelinesstandard 2.2:�Human�resources�management�supports�quality�health�care,�a�competent�workforce�and�a�satisfying�working�environment�for�staff
302 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 2.2.3
The�continuing�employment�and�performance�development�system�ensures�the�competence�of�staff�and�volunteers.�(continued)
The�AHPRA�national�healthcare�professional�boards�each�have�a�code�of�professional�conduct�by�which�their�members�are�expected�to�abide.�The�boards�receive�complaints�about,�and�notifications�of�health�issues�that�are�affecting,�professional�performance.�Following�a�complaint�or�notification,�the�relevant�board�reviews�the�case�and�decides�on�appropriate�action.�Clinicians�are�required�to�commit�to�fulfil�the�board’s�decision.�Any�notifications�are�recorded�beside�the�clinician’s�name�on�the�website�of�the�appropriate�boards�for�a�predetermined�period�of�time.�If�conditions�are�met�and�no�further�complaints�/�notifications�received�within�the�prescribed�time�period,�the�notification�is�subsequently�removed�from�the�public�record.
Prompt points
¼ What system is used for ensuring that all associated clinicians have maintained their registration? Would this process alert the organisation to a clinician who has received a notification from their professional board? In these cases, what, if any, action would be taken to follow up?
¼ How does the organisation use AHPRA’s registers of practitioners? Is the organisation recording AHPRA registration numbers for their practitioners to facilitate group checks?
¼ How does the organisation use the published professional codes of practice in their management of clinical staff?
Performance development and reviewThe�performance�development�system�aligns�employees’�goals,�skills,�talents,�and�performance�outcomes�with�the�organisation’s�vision,�mission,�and�goals�by�supporting�continuous�learning�and�competence�development,�by�clarifying�expectations�and�performance�standards�and�providing�feedback,�evaluation,�and�recognition�of�performance.�It�is�designed�to�promote�and�support�the�professional�development�of�the�organisation’s�employees.2
All�staff�should�be�informed�about�how�their�performance�will�be�managed�and�the�results�of�their�performance�review.�A�proper�assessment�of�the�employee’s�performance�takes�into�account�both�the�work-related�requirements�of�the�organisation�and�identified�employee�interests.�Wherever�possible,�aligning�individual�goals�with�the�goals�of�the�unit,�department�and�organisation�should�build�the�staff-employer�relationship�and�promote�staff�retention.�
Performance�review�of�all�staff�should3:�
• be�assessed�and�documented�three�months�after�initial�employment,�or�as�agreed�in�the�contract,�and�then�annually�or�according�to�the�employment�contract
• be�impartial,�transparent�and�capable�of�review�
• be�based�on�the�staff�member’s�position�description,�and�consider�any�changes�to�that�position�description
• be�in�accordance�with�organisation-wide�requirements
• identify�strengths�in�performance�
• include�the�active�participation�of�managers�and�staff
• involve�setting�performance�goals�
• follow�up�issues�from�previous�reviews.
Contracted�staff�fulfil�roles�within�an�organisation,�while�employed�by�an�intermediary�organisation.�The�roles�are�usually�casual�and/or�project-based.�Agency�nurses�are�contracted�staff.�Feedback�regarding�the�performance�of�contracted�staff�will�usually�be�made�through�their�employing�agency.�In�cases�where�performance�is�considered�inadequate,�the�organisation�/�ward�/�department�may�request�that�this�person�not�be�sent�again.�By�maintaining�a�centralised�record�system,�the�organisation�can�avoid�having�the�same�person�contracted�to�different�departments�within�the�organisation�subsequent�to�their�performance�being�considered�inadequate.�
October 2010 303
The�performance�review�for�volunteers�should�not�be�a�threatening�process.�Instead,�the�discussion�should�allow�the�goals�of�both�the�organisation�and�the�individual�to�be�clearly�understood,�facilitating�reassignment�of�tasks�or�improvements�to�internal�processes.�
Organisations�are�not�expected�to�complete�performance�reviews�on�all�volunteer�staff.�Within�a�large�volunteer�program,�records�of�participant�training�should�be�maintained.�It�would�be�considered�acceptable�for�performance�reviews�to�be�conducted�on�a�grouped�/�team�basis�or�to�follow�up�identified�performance�issues.�Methods�and�approaches�would�be�proportionate�to�the�roles�and�responsibilities�of�the�volunteers.�
Organisations�that�appoint�consumer�representatives�to�committees�should�consider�these�roles�and�their�HR�designations,�as�this�may�have�implications�for�insurance�cover,�payments�for�meals,�travel�or�parking,�training,�and�performance�review�needs.�Procedures�should�be�updated�accordingly.�
Regardless�of�whether�the�format�is�formal�or�casual,�and�the�circumstances�positive�or�strained,�exit�interviews�with�departing�staff�and�volunteers�should�be�undertaken�and�the�information�recorded�to�facilitate�further�planning�and�refinement�of�the�program.�
Prompt points
¼ How is the performance evaluation system designed so that performance reviews are conducted in an objective, constructive manner? How are the process and outcomes of performance management monitored against the organisation’s requirements?
¼ How is the performance of volunteers reviewed and reported?
¼ How does the system monitor the performance of clinicians? How does it ensure that clinicians are working within their defined scope of practice? How are clinicians supported in expanding their competencies within the organisation’s goals?
¼ What processes are used for identifying areas for performance improvement and ensuring that appropriate experience / training / education occurs?
SupervisionStaff�and�volunteers�should�be�provided�with�supervision,�management�and�professional�support.�
Clarity�regarding�supervisory�roles�and�responsibilities�will�be�required.�The�long-held�clinical�teaching�philosophy,�“see�one,�do�one,�teach�one”,�is�inadequate�to�ensure�competency�as�it�fails�to�take�into�consideration�differences�between�individual�practitioners�and�puts�consumers�/�patients�at�risk.�
Important�points�to�note�are:
• consultants�identified�as�responsible�for�clinical�care�should�understand�and�actively�participate�in�their�teaching�/�coordination�/�supervision�role.�To�achieve�accountability,�this�responsibility�must�be�clearly�documented�in�the�agreement�with�the�consultant
• orientation�of�junior�clinicians�should�extend�beyond�administrative�responsibilities�to�cover�clinical�care�responsibility�and�routes�for�accessing�assistance�when�required.
Mentoring�is�one�form�of�supervision.�In�clinical,�support�and�administrative�areas,�mentoring�programs�may�facilitate�professional�growth;�provide�information,�guidance�and�constructive�feedback;�assist�with�reviewing�decisions;�support�and�encourage;�highlight�shortfalls�in�agreed�performance;�and�should�maintain�confidentiality.
This�may�occur�through:
• informal�or�formal�support�by�a�more�experienced�person
• a�mutual�relationship�where�employees�share�experiences
• a�developmental�process�where�the�mentee�grows�in�skills,�knowledge�and�confidence
• a�strategy�to�share�intellectual�and�other�resources
• guided�learning�by�a�mentor.�
Traditionally�this�has�been�a�one-to-one�relationship,�but�group�mentoring�may�be�a�beneficial�option.4
Not�all�supervision�and�support�should�be�provided�by�a�person’s�direct�manager�/�supervisor.�Organisations�could�consider�the�use�of�peer�supervision�and�support.�Peer�supervision�can�take�a�number�of�forms�and�is�relatively�common�in�both�the�nursing�and�allied�health�professions.5
seCtion 5Standards, criteria, elements and guidelinesstandard 2.2:�Human�resources�management�supports�quality�health�care,�a�competent�workforce�and�a�satisfying�working�environment�for�staff
304 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 2.2.3
The�continuing�employment�and�performance�development�system�ensures�the�competence�of�staff�and�volunteers.�(continued)
Prompt points
¼ What processes / systems ensure that there is adequate supervision for junior clinical staff on all shifts?
¼ What processes / systems are used to ensure that senior clinical staff meet the obligations within their position descriptions for the supervision and development of junior staff?
Complaints about staffA�complaint�or�concern�about�a�clinician,�contracted�staff�member�or�volunteer�may�come�from�another�staff�member,�a�professional�group�/�team,�or�from�an�external�source.
In�reality,�there�are�many�ways�that�the�organisation�could�be�alerted�to�concerns�about�a�clinician:
• receipt�of�a�complaint�from�a�consumer�/�patient,�family�member,�or�person�external�to�the�organisation
• receipt�of�a�complaint�or�concern�raised�by�other�clinicians�or�staff�within�the�organisation
• an�external�investigation,�such�as�coronial�inquiries,�or�by�a�centralised�complaint�body,�such�as�the�health�services�ombudsman�or�similar�independent�body
• during�normal�performance�review�processes�
• during�the�investigation�of�an�incident�or�routine�case�review�processes
• during�review�of�consumer�/�patient�records�for�another�purpose
• during�routine�peer�reviews.
A�policy�and�system�should�be�in�place�to�manage�complaints�or�concerns�about�a�clinician.�This�is�an�important�component�of�improving�consumer�/�patient�safety�and�clinical�quality�within�an�organisation.�Some�organisations�may�choose�to�address�the�process�for�management�of�a�complaint�or�concern�about�a�clinician�in�their�by-laws.
Organisations�should�be�cognisant�that�HealthPractitionerRegulationNationalLawAct2009�(Cth)�obliges�those�healthcare�professionals�that�fall�under�the�auspice�of�this�law�to�notify�the�relevant�professional�board�of�impaired�behaviour�that�might�lead�to�the�public�being�placed�at�risk�of�harm�by�healthcare�professionals�(see�S.140�of�the�Act�above).6�Decisions�in�response�to�such�notifications�will�be�made�by�the�boards�of�the�relevant�professional�bodies.
Steps�for�managing�a�complaint�or�concern�about�a�clinician�include7:
• identification�of�the�complaint
• notification�to�relevant�managers�/�stakeholders
• investigation�of�the�complaint
• actions�in�response�to�the�identified�performance�issues
• reporting�the�outcomes�to�any�relevant�internal�or�external�organisations.�
Where�complaints�about�senior�staff�members�are�raised�by�staff,�management�should�also�be�conscious�of�the�potential�threat�to�a�‘whistleblower’;�action�may�be�needed�to�protect�whistleblowers�from�intimidation�or�to�counter-suggestions�of�incompetence.8,�9
Bullying�and�harassment�are�an�ongoing�issue�in�many�areas�of�health�care.�Some�national�professional�bodies,�including�the�Royal�Australasian�College�of�Surgeons10�and�the�Australian�Medical�Association11,�have�prepared�public�papers�on�respectful�behaviour�and�management�of�bullying�and�harassment.�Where�the�allegation�is�of�criminal�misconduct,�the�organisation�has�an�obligation�to�notify�police�and/or�other�relevant�bodies�such�as�Commissions�against�Corruption.�Complaints�regarding�registered�health�practitioners�should�be�referred�to�the�relevant�professional�board.
October 2010 305
Prompt points
¼ How does the organisation’s system / process for managing a complaint about a clinician meet legislated requirements? How does this compare to the processes used to manage complaints about a non-clinical staff member? A volunteer? Subcontracted staff?
¼ Is protection for staff who submit a complaint (a ‘whistleblower’) State / Territory legislated, or covered by organisational policy? How does the complaint investigation process protect a complainant during the period of the investigation?
Evidence commonly presented
Consider whether the following will help to address criterion 2.2.3
¼ Education records
¼ Index / file of position descriptions
¼ Records of regular performance reviews
¼ Records of training provided
¼ Checks of clinicians’ registration – against the professional register or through filed copies of the registration papers
¼ Performance management policies, guidelines, templates
Performance measurementThis�criterion�states�that:�“The�continuing�employment�and�performance�development�system�ensures�the�competence�of�staff�and�volunteers”.�The�organisation�should�be�able�to�demonstrate�its�commitment�to�the�support�and�development�of�its�staff�via�policies�and�processes�governing�training,�education,�supervision,�performance�reviews�and�complaints�handling.
Some�common�suggested�performance�measures�are�as�follows:
Number�of�appointments�made�to�internal�candidates
Total number of appointments made
Comment:numbermaybeatotalcountorcalculatedbasedonfull-timeequivalents(FTEs)
Number�of�permanent�staff�with�current�position�descriptions�
Total number of permanent staff
Comment:numbermaybeatotalcountorcalculatedbasedonfull-timeequivalents(FTEs)
Number�of�identified�staff�who�successfully�complete�relevant�work�competencies�
Total number of identified staff required to complete work competencies
Comment:e.g.bloodmanagement,firetraining,manualhandling/task
Number�of�staff�who�participate�in�performance�reviews
Total number of staff
seCtion 5Standards, criteria, elements and guidelinesstandard 2.2:�Human�resources�management�supports�quality�health�care,�a�competent�workforce�and�a�satisfying�working�environment�for�staff
306 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 2.2.3
The�continuing�employment�and�performance�development�system�ensures�the�competence�of�staff�and�volunteers.�(continued)
Number�of�staff�with�development�needs�identified�at�appraisals,�whose�needs�have�been�met�
Total number of staff with development needs identified at appraisals
Comment:followupatnextperformancereview
Number�of�complaints�received�about�staff�members
Total number of staff
Number�of�harassment�complaints�received
Total number of staff
Number�of�discrimination�complaints�received
Total number of staff
October 2010 307
References1.� Australian�Institute�for�Community�Practice�and�Governance�
(AICPG).�Designingpositiondescriptionsforvolunteers.�Melbourne�VIC;�AICPG.�Accessed�from�http://www.ourcommunity.com.au/management/view_help_sheet.do?articleid=83�on�13�April�2010.
2.� De�Cieri�H,�Kramer�R,�Noe�R�etal.HumanresourcemanagementinAustralia:strategy–people–performance.Sydney�NSW;�McGraw�Hill;�2003.
3.� University�of�Denver.�Performancereviewanddevelopmentsystem.�Denver�USA;�Denver�University.�Accessed�from�http://www.du.edu/hr/employment/performance_management.html�on�31�August�2010.
4.� McIntyre�E�and�Mills�J.�Mentoring�matters.�Adelaide�SA;�Primary�Health�Care�Research�&�Information�Service�(PHC�RIS);�2009.
5.� NSW�Health.�Guideline:Clinician’stoolkitforimprovingpatientcare.�Sydney;�NSW�Health;�2005.
6.� AHPRA�Medical�Board�of�Australia.�Consultationpaperoncodesandguidelinescomprisingguidelinesonadvertisingandguidelinesonmandatorynotification.Melbourne�VIC;�Medical�Board�of�Australia;�2010.
7.� Hunter�New�England�Area�Health�Service�(HNEAHS).�Managingaconcernorcomplaintaboutaclinician.Newcastle;�NSW�Health.�Accessed�from�http://www.hnehealth.nsw.gov.au/cg2/professional_practice/concern_or_complaint_about_a_clinician�on�13�April�2010.
8.� Faunce�TA�and�Bolsin�SN.�Three�Australian�whistleblowing�sagas:�lessons�for�internal�and�external�regulation.�MedJAust�2004;�181(1):�44-47.
9.� Johnstone�M-J.�Patient�safety,�ethics�and�whistleblowing:�a�nursing�response�to�the�events�at�the�Campbelltown�and�Camden�hospitals.�AustHealthRev2004;�28(1):�13-19.
10.� Royal�Australasian�College�of�Surgeons�(RACS).�Bullyingandharassment–recognition,avoidanceandmanagement.�Melbourne�VIC;�RACS;�not�dated.
11.� Australian�Medical�Association�(AMA).�Workplacebullyingandharassment–AMApositionstatement.Canberra�ACT;�AMA;�2009.
seCtion 5Standards, criteria, elements and guidelinesstandard 2.2:�Human�resources�management�supports�quality�health�care,�a�competent�workforce�and�a�satisfying�working�environment�for�staff
308 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
IntentThe�intent�of�this�criterion�is�to�ensure�that�the�organisation’s�learning�and�development�system�for�its�staff�and�volunteers�is�structured,�planned�and�comprehensive.�
Relationships of 2.2.4 with other criteriaLearning�and�development�is�an�important�aspect�of�the�creation�of�a�competent�workforce�that�performs�within�a�satisfying�working�environment�(Standard�2.2).�Some�aspects�of�learning�and�development�will�be�voluntary,�while�others�will�be�mandated�by�legislation�or�policy,�for�example,�fire�and�disaster�safety�training�(Criterion�3.2.4)�and�health�records�management�(Criterion�2.3.1).�For�clinical�staff,�learning�and�development�can�facilitate�credentialling�and�expanding�the�scope�of�clinical�practice�(Criterion�3.1.3).�It�is�also�vital�for�those�clinicians�who�recruit�consumers�/�patients�for�research�projects,�and�associated�staff�involved�in�such�projects�(Criterion�2.5.1).�
Criterion LA – Awareness sA – implementationLA plus the following
MA – evaluationSA plus the following
eA – excellenceMA plus the following
oA – LeadershipEA plus the following
Criterion 2.2.4
The�learning�and�development�system�ensures�the�skill�and�competence�of�staff�and�volunteers.
a)� The�organisation�provides�training�in�accordance�with�legislative�and�policy�requirements.�
b)� Staff�and�volunteers�are�consulted�about�their�learning�and�development�needs.
a)� There�is�a�planned�and�documented�staff�development�program.
b)� There�is�an�evidence-based�learning�and�development�system�available�to�staff�and�volunteers�that:
� (i)� �identifies�both�the�needs�of�the�organisation�and�the�staff
� (ii)� �is�linked�to�the�performance�development�system
� (iii)� �ensures�staff�remain�competent�to�perform�their�work.
c)� There�is�a�process�to�identify�mandatory�training�for�staff�and�volunteers.
d)� The�organisation�provides�adequate�resources�for�learning�and�development.�
e)� Staff�contribute�to�the�teaching�and�supervision�of�students�when�relevant.
a)� Performance�measures�are�used�to�evaluate�learning�and�development�systems,�and�the�systems�are�improved�as�required.�
b)� The�student�teaching�and�supervision�program�is�evaluated,�and�improved�as�required.
a)� Performance�measures�for�learning�and�development�are�used,�compared�internally�and�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.
and/or
b)� The�student�teaching�and�supervision�program�is�compared�with�external�programs,�and�improvements�are�made�to�ensure�better�practice.
and/or
c)� There�are�innovative�practices�for�learning�and�development.
a)� The�organisation�demonstrates�it�is�a�leader�in�learning�and�development�systems.
October 2010 309
Staff learning and development system The�learning�and�development�system�identifies�the�development�and�education�needs�of�the�organisation�and�individual�staff.1�
Depending�upon�on�the�organisation’s�specific�circumstances�and�needs,�the�learning�and�development�system�may�oversee:
• mandatory�training�that�responds�to�legislated�requirements�–�for�example,�fire�and�emergency�management,�OH&S,�health�records�management
• training�in�organisational�systems,�programs,�equipment�and�administrative�/�governance�structures�at�an�organisation-wide�or�departmental�level�
• training�in�response�to�identified�performance�gaps�–�for�instance,�based�on�review�and�benchmarking�of�performance�indicators,�a�series�of�complaints,�findings�of�an�investigation�of�a�consumer�/�patient�or�staff�safety�incident,�or�in�response�to�ACHS�survey�recommendations
• continuing�professional�development�–�to�advance�clinical�knowledge�and�to�meet�individuals’�mandated�requirements�for�ongoing�professional�registration
• personal�mentoring�coordinated�within�the�organisation’s�planning�(mentors�may�be�sourced�from�within�or�outside�the�organisation;�some�professional�organisations,�such�as�the�Australasian�Council�of�Health�Service�Management�(ACHSM)2,�facilitate�mentoring)
• advanced�skills�accreditation�for�relevant�professionals
• broadly�relevant�training�in�people�skills,�counselling,�teamwork,�communication,�management�and/or�continuous�quality�improvement.
Criterion LA – Awareness sA – implementationLA plus the following
MA – evaluationSA plus the following
eA – excellenceMA plus the following
oA – LeadershipEA plus the following
Criterion 2.2.4
The�learning�and�development�system�ensures�the�skill�and�competence�of�staff�and�volunteers.
a)� The�organisation�provides�training�in�accordance�with�legislative�and�policy�requirements.�
b)� Staff�and�volunteers�are�consulted�about�their�learning�and�development�needs.
a)� There�is�a�planned�and�documented�staff�development�program.
b)� There�is�an�evidence-based�learning�and�development�system�available�to�staff�and�volunteers�that:
� (i)� �identifies�both�the�needs�of�the�organisation�and�the�staff
� (ii)� �is�linked�to�the�performance�development�system
� (iii)� �ensures�staff�remain�competent�to�perform�their�work.
c)� There�is�a�process�to�identify�mandatory�training�for�staff�and�volunteers.
d)� The�organisation�provides�adequate�resources�for�learning�and�development.�
e)� Staff�contribute�to�the�teaching�and�supervision�of�students�when�relevant.
a)� Performance�measures�are�used�to�evaluate�learning�and�development�systems,�and�the�systems�are�improved�as�required.�
b)� The�student�teaching�and�supervision�program�is�evaluated,�and�improved�as�required.
a)� Performance�measures�for�learning�and�development�are�used,�compared�internally�and�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.
and/or
b)� The�student�teaching�and�supervision�program�is�compared�with�external�programs,�and�improvements�are�made�to�ensure�better�practice.
and/or
c)� There�are�innovative�practices�for�learning�and�development.
a)� The�organisation�demonstrates�it�is�a�leader�in�learning�and�development�systems.
seCtion 5Standards, criteria, elements and guidelinesstandard 2.2:�Human�resources�management�supports�quality�health�care,�a�competent�workforce�and�a�satisfying�working�environment�for�staff
310 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 2.2.4
The�learning�and�development�system�ensures�the�skill�and�competence�of�staff�and�volunteers.�(continued)
Planning�should�define�the�objectives�of�learning�before�determining�the�mode�for�delivery�of�education,�and�should�evaluate�the�effectiveness�and�cost-benefit�of�any�program�against�these�pre-identified�goals.
Documents�that�demonstrate�organisational�planning�for�the�learning�and�development�program�may�include:
• training�/�learning�needs�analysis�reports�or�submissions
• an�annual�learning�and�development�plan�that�refers�to�the�organisation’s�strategic�and�operational�plans,�and/or�reflects�feedback�received�through�questionnaires,�focus�groups�or�staff�performance�reviews
• tenders�or�requests�for�quote�that�specify�learning�objectives
• training�program�proposals�that�reflect�identified�and�communicated�learning�objectives.
Evidence�that�the�learning�program�reflects�the�needs�of�the�organisation�may�include:
• matching�of�staff�development�/�learning�program�goals�to�organisation�goals�or�expanded�service�plans
• identification�of�the�organisation’s�mandatory�training�components�and�evidence�that�staff�attend�applicable�mandatory�training�sessions,�for�example,�fire�training,�infection�control,�risk�management,�CPR,�OH&S
• continuing�education�programs�(internal�and�external)�relevant�to�expanding,�changing�or�specialty�areas�of�service�provision,�or�to�the�specific�populations�that�it�services�(e.g.�age�groups,�categories�of�disability�or�cultures)
Evidence�that�the�learning�program�reflects�the�needs�of�staff�may�be�demonstrated�through:
• links�to�the�performance�development�system
• links�to�a�staff�survey
• attainment�of�competency�ratings,�advanced�skills�accreditation�or�expanded�scopes�of�practice�that�meet�goals�expressed�during�performance�review
• surveys�/�feedback�from�staff�attending�organisation-funded�training.
In�the�case�of�volunteers,�depending�upon�the�size�and�scope�of�the�program,�formal�training�may�not�be�cost-effective.�However,�a�process�of�orientation,�in-house�training�and�regular�revision�of�competencies�could�be�followed.�
A�policy�on�training�and�development�for�volunteers�may�include3:
• the�objectives�for�volunteer�training�and�development
• an�outline�of�training�programs�available�or�learning�goals
• the�appraisal�of�volunteer�performance�
• provision�of�feedback�/�acknowledgement�to�volunteers.
Topics�that�may�be�valuable�to�volunteers�include�an�organisational�overview�describing�areas�of�current�volunteer�involvement,�volunteer�responsibilities�and�expectations.�Information�on�infection�control,�confidentiality�guidelines,�and�information�to�assist�interactions�with�vulnerable�people�or�multicultural�groups�may�also�be�useful.�Attendance�at�training�sessions�should�be�documented�in�the�volunteer’s�record.
Prompt points
¼ How is the education and training component of the organisation’s staff development plan linked back to other organisational plans?
¼ What records are kept of staff development? How are these used for reporting to management on an organisation-wide or departmental basis, and for documenting individual compliance with mandatory training?
¼ Who is responsible for learning and development at the organisation? How does the organisation monitor whether its clinical training is evidence-based?
Mandatory training Mandatory�training�requirements�differ�between�jurisdictions,�however�across�many�jurisdictions�mandatory�training�relates�to�emergency�and�disaster�management,�occupational�health�and�safety,�health�records�management�and�privacy.�Additional�training�/�certification�may�be�required�for�staff�working�with�dangerous�goods,�radiation,�children,�food�and�in�other�specific�areas.
October 2010 311
Organisations�should�be�aware�of�the�specific�legislative�requirements�for�their�jurisdiction,�and�may�demonstrate�compliance�through�evidence�that:�
• approved�training�programs�were�provided�by�appropriately�qualified�trainers�
• training�was�attended�by�sufficient�numbers�of�relevant�staff�to�manage�risks�to�the�organisation�and�to�its�consumers�/�patients�(for�instance,�that�night�duty�staff�and�visiting�medical�staff�could�access�and�attend�emergency�training)
• records�of�attendance�have�been�included�in�/�linked�to�the�performance�records�of�individual�staff.
Training�may�also�be�mandated�for�specific�staff�by�the�employing�organisation,�a�department�of�health,�local�council,�ownership�body�or�public�service�authority.�Such�training�will�usually�be�documented�in�policy.�Similar�attention�to�record�keeping�will�be�expected�so�that�organisations�can�monitor�and�ensure�attendance�by�relevant�staff.
Prompt points
¼ What proportion of staff has attended mandatory training in handling an emergency such as a fire? What records are used to track attendance?
¼ What other training is mandatory in the organisation’s jurisdiction?
Determining learning and development needs Annual�performance�review�provides�an�opportunity�for�managers�to�determine�the�career�goals�of�their�staff�and�to�suggest�specific�training�/�education�to�address�identified�areas�for�development�and�improvement.�Review�meeting�notes�should�record�the�agreed�goals�for�personal�learning�and�development.�Team�meetings�or�feedback�forms�may�also�be�used�to�gain�information�on�staff�and�volunteer�learning�and�development�needs.
It�is�rarely�possible�to�align�organisational�/�departmental�goals�with�the�training�goals�and�ambitions�of�all�staff.�However,�managers�should�objectively�consider�personal�goals�alongside�team�dynamics,�personal�strengths�and�aptitudes,�budgets,�staffing�schedules,�and�proposed�changes�to�departmental�services,�when�assigning�staff�to�training�programs.�
Prompt points
¼ How satisfied are staff members with the accessibility and quality of learning and development?
¼ How are peers, managers and/or supervisors involved in applying learning to the workplace?
Evaluating and improving learning and development systemsTo�effectively�evaluate�a�program,�it�is�important�that�there�are�clear�organisational�goals�for�commissioning�a�training�course�or�for�sending�staff�members�to�attend�one.�Even�though�time�may�have�passed�since�the�original�decision�regarding�training�was�made,�the�evaluation�should�be�against�the�original�goals�that�guided�the�decision�or�the�brief�given�to�trainers.�
Evaluation�forms�will�usually�be�completed�following�a�training�session.�Feedback�provides�a�useful�guide�for�refining�future�training�programs.�In�addition�to�collating�feedback�from�onsite�programs�commissioned�by�the�organisation,�feedback�from�staff�attending�programs�off-site�may�be�used�to�evaluate�their�relevance�and�cost-effectiveness.�Post-training�testing�or�follow-up�reviews�provide�useful�feedback�on�the�effectiveness�of�learning�and�development�programs.�
Staff�surveys�offer�a�valuable�opportunity�to�determine�whether�the�learning�and�development�program�responds�to�those�needs�previously�identified�by�staff�and�whether�staff�believe�their�training�has�relevance�to�changing�workplace�needs.
In�addition,�indicators�may�be�collected�to�monitor�overall�compliance�with�legislated�training�requirements�(i.e.�proportion�of�staff�attending�specific�mandatory�training�within�designated�time�periods).�From�a�risk�management�perspective,�the�importance�of�mandatory�training�is�reflected�in�organisational�culture.�
Prompt points
¼ What does the organisation do with feedback from training programs?
seCtion 5Standards, criteria, elements and guidelinesstandard 2.2:�Human�resources�management�supports�quality�health�care,�a�competent�workforce�and�a�satisfying�working�environment�for�staff
312 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 2.2.4
The�learning�and�development�system�ensures�the�skill�and�competence�of�staff�and�volunteers.�(continued)
Teaching and supervision of students Consumer�/�patient�safety�is�dependent�on�adequate�supervision�of�students�and�newly�graduated�clinicians.�In�the�context�of�this�criterion,�any�reference�to�‘students’�includes�interns�and�registrars,�as�well�as�experienced�staff�who�are�still�learning.�
There�are�large�variations�in�competencies�among�new�graduates,�due�to�their�natural�abilities�and�variations�between�different�universities.4�Since�2010,�national�competency�frameworks�have�been�developed�for�each�nationally�registered�profession5,�aiming�to�provide�more�solid�measures�against�which�healthcare�organisations�can�consider�their�programs�for�student�training.�
Some�State�/�Territory�health�departments�have�procedures6,�7,�8�and�offer�or�support�education�programs9,�10�or�guidelines11�to�develop�the�teaching�and�supervision�skills�of�their�staff.�
The�Australian�Medical�Association�undertakes�an�annual�survey�of�junior�doctor�training,�education�and�supervision,�which�is�available�from�their�website,�at�http://ama.com.au.�The�national�feedback�on�teaching�and�supervision�in�the�nation’s�public�teaching�hospitals�provides�a�useful�foundation�for�review�of�training�issues�in�a�teaching�organisation.�
Organisations�must�plan�their�approach�to�the�management�of�junior�clinical�staff�and�students�working�on�their�premises�so�that:
• impositions�on�consumers�/�patients�are�controlled�
• students�have�opportunities�to�gain�essential�skills�
• risks�of�error�are�minimised
• wherever�possible,�supervisory�staff�can�also�gain�from�the�experience.�
These�objectives�create�conflicting�demands�which�will�only�be�resolved�by�monitoring�indicators�of�performance,�and�responding�to�feedback�from�both�supervisors�and�those�who�are�supervised.
Prompt points
¼ How is supervision of students / junior staff encouraged and improved?
¼ What actions have been taken to manage any risks associated with care provided by junior clinicians / students?
¼ How does the organisation evaluate its teaching programs for students?
Resources for learning and developmentLearning�and�development�options�will�depend�on�resources;�these�are�likely�to�be�financial,�but�may�also�be�related�to�staffing,�equipment�and�physical�access.�
For�most�onsite,�face-to-face�training,�cost-effectiveness�will�be�greatest�when�all�available�positions�in�a�training�session�can�be�filled.�
Developing�a�learning�and�development�budget�will�assist�in�determining�whether�proposed�training�plans�can�be�supported.�It�is�important�to�consider�both�direct�and�indirect�costs�in�a�training�budget.�Direct�education�costs�are�the�easily�identified,�concrete�costs�for�the�program�–�fees�for�attendance,�the�providers’�fees�and�salaries�of�training�coordinators.�Indirect�costs�of�learning�and�development�include�participants’�wages,�the�cost�of�covering�the�workload�of�absent�staff�and�administration�associated�with�training.
Where�budgets�are�limited,�research�may�identify�alternatives�to�traditional�learning�structures.�Consider�the�scope�for�on-the-job�coaching�and�mentoring,�extra-curricular�positions,�360�degree�feedback,�self-directed�study,�video�presentations,�teleconferencing,�job�shadowing,�group�training,�higher�duties�assignments�or�secondments,�special�projects,�training�one�person�to�teach�other�staff,�internal�and�external�networking,�buddy�systems,�professional�reading�and�e-learning.
Mandatory�training�is�an�unavoidable�investment.�Where�there�is�potential�for�disagreements�regarding�the�allocation�of�learning�and�development�resources,�there�should�be�a�guiding�document�against�which�planning�decisions�are�made.�This�is�likely�to�be�the�operational�plan�or�the�workforce�development�plan.
October 2010 313
Where�it�impacts�performance�in�key�areas,�training�can�have�immediate�benefits.�In�other�areas,�the�investment�may�be�less�tangible�and�more�difficult�to�measure.�As�a�result,�learning�and�development�may�be�seen�as�an�‘easy�target’�for�cost-cutting.�When�justifying�the�allocation�of�‘adequate’�resources�to�learning�and�development,�it�may�be�helpful�to�present�the�benefits�of�training�/�education12�in�a�financially�driven�context,�such�as:
• safer�practices�that�can�reduce�insurance�premiums
• increased�productivity,�which�can�improve�consumer�/�patient�throughput
• reduced�maintenance�and�repair�costs
• greater�commitment�from�staff
• improved�staff�retention
• less�lost�time�or�other�wastage.
Prompt points
¼ How is learning and development resourced to meet both the short- and long-term goals of the organisation?
¼ What recognition and resourcing for learning and development is there by management?
Evidence commonly presented
Consider whether the following will help to address criterion 2.2.4
¼ Learning and development plan / staff development plan
¼ Ongoing education programs / training linked to assessment
¼ Identified mandatory training schedule, attendance register and follow-up of non-attendees
¼ Links to the education program from identification of training needs in performance appraisal system
¼ Assessment / evaluation of learning and development needs – satisfaction of staff
¼ Conference attendance support
¼ Access to journals and reference material
seCtion 5Standards, criteria, elements and guidelinesstandard 2.2:�Human�resources�management�supports�quality�health�care,�a�competent�workforce�and�a�satisfying�working�environment�for�staff
314 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 2.2.4
The�learning�and�development�system�ensures�the�skill�and�competence�of�staff�and�volunteers.�(continued)
Performance measurementThis�criterion�states�that:�“The�learning�and�development�system�ensures�the�skill�and�competence�of�staff�and�volunteers”.�The�organisation�should�be�able�to�demonstrate�that�it�meets�its�requirements�with�respect�to�mandatory�training�/�education,�and�also�facilitates�the�voluntary�learning�and�development�of�its�staff.�
Some�common�suggested�performance�measures�are�as�follows:
Number�of�staff�who�have�completed�all�appropriate�mandatory�training�sessions�
Total number of staff required to complete mandatory training
Number�of�mandatory�training�programs�reviewed�within�the�past�two�years�to�meet�changing�needs
Total number of mandatory training programs
Comment:thismeasurecouldbeseparatelyextendedtonon-mandatorytrainingprograms,butinthatcontext,itwouldmeasurelevelofinterestandaccessratherthancompliance
Number�of�staff�who�request�to�attend�an�external�training�session�and�who�attend
Total number of staff who request to attend an external training session
Number�of�staff�participating�in�internal�training�sessions
Total number of staff invited to attend internal training sessions
Number�of�internal�training�sessions�that�satisfy�staff�needs
Total number of internal training sessions held
October 2010 315
References1.� Gephart�MA,�Marsick�VJ,�Van�Buren�ME�and�Spiro�
MS.�Learning�organizations�come�alive.�TrainingandDevelopment1996;�50:�34-45.
2.� Australasian�College�of�Health�Service�Management.�Mentoring.�Sydney�NSW;�ACHSE.�Accessed�from�http://www.achsm.org.au/members-services/mentoring/�on�10�August�2010.
3.� National�Health�and�Medical�Research�Council�(NHMRC).�Workingwithvolunteersandmanagingvolunteerprogramsinhealthcaresettings.Melbourne�VIC;�NHMRC;�2003.
4.� Productivity�Commission.Australia’shealthworkforce.Canberra�ACT;�Productivity�Commission;�2006.
5.� Australian�Health�Practitioner�Regulation�Agency�(AHPRA).�Approvedprogramsofstudy.Canberra�ACT;�AHPRA.�Accessed�from�http://www.ahpra.gov.au/en/Education/Approved-Programs-of-Study.aspx�on�10�August�2010.
6.� Victoria’s�Mental�Health�Services.�Clinicalsupervisionguidelines.Melbourne;�Victorian�Dept�of�Health;�2005.
7.� NSW�Health.�Drugandalcoholclinicalsupervisionguidelines.�Sydney;�NSW�Health;�2006.
8.� WA�Mental�Health�Commission.ClinicalsupervisionframeworkforWAmentalhealthservicesandclinicians.�Perth;�WA�Department�of�Health;�2005.
9.� WA�Department�of�Health.�Culturallysecureapproachtoclinicalsupervision.�Perth;�WA�Health.�Accessed�from�http://www.healthinfonet.ecu.edu.au/health-resources/conferences?cid=575�on�9�August�2010.
10.� University�of�Western�Australia,�Faculty�of�Medicine,�Dentistry�and�Health�Sciences.�Teachingontherun.Perth�WA;�University�of�Western�Australia.�Accessed�from�http://www.meddent.uwa.edu.au/teaching/on-the-run�on�9�August�2010.
11.� Postgraduate�Medical�Council�of�Western�Australia�(PMCWA).�WesternAustralianjuniordoctorcurriculum–guidelinesforteachingandlearning:postgraduateyears1and2.Perth�WA;�PMCWA;�2006.
12.� Qld�Dept�of�Education�and�Training.Benefitsoftraining.Brisbane;�Queensland�Government.�Accessed�from�http://www.training.qld.gov.au/employers/training-staff/benefits.html�on�18�May�2010.
seCtion 5Standards, criteria, elements and guidelinesstandard 2.2:�Human�resources�management�supports�quality�health�care,�a�competent�workforce�and�a�satisfying�working�environment�for�staff
316 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
IntentEmployee�support�systems�and�workplace�relations�are�a�vital�aspect�of�the�organisation’s�human�resources�management.�The�intent�of�this�criterion�is�to�promote�a�structured,�planned�and�comprehensive�system�for�managing�workplace�relations,�and�to�ensure�that�there�is�an�effective�employee�assistance�system�that�is�tailored�to�specific�staff�requirements�and�permits�the�development�of�a�network�of�support�for�staff�within�the�organisation.
Relationships of 2.2.5 with other criteriaThe�provision�of�employee�support�systems�and�the�facilitation�of�workplace�relations�is�a�vital�component�of�the�organisation’s�management�of�human�resources�(Standard�2.2)�and�will�support�the�organisation’s�staff�recruitment�and�appointment�(Criterion�2.2.2),�performance�development�(Criterion�2.2.3),�and�learning�and�professional�development�(Criterion�(2.2.4).�A�secure,�motivated�workforce�is�essential�for�the�provision�of�quality,�safe�care�and�services�(Criterion�3.1.1).�The�organisation’s�management�of�its�workforce�is�an�aspect�of�its�integrated�risk�management�framework�(Criterion�2.1.2),�and�failure�to�implement�proper�support�systems�and�workplace�relations�may�lead�to�incidents�(Criterion�2.1.3)�and�complaints�(Criterion�2.1.4).
Criterion LA – Awareness sA – implementationLA plus the following
MA – evaluationSA plus the following
eA – excellenceMA plus the following
oA – LeadershipEA plus the following
Criterion 2.2.5
Employee�support�systems�and�workplace�relations�assist�the�organisation�to�achieve�its�goals.
a)� The�workplace�rights�and�responsibilities�of�management�and�staff�are�clearly�defined,�communicated�and�respected.
b)� Staff�are�consulted�about�industrial�relations�and�support�services�in�their�workplace.
c)� Managers�have�the�skills�to�identify�‘at�risk’�staff�behaviour.�
d)� Staff�know�how�to�access�employee�support�services.
e)� Management�and�staff�have�access�to�information�about�grievance�processes.�
a)� Management�and�staff�work�cooperatively�to�achieve�effective�workplace�relations.
b)� The�organisation�supports�flexible�work�practices�to�sustain�work-life�balance.
c)� There�is�a�system�that�motivates�staff�and�identifies�the�value�of�staff�through�appropriate�acknowledgement.
d)� Managers�facilitate�staff�access�to�industrial�relations�and�employee�support�services.
e)� An�employee�assistance�program�is�implemented.
f)� There�is�a�consultative�and�transparent�system�to�identify,�manage�and�resolve�workplace�relations�issues.
g)� Workplace�relations�are�coordinated�with�relevant�external�groups.
a)� Performance�measures�are�used�on�a�regular�basis�to�evaluate�workplace�relations,�and�improvements�are�made�as�required.
b)� Performance�measures�are�used�on�a�regular�basis�to�evaluate�staff�support�services,�and�improvements�are�made�as�required.
a)� Performance�measures�for�workplace�relations�are�measured,�compared�internally�and�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.
and/or
b)� Performance�measures�for�staff�support�services�are�compared�internally�and�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.
a)� The�organisation�demonstrates�it�is�a�leader�in�employee�support�systems�and�workplace�relations.
October 2010 317
Staff support and assistance servicesOrganisational�employee�support�services�should�enhance�a�productive,�flexible�workplace.�The�services�provided�may�be�available�onsite�or�sourced�through�a�collaborative�agreement�with�another�provider,�who�may�have�an�office�onsite�or�at�another�location.�The�key�point�is�that�the�organisation�works�to�ensure�that�staff�are�aware�of�the�services�available�and�know�how�to�access�them.�
An�employee�assistance�program�(EAP)�is�a�proven�strategy�for�assisting�employees�and�their�families�with�personal�and�work-related�problems,�difficulties�and�concerns�that�they�may�experience�from�time�to�time,�and�which�affect�the�work�performance�of�an�employee.�
An�employee�assistance�program�may�include:
• mechanisms�for�early�intervention�to�enable�staff�to�seek�assistance�and�support
• encouragement�of�staff�to�recognise�and�seek�assistance�with�personal�problems�before�they�escalate
• an�effective�human�resources�and�OH&S�framework�that�promotes�workplace�health,�preventative�services�and�the�wellbeing�of�staff
• childcare�information�and�referral�services�
• elder�care�information�and�referral�services�
• support�groups�for�employees�with�family�issues
• counselling�services�
• recognition�and�reward�programs
• caring�for�those�with�work-�and�non-work�related�injuries.
Work-related�issues�where�the�EAP�may�provide�useful�support�include�internal�conflict�situations�and�stress�management�following�a�trauma�crisis�or�another�significant�incident.�The�EAP�provider�may�suggest�that�an�employee�seek�other�specific�professional�assistance,�such�as�from�a�medical�or�legal�practitioner.�Some�EAPs�extend�service�provision�to�immediate�family�members.
Criterion LA – Awareness sA – implementationLA plus the following
MA – evaluationSA plus the following
eA – excellenceMA plus the following
oA – LeadershipEA plus the following
Criterion 2.2.5
Employee�support�systems�and�workplace�relations�assist�the�organisation�to�achieve�its�goals.
a)� The�workplace�rights�and�responsibilities�of�management�and�staff�are�clearly�defined,�communicated�and�respected.
b)� Staff�are�consulted�about�industrial�relations�and�support�services�in�their�workplace.
c)� Managers�have�the�skills�to�identify�‘at�risk’�staff�behaviour.�
d)� Staff�know�how�to�access�employee�support�services.
e)� Management�and�staff�have�access�to�information�about�grievance�processes.�
a)� Management�and�staff�work�cooperatively�to�achieve�effective�workplace�relations.
b)� The�organisation�supports�flexible�work�practices�to�sustain�work-life�balance.
c)� There�is�a�system�that�motivates�staff�and�identifies�the�value�of�staff�through�appropriate�acknowledgement.
d)� Managers�facilitate�staff�access�to�industrial�relations�and�employee�support�services.
e)� An�employee�assistance�program�is�implemented.
f)� There�is�a�consultative�and�transparent�system�to�identify,�manage�and�resolve�workplace�relations�issues.
g)� Workplace�relations�are�coordinated�with�relevant�external�groups.
a)� Performance�measures�are�used�on�a�regular�basis�to�evaluate�workplace�relations,�and�improvements�are�made�as�required.
b)� Performance�measures�are�used�on�a�regular�basis�to�evaluate�staff�support�services,�and�improvements�are�made�as�required.
a)� Performance�measures�for�workplace�relations�are�measured,�compared�internally�and�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.
and/or
b)� Performance�measures�for�staff�support�services�are�compared�internally�and�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.
a)� The�organisation�demonstrates�it�is�a�leader�in�employee�support�systems�and�workplace�relations.
seCtion 5Standards, criteria, elements and guidelinesstandard 2.2:�Human�resources�management�supports�quality�health�care,�a�competent�workforce�and�a�satisfying�working�environment�for�staff
318 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 2.2.5
Employee�support�systems�and�workplace�relations�assist�the�organisation�to�achieve�its�goals.�(continued)
Employee�assistance�program�services�are�often�outsourced,�which�may�provide�advantages�of�confidentiality,�particularly�where�services�cover�personal�or�work-related�issues�that�may�threaten�job�security�such�as�alcohol�and�drug�issues,�family�issues�and�relationship�difficulties,�grief�and�bereavement,�health�and�lifestyle�issues,�gambling�and�addictions,�financial�/�legal�referrals,�mental�health�issues,�and�work-family�issues.�Organisations�should�work�with�their�employees�to�provide�services�that�meet�identified�needs,�are�accessible�and�as�far�as�possible,��cost-effective.
The�role�and�proactivity�of�labour�unions�within�the�health�service�varies�between�professions�and�between�jurisdictions.�The�introduction�of�‘modern�awards’�has�changed�the�roles�and�relationships�of�industrial�relations�in�recent�years.�The�key�point�is�that�whenever�industrial�relations�issues�are�dealt�with,�there�should�be�representation�for�staff�by�elected�representatives�who�require�support�from�persons�qualified�in,�or�with�access�to�advice�on,�the�relevant�legal�issues.�
The�AustralianFairWorkAct2009�(Cth)�sets�a�minimum�standard�for�industrial�relations�support�for�Australian�workers.�It�recognises�a�legitimate�role�for�unions�and�employer�organisations.�Freedom�of�association�laws�ensure�that�an�employer�cannot�dismiss�an�employee�because�he�or�she�is,�or�is�not,�a�member�of�a�union;�all�employees�have�access�to�remedies�for�breaches�of�freedom�of�association�provisions.�Organisations�should�support�these�rights�and�negotiate�with�workers�towards�mutually�acceptable�conditions.
Prompt points
¼ How is the availability of EAP services communicated to staff? Does the organisation know (preferably anonymously) whether the service is used?
¼ How active are unions / professional bodies within the organisational workforce? How does the organisation facilitate staff access to industrial relations information and support?
Workplace rights and responsibilitiesIn�Australia,�many�rights�and�responsibilities�of�workers�and�of�employers�are�recorded�in�jurisdictional�legislation.�Information�for�workers�who�are�employed�under�Commonwealth�legislation�is�available�from�the�Fair�Work�website�at�http://www.fairwork.gov.au/Pages/default.aspx,�which�has�separate�sections�providing�information�for�employees,�employers�and�contractors.�In�2009,�ten�minimum�standards�of�employment�were�included�within�the�FairWorkAct2009�(Cth).�These�apply�for�all�employees�covered�by�the�national�workplace�relations�system�and�relate�to�hours�and�timing�of�work,�leave�entitlements,�termination�and�redundancy,�and�the�provision�of�a�Fair�Work�information�statement.�Many�healthcare�positions�involve�shift�work,�uniforms,�equipment,�travel�and/or�supervisory�responsibilities;�the�specific�details�of�responsibilities�associated�with�these�should�be�clearly�outlined�in�position�descriptions�to�avoid�misunderstandings.�
Further�rights�and�responsibilities�may�also�be�included�within�specific�workplace�agreements�and�awards.�An�example�would�be�any�references�to�grievance�management.�
Some�health�departments�(all�but�Victoria,�NT,�ACT)�continue�to�operate�under�their�State�/�Territory�workplace�legislation;�rights�and�responsibilities�should�be�guided�by�the�jurisdictional�legislation�that�applies.�There�may�also�be�variations�between�jurisdictions�(and�even�between�organisations)�regarding�the�awards�on�which�salaries�are�set.�
Additional�rights�and�responsibilities�are�associated�with�professional�legislation,�codes�and�guidelines.�For�the�ten�nationally�registered�professions,�associated�regulations�can�be�accessed�through�links�to�the�appropriate�boards�from�the�Australian�Health�Practitioner�Regulation�Agency�website1,�as�can�details�of�any�relevant�codes�and�guidelines�http://www.ahpra.gov.au/Education/Continuing-Professional-Development.aspx�
Physicians�and�other�clinicians�who�operate�from�an�independent�practice�will�also�have�obligations�arising�from�their�business�arrangements�with�the�organisation,�and�in�this�context�it�is�extremely�important�that�the�respective�rights�and�responsibilities�of�both�business�entities�are�stated�clearly�in�their�agreement.�Registered�clinicians�would�be�expected�to�also�abide�by�these�conditions,�and�would�be�reported�to�their�professional�board�for�failure�to�comply.
October 2010 319
Prompt points
¼ What rights and responsibilities are outlined in employment agreements for different categories of staff employed by or contracted to the organisation?
‘At-risk’ staff behaviour‘At-risk’�behaviour�involves�actions�and�reactions�from�health�professionals�and�other�staff�that�put�consumer�/�patient�care�and�safety�at�risk.�
The�HealthPractitionerRegulationNationalLawAct2009�(Cth)�obliges�those�healthcare�professionals�that�fall�under�the�auspices�of�this�law�to�notify�the�relevant�professional�board�of�impaired�behaviour�that�might�lead�to�the�public�being�placed�at�risk�of�harm�by�healthcare�professionals.2�Organisations�should�consider�this�Act�when�developing�systems�around�identifying�and�responding�to�‘at-risk’�behaviour.
Responding�to�disruptive�behaviours�can�present�challenges�for�managers�who�must�find�a�balance�between�supportive�and�disciplinary�responses.�Training�in�counselling�and�team�building�may�assist�managers�to�respond�empathetically�to�these�issues�if�and�when�they�arise.
Prompt points
¼ How does the organisation manage disruptive behaviours?
¼ What training is available to managers to assist them to recognise and manage ‘at-risk’ behaviours by team members?
Resolving workplace relations issuesStrategies�that�may�be�used�to�implement�effective�workplace�relations�could�include:
• incident�monitoring�that�identifies�workplace�issues
• distributing�documents�on�rights�and�responsibilities,�for�example,�codes�of�conduct,�prevention�of�harassment,�discrimination,�natural�justice,�standards�of�workplace�behaviour,�OH&S�standards,�access�to�industrial�relations�information
• monitoring�compliance�with�policies�and�procedures�and�statutory�requirements�
• identification�of�relevant�external�groups
• active�involvement�of�managers,�employees�and,�where�applicable,�their�representative�associations
• formal�training�and�development�for�managers�and�staff�
• a�formal�mechanism�for�staff�representation�and�evidence�of�regular�consultation�and�communication�between�staff�and�management
• a�staff�grievance�process�or�other�systems�to�manage�misunderstandings�/�disputes
• appropriate�monitoring�of�the�workplace�relations�management�system.
Data�on�workplace�issues�should�be�monitored�and�analysed�and�systems�put�in�place�to�facilitate�this.�Workplace�relations�management�should�be�included�in�the�overall�risk�management�plan�of�the�organisation.
Workplace�grievances�should�be�managed�in�an�effective�and�fair�way�for�all�parties�concerned.�Organisations�need�to�ensure�that:
• grievance�procedures�are�understood�by�both�management�and�staff
• all�staff�have�access�to�effective�and�fair�processes
• relevant�jurisdictional�legislative�requirements�are�met.
To�resolve�issues�in�the�workplace,�there�should�be�formal�processes�to�facilitate�discussions�between�the�different�parties,�with�the�goal�of�solving�disagreements�without�the�involvement�of�lawyers.�
Collective�workplace�agreements�may�include�processes�for�handling�grievances;�these�formalise�the�responsibilities�of�the�respective�parties�in�resolving�disagreements.�It�is�important�that�any�workplace�agreement�processes�align�with�existing�organisational�procedures�for�handling�internal�complaints�about�working�conditions.�Both�staff�and�management�should�understand�the�process�to�be�followed,�and�be�able�to�access�this�information�if�and�when�it�is�needed.�The�information�should�be�appropriate�so�that�both�parties�can�seek�information�and�advice�about�resolving�any�issue(s).�
Ideally,�industrial�relations�processes�provide�a�mechanism�that�will�prevent�relations�deteriorating�to�disputes.�Performance�measures�can�track�the�numbers�of�hours�lost�per�employee�in�industrial�relations�meetings�and�more�specifically,�disputes.�Similarly,�a�rise�in�the�number�of�disputes�that�result�in�court�appearances�may�indicate�a�failure�to�resolve�issues�through�alternative�mechanisms.�Surveys�of�staff�can�also�monitor�the�whether�workplace�relations�processes�are�meeting�staff�needs.�
seCtion 5Standards, criteria, elements and guidelinesstandard 2.2:�Human�resources�management�supports�quality�health�care,�a�competent�workforce�and�a�satisfying�working�environment�for�staff
320 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 2.2.5
Employee�support�systems�and�workplace�relations�assist�the�organisation�to�achieve�its�goals.�(continued)
Prompt points
¼ What systems are used to manage workplace relations issues within the organisation?
¼ What mechanisms ensure that processes are consultative and transparent?
¼ What outside groups provide support to employees and assist them to manage workplace relations discussions?
Maintaining work-life balanceThe�National�Employment�Standards3�which�were�initiated�in�2010�include�specific�recognition�of�a�need�for�flexible�work�practices�to�assist�workers�to�maintain�their�family�life�and�to�support�voluntary�community�service�in�specific�areas.
Work-life�balance�initiatives�can�help�employers�and�employees�to�be�productive�and�healthy�in�their�work�and�community�lives.�Flexible�work�arrangements�will�assist�staff�at�different�times�in�their�lives�to�allow�for�young�people�to�study,�parents�to�have�time�with�children,�employees�to�maintain�their�health�and�be�active�in�the�community�and�for�the�older�workers�approaching�retirement�to�contribute�on�reduced�hours.
The�nature�of�the�work�within�a�healthcare�setting�may�preclude�some�forms�of�flexible�work�practices,�however�organisations�should�consider�individual�circumstances�in�their�decision�making�in�relation�to:�
• working�hours�including�reduction�in�hours�worked,�changes�to�start�/�finish�times,�working�additional�hours�to�make�up�for�lost�time
• flexible�work�patterns�such�as�working�‘split-shifts’�or�job-sharing�arrangements,�or�taking�time�off�in�lieu�of�overtime�payments
• flexible�work�locations,�which�may�be�applicable�for�some�positions
• flexible�leave�arrangements,�for�instance�accessing�annual�leave�in�single�day�periods�or�as�part�of�single�days�or�taking�accrued�rostered�days�off�as�part�days.
Some�workers�may�choose�to�support�emergency�organisations�such�as�reserve�defence�forces�
and�community�emergency�teams.�Workplace�entitlements�are�now�in�place�under�the�National�Employment�Standards�to�support�community�service�commitments;�organisations�may�choose�to�extend�their�support�beyond�the�minimum�time�periods�stated�or�to�additional�community�service�organisations.�
Prompt points
¼ What actions have been taken by the organisation to support the work-life balance of its employees?
¼ What has been the impact of any efforts to improve the flexibility of work practices within the organisation?
Staff motivation and acknowledgement of performanceIn�all�professions,�most�workers�seek�three�overarching�goals�from�their�work4:�
• equity:�to�be�respected�and�to�be�treated�fairly�in�areas�such�as�pay,�benefits,�and�job�security
• achievement:�to�be�proud�of�one’s�job,�accomplishments,�and�employer
• camaraderie:�to�have�good,�productive�relationships�with�fellow�employees.�
To�maintain�an�enthusiastic�workforce,�management�must�meet�all�three�goals.�Indeed,�employees�who�work�for�companies�where�just�one�of�these�factors�is�missing�are�three�times�less�enthusiastic�than�workers�at�companies�where�all�elements�are�present.�Goals�cannot�be�substituted:�improved�recognition�cannot�replace�better�pay,�money�cannot�substitute�for�taking�pride�in�a�job�well�done,�and�pride�alone�will�not�pay�the�mortgage.
Examples�of�methods�that�organisations�and/or�managers�may�use�to�acknowledge�performance�include:
• formal�awards,�such�as�employee-of-the-year,�or�similar
• thank�you�notes
• celebratory�meals�for�the�team
• time-in-lieu�following�periods�of�hard�work
• bonus�payments
• opportunities�to�attend�conferences�or�other�events
• ensuring�that�external�compliments�are�passed�on.
October 2010 321
Motivation�should�be�monitored�through�performance�reviews,�other�meetings�and�interviews�and�staff�surveys.�
Prompt points
¼ What measures does the organisation use to monitor motivation?
¼ How does the organisation acknowledge and reward high performance?
Evidence commonly presented
Consider whether the following will help to address criterion 2.2.5
¼ Employee assistance program (EAP) utilisation records
¼ Records of negotiations of flexible work practices with staff
¼ Documentation of flexible work arrangements
¼ Employee acknowledgement awards
¼ Workplace relations disputes / grievances reports and documented resolution
¼ Records of communication between the organisation and relevant unions
¼ Staff satisfaction surveys of workplace relations issues such as pay and conditions, participation in workplace decisions, teamwork, workplace culture and knowledge of employee support programs
¼ Training records regarding workplace relations issues such as conflict resolution, discrimination, bullying and harassment prevention
¼ Records of how occurrences of ‘at-risk’ staff behaviours are addressed
¼ Communication materials about employee support services
¼ Internal communications regarding workplace relations issues
¼ Demonstrated use of employee support programs
¼ Evaluation of quality of staff information about employee support services
Performance measurementThis�criterion�states�that:�“Employee�support�systems�and�workplace�relations�assist�the�organisation�to�achieve�its�goals”.�The�organisation�should�be�able�to�demonstrate�that�it�meets�its�legislative�requirements�in�terms�of�workplace�relations,�and�that�it�provides�systems�of�support�for�its�staff,�including�a�formal�employee�assistance�program,�that�facilitate�the�meeting�of�organisational�goals.
Some�common�suggested�performance�measures�are�as�follows:
Number�of�staff�who�are�aware�of�the�employee�assistance�program�
Total number of staff surveyed
Comment:i.e.thatthisisafreeandconfidentialserviceavailableforstafftoaccess
Number�of�staff�who�are�satisfied�with�the�employee�assistance�program
Total number of staff who have used the employee assistance program
Comment:asprovidedinde-identifiedformbyEAPprovider
seCtion 5Standards, criteria, elements and guidelinesstandard 2.2:�Human�resources�management�supports�quality�health�care,�a�competent�workforce�and�a�satisfying�working�environment�for�staff
322 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 2.2.5
Employee�support�systems�and�workplace�relations�assist�the�organisation�to�achieve�its�goals.�(continued)
Number�of�episodes�of�harassment�/�bullying�/�discrimination
Total number of staff
Number�of�hours�lost�due�to�disputes
Total number of work hours
Number�of�hours�leave�taken�due�to�stress
Total number of hours of leave taken
Number�of�staff�undertaking�industrial�relations�training
Total number of FTE staff
Comment:FTE=full-timeequivalent
Number�of�staff�satisfied�with�the�management�of�workplace�issues
Total number of staff surveyed
References1.� Australian�Health�Practitioner�Regulation�Agency�(AHPRA).�
AboutAHPRA.Canberra�ACT;�AHPRA.�Accessed�from�http://www.ahpra.gov.au/About-AHPRA.aspx�on�31�August�2010.
2.� AHPRA�Medical�Board�of�Australia.�Consultationpaperoncodesandguidelinescomprisingguidelinesonadvertisingandguidelinesonmandatorynotification.Melbourne�VIC;�Medical�Board�of�Australia;�2010.
3.� Fair�Work�Australia.�TheNationalEmploymentStandards(Part2-2).�Canberra�ACT;�Fair�Work�Australia.�Accessed�from�http://www.fwa.gov.au/documents/awardmod/nes.pdf�on�21�June�2010.
4.� Sirota�D,�Mischkind�LA�and�Meltzer�MI.�Stop�demotivating�your�employees!�HarvardManagementUpdate�2006;�11(1).�Accessed�from�http://www.sirota.com/pdfs/Stop_Demotivating_Your_Employees_Harvard_Management_Update_Jan_2006.pdf�on�6�September�2010.
October 2010 323
2.3�Information�Management�Standard
The�standard�is:�Information management systems enable the organisation’s goals to be met.
The�intent�of�this�standard�is�to�ensure�that�data�and�information�meets�the�organisation’s�needs�and�supports�the�delivery�of�quality�care�and�service.�
The�principles�of�good�information�management�are�the�same�regardless�of�the�size�and�type�of�organisation�and�the�complexity�of�the�information�technology.�There�are�increasing�requirements�for�information�management�to�support�organisational�performance�and�healthcare�delivery.�
There�are�four�criteria�in�this�standard.�They�are:
2.3.1� �Health records management�systems�support�the�collection�of�information�and�meet�the�consumer�/�patient�and�organisation’s�needs.
2.3.2� Corporate�records�management�systems�support�the�collection�of�information�and�meet�the�organisation’s�needs.
2.3.3� Data and information are collected, stored and used�for�strategic,�operational�and�service�improvement�purposes.
2.3.4� �The�organisation�has�an�integrated�approach�to�the�planning,�use�and�management�of�information and communication technology�(I&CT).
seCtion 5Standards, criteria, elements and guidelines
seCtion 5Standards, criteria, elements and guidelinesstandard 2.3:�Information�management�systems�enable�the�organisation’s�goals�to�be�met
324 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion LA – Awareness sA – implementationLA plus the following
MA – evaluationSA plus the following
eA – excellenceMA plus the following
oA – LeadershipEA plus the following
Criterion 2.3.1
Health�records�management�systems�support�the�collection�of�information�and�meet�the�consumer�/�patient�and�organisation’s�needs.
a)� There�is�a�health�records�management�policy�and�system�that�ensures:
� (i)� �the�secure,�safe�and�systematic�storage�of�data�and�records
� (ii)� �timely�and�accurate�retrieval�of�records�stored�on�or�off-site
� (iii)� �consumer�/�patient�privacy�when�information�is�communicated
� (iv)� �retention�and�destruction�according�to�all�relevant�standards�/�legislation�/�policy�/�guidelines.
b)� Each�consumer�/�patient�is�allocated�an�organisation-wide�unique�identifier.
c)� Where�multiple�records�for�the�consumer�/�patient�exist�they�are�cross-referenced.
d)� Clinical�classification�is�undertaken�for�all�inpatient�admissions�in�accordance�with�jurisdictional�standards,�where�available,�or�guidelines.�
e)� Documented�guidelines�are�available�for�consumers�/�patients�on�how�to�access�their�health�records.
a)� The�health�records�management�system�is�managed�with�reference�to�any�relevant�standards,�codes�of�practice�and�industry�guidelines.
b)� There�is�a�system�to�support�the�allocation�and�maintenance�of�the�unique�identifier.
c)� A�central�index�of�identifiers�is�maintained.
d)� The�health�record�is�linked�to�other�health�information�systems�using�the�unique�identifier.
e)� All�components�of�the�health�record�are�accounted�for�at�a�central�point,�and�are�monitored.�
f)� Training�on�health�record�keeping�and�records�management�is�available�for�relevant�staff.
g)� Coding�and�reporting�time�frames�meet�internal�and�external�requirements.
h)� Healthcare�workers�participate�in�the�analysis�of�data�including�clinical�classification�information.�
i)� Requests�by�consumers�/�patients�for�access�to�health�records�are�met�within�a�set�period�in�accordance�with�jurisdictional�policy�/�legislation.
a)� Health�records�management�systems�are�evaluated,�and�improvements�are�made�as�required.
b)� Checks�for�consumers�/�patients�that�have�multiple�identifiers�are�regularly�made�on�the�central�index,�and�improvements�/�links�are�made�when�required.
c)� The�tracking�and�monitoring�of�health�records�is�evaluated,�and�improvements�are�made�when�required.
d)� Coding�and�reporting�processes�are�evaluated,�and�improvements�are�made�when�required.
a)� Health�records�management�systems�are�compared�internally�and�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.
and/or
b)� Systems�for�managing�unique�identifiers�are�compared�internally�and�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.
and/or
c)� Coding�performance�indicators�are�compared�externally,�and�improvements�are�made�to�ensure�better�practice.
a)� The�organisation�demonstrates�it�is�a�leader�in�health�records�management.
October 2010 325
Criterion LA – Awareness sA – implementationLA plus the following
MA – evaluationSA plus the following
eA – excellenceMA plus the following
oA – LeadershipEA plus the following
Criterion 2.3.1
Health�records�management�systems�support�the�collection�of�information�and�meet�the�consumer�/�patient�and�organisation’s�needs.
a)� There�is�a�health�records�management�policy�and�system�that�ensures:
� (i)� �the�secure,�safe�and�systematic�storage�of�data�and�records
� (ii)� �timely�and�accurate�retrieval�of�records�stored�on�or�off-site
� (iii)� �consumer�/�patient�privacy�when�information�is�communicated
� (iv)� �retention�and�destruction�according�to�all�relevant�standards�/�legislation�/�policy�/�guidelines.
b)� Each�consumer�/�patient�is�allocated�an�organisation-wide�unique�identifier.
c)� Where�multiple�records�for�the�consumer�/�patient�exist�they�are�cross-referenced.
d)� Clinical�classification�is�undertaken�for�all�inpatient�admissions�in�accordance�with�jurisdictional�standards,�where�available,�or�guidelines.�
e)� Documented�guidelines�are�available�for�consumers�/�patients�on�how�to�access�their�health�records.
a)� The�health�records�management�system�is�managed�with�reference�to�any�relevant�standards,�codes�of�practice�and�industry�guidelines.
b)� There�is�a�system�to�support�the�allocation�and�maintenance�of�the�unique�identifier.
c)� A�central�index�of�identifiers�is�maintained.
d)� The�health�record�is�linked�to�other�health�information�systems�using�the�unique�identifier.
e)� All�components�of�the�health�record�are�accounted�for�at�a�central�point,�and�are�monitored.�
f)� Training�on�health�record�keeping�and�records�management�is�available�for�relevant�staff.
g)� Coding�and�reporting�time�frames�meet�internal�and�external�requirements.
h)� Healthcare�workers�participate�in�the�analysis�of�data�including�clinical�classification�information.�
i)� Requests�by�consumers�/�patients�for�access�to�health�records�are�met�within�a�set�period�in�accordance�with�jurisdictional�policy�/�legislation.
a)� Health�records�management�systems�are�evaluated,�and�improvements�are�made�as�required.
b)� Checks�for�consumers�/�patients�that�have�multiple�identifiers�are�regularly�made�on�the�central�index,�and�improvements�/�links�are�made�when�required.
c)� The�tracking�and�monitoring�of�health�records�is�evaluated,�and�improvements�are�made�when�required.
d)� Coding�and�reporting�processes�are�evaluated,�and�improvements�are�made�when�required.
a)� Health�records�management�systems�are�compared�internally�and�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.
and/or
b)� Systems�for�managing�unique�identifiers�are�compared�internally�and�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.
and/or
c)� Coding�performance�indicators�are�compared�externally,�and�improvements�are�made�to�ensure�better�practice.
a)� The�organisation�demonstrates�it�is�a�leader�in�health�records�management.
seCtion 5Standards, criteria, elements and guidelinesstandard 2.3:�Information�management�systems�enable�the�organisation’s�goals�to�be�met
326 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 2.3.1
Health�records�management�systems�support�the�collection�of�information�and�meet�the�consumer�/�patient�and�organisation’s�needs.�(continued)
IntentThe�intent�of�this�criterion�is�to�ensure�that�the�organisation’s�health�records�management�system�facilitates�the�provision�of�care.�A�key�purpose�of�health�records�is�to�support�continuity�of�care.�Health�records�must�therefore�be�managed�so�as�to�be�kept�complete,�up-to-date�and�available�to�relevant�clinicians�in�a�timely�manner.
Each�organisation�should�ensure�the�integrity,�safety,�controlled�access�to�and�security�of�all�health�records.
Although�issues�related�to�paper-based�records�systems�versus�electronic�systems�may�differ,�the�goals�of�record�keeping�are�fundamental�regardless�of�the�method(s)�used�to�maintain�those�records.�The�health�records�management�criterion�does�not�direct�the�form�of�record�keeping,�but�is�provided�to�ensure�that�health�records�are�maintained�to�manage�risk�to�the�organisation.
Relationships of 2.3.1 with other criteriaSafe,�high�quality�care�depends�upon�the�timely�and�accurate�gathering�of�data�into�the�health�record�(Criterion�1.1.8),�which�must�then�be�kept�secure�yet�accessible�to�relevant�clinicians�by�an�effective�health�records�management�system,�and�which�may�be�wholly�or�partly�operated�through�the�organisation’s�information�and�communication�technology�framework�(Criterion�2.3.4).
Efficient�health�records�management�supports�effective�ongoing�care�(Criterion�1.1.6)�and�the�processes�of�clinical�handover�(Criterion�1.1.5).�It�is�an�aspect�of�the�organisation’s�integrated�risk�management�framework�(Criterion�2.1.2),�and�failure�to�implement�a�fully�effective�system�may�lead�to�incidents�(Criterion�2.1.3)�and�complaints�(Criterion�2.1.4).�Access�to�his�or�her�health�record�is�a�fundamental�right�of�the�consumer�/�patient�(Criterion�1.6.2).
Health records management systemPolicies�and�procedures�for�the�health�records�management�system�should�include�the�following�areas:
• information�privacy
• updating�of�information,�such�as�consumer�/�patient�information
• storage�
• damage
• retrieval
• retention
• destruction
• unique�identification
• personal�identification
• clinical�classification.
Three�Australian�standards�(AS)�provide�guidance�in�relation�to�health�records:
• AS�2828:1999�Paper-basedhealthcarerecords
• AS�ISO�15489.1:2002Recordsmanagement–General
• AS�ISO�15489.2:2002�Recordsmanagement–Guidelines
• AS�ISO�23081.1:2006�Informationanddocumentation–Recordsmanagementprocesses–Metadataforrecords.Part1:Principles.
Records�management�involves�the�planning,�control�and�protection�of�records�and�documents�of�the�organisation.�For�the�purpose�of�this�criterion,�records�refer�to�all�clinical�records,�both�electronic�and�paper-based,�and�should�refer�to�AS�ISO�15489:2002�Recordsmanagement,�health�records�acts�and�jurisdictional�privacy�laws.�Information�is�available�for�individual�States�and�Territories�from�the�Office�of�the�Federal�Privacy�Commissioner.1
Damage�to�paper�records�can�be�minimised�by�ensuring�that�light,�humidity,�heat,�vermin�and�moisture�are�monitored�and�controlled,�and�that�fire�prevention�practices�and�detection�systems�are�used.�
Storage�areas�or�systems�should�enable�storage�of�records�for�at�least�as�long�as�required�by�legislation.�
Each�State�/�Territory�health�department�has�set�schedules�for�retention�and�disposal�of�various�record�types.�Policy�and�procedure�should�direct�staff�as�to�how�long�records�should�be�kept�and�responsibility�for�destruction�of�records�should�be�assigned�to�the�relevant�authority.�
October 2010 327
Destruction�procedures�should�consider:
• destruction�according�to�the�retention�schedule
• systems�for�easy�identification�of�records�that�should�be�culled�and�destroyed,�such�as�having�a�year�of�last�use�on�the�front�of�the�record
• confidentiality
• that�contractors,�if�used,�are�destroying�records�according�to�the�contract�and�that�evidence�of�destruction�is�provided
• the�best�method�of�destruction,�for�example�burning�or�shredding�for�hard�copy�records,�wiping�disks�clean�or�the�disks�physically�destroyed�for�electronic�records.�
Organisations�should�ensure�that�records�stored�by�contractors�are�retained�under�appropriate�standards�and�according�to�organisational�policy.
Regardless�of�whether�the�record�is�in�primary�or�secondary�storage,�accurate�and�timely�data�/�information�retrieval�relies�upon�satisfactory:
• record�filing�systems�
• record�tracking�systems
• a�retrieval�system�that�meets�needs
• policies�and�procedures�that�are�useful,�especially�for�casual�employees�and�after-hours�staff
• compliance�with�policies�and�procedures.
This�can�be�monitored�by�tracking�the:
• timeliness�of�record�retrieval�
• accuracy�of�responses�to�requests�for�records
• satisfaction�of�staff�/�consumers�who�request�records.�
Prompt points
¼ How does the organisation manage hard copy and electronic records in a way that makes it easy for approved people to find the information they need?
¼ What are the systems for health records storage, retrieval and destruction? How are staff advised of these procedures?
¼ How are paper records stored? How are records destroyed?
¼ How are electronic records archived?
¼ What future planning is in place for electronic records storage, retention and destruction?
Consumer / patient access The�organisation�should�have�processes�in�place�by�which�the�consumer�/�patient�can�gain�access�to�his�or�her�own�health�record,�and�this�information�should�be�proactively�provided�to�the�individual�prior�to�or�upon�admission.�This�aspect�of�consumer�/�patient�rights�is�discussed�in�more�detail�within�criterion�1.6.2.�Organisations�should�have�policy�and�procedures�to�manage�requests�for�access�to�personal�health�records�and�any�requests�should�be�noted�in�the�consumer�/�patient’s�health�record.�The�period�of�time�within�which�the�organisation�must�respond�to�a�request�for�access�to�a�health�record�will�be�jurisdictionally�determined.
The�content�of�the�health�record�must�be�protected�because�it�contains�information�about�individuals�that�may�be�personally�or�financially�damaging�if�accessed�inappropriately.�
The�National�Privacy�Principles�(2001)2–4�and�the�PrivacyAct1988�(Cth)�can�assist�organisations�to�implement�systems�to�protect�the�privacy�of�consumer�/�patient�information.�Most�States�and�Territories�have�developed�guidelines�and�legislation�in�relation�to�information�privacy.�Healthcare�organisations�should�refer�to�both�Commonwealth�and�State�/�Territory�legislation�for�direction�in�meeting�the�principles�of�privacy.
Prompt points
¼ Where is the organisation’s information on consumer / patient access to their health records available?
¼ How are consumers / patients advised about access to their health record?
¼ How are staff made aware of the procedures? How is compliance with procedures and timeliness of response to consumer requests for health record access monitored?
seCtion 5Standards, criteria, elements and guidelinesstandard 2.3:�Information�management�systems�enable�the�organisation’s�goals�to�be�met
328 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 2.3.1
Health�records�management�systems�support�the�collection�of�information�and�meet�the�consumer�/�patient�and�organisation’s�needs.�(continued)
Unique identifier A�unique�identifier�is�an�organisation-produced�number,�code,�or�letters,�of�whatever�sort,�given�to�a�single�consumer�/�patient,�for�the�first�and�every�subsequent�attendance�at�the�organisation.�The�unique�identifier�helps�to�identify�each�consumer�/�patient�and�ensures�continuity�of�care.�Safety�and�quality�can�be�compromised�if�the�consumer�/�patient�is�not�correctly�identified,�and�when�wrong�or�insufficient�health�information�is�used�for�care.�Development�of�policy�and�procedure�would�include�consideration�of:
• personal�details�that�should�be�collected�to�adequately�allocate�the�consumer�/�patient�unique�identifier.�State�/�Territory�health�departments�have�guidelines�for�identification�information�that�should�be�referenced
• systems�to�support�the�allocation�and�maintenance�of�the�unique�identifier�
• cross-referencing�of�unavoidable�multiple�records
• the�need�for�phonetic�searches�of�names�that�sound�alike�but�are�spelt�differently
• the�need�for�alias�searches�to�identify�people�who�use�more�than�one�name
• processes�to�differentiate�between�people�with�the�same�name
• processes�for�tracking�provision�of�care�where�consumers�/�patients�access�services�anonymously.
Prompt points
¼ What system-based precautions prevent different sites / departments issuing a second identifier to the same person?
¼ How are multiple identifiers revealed? What process is followed when multiple identifiers are discovered?
¼ What changes have / will be made for the roll out of the individual health identifier (HPI-I) and health provider identifiers (HPI-O)?
Monitoring and tracking health recordsConsumer�/�patient�health�records�have�multiple�uses�and�many�people�have�legitimate�access�to�them.�As�more�organisations�begin�to�move�to�electronic�health�records,�security�will�become�more�of�an�issue.�The�risks�in�health�record�security�have�become�more�than�a�matter�of�controlling�access�to�the�storage�area�of�paper�files.
Potential�risks�associated�with�inappropriate�access�to�health�information�include:
• incorrect�or�misinformed�perceptions�by�persons�whose�knowledge�has�not�been�authorised�by�the�consumer�/�patient
• fraudulent�claims�tied�to�Medicare�numbers�or�private�health�insurance�details
• the�publicising�of�historical�health�events�or�disabilities�in�contexts�that�may�disadvantage�or�embarrass�an�individual
• reluctance�of�insurers�to�accept�applications�from�higher-risk�individuals
• falsification�of�records�by�researchers�seeking�career�benefits�linked�to�research�funding,�recruitment�for�clinical�trials�or�positive�outcomes�of�treatment�protocols
• unsought�involvement�of�consumers�/�patients�in�legal�proceedings�related�to�quality�of�care
• inappropriate�direct�marketing�from�suppliers�of�drugs,�devices�or�even�nutritional�products�and�services�for�specific�classes�of�consumer�/�patient.
Health�information�is�valuable�only�if�it�is�accurate,�complete�and�available�for�use�when�needed.�In�order�for�this�to�occur,�organisations�must�implement�systems�to�ensure�all�of�the�health�information�about�a�consumer�/�patient�is�in�one�central�place,�or�that�it�can�be�easily�located�when�different�parts�of�a�health�record�are�not�stored�together.�This�means�that,�centrally,�there�is�a�record�of�where�all�elements�or�components�of�the�health�record�are�at�any�given�time.5
Where�there�are�different�components�of�an�individual�health�record,�these�should�be�cross-referenced.�Instances�where�health�records�may�need�to�be��cross-referenced�include,�but�are�not�limited�to:
• health�records�that�are�part�paper-based�and�part�electronic�
• paper-based�health�records�that�have�been�separated�because�of�their�bulk�and�older�entries�archived
• health�records�stored�in�different�wards�/�departments�within�one�organisation
October 2010 329
• records�that�include�items�that�require�incompatible�storage�systems,�such�as�video�footage,�large�radiographs,�sound�recordings
• health�records�that�are�used�for�staff�working��off-site�that�are�a�component�of�an�organisation-wide�health�record.
Organisations�should�ensure�that�all�components�of�the�health�record�are�tracked�and�monitored.�
Tracking�the�location�of�components�of�the�health�record�requires�a�system�that�monitors�removal�of�a�health�record�and�records�the�department�/�person�responsible�for�that�record�until�the�health�record�is�returned�to�the�central�location�and�the�system�updated.�Health�record�policy�should�also�address�circumstances�where�a�health�record�is�temporarily�removed�from�the�premises.�
Some�organisations�store�information�within�different�systems�and�in�these�instances�the�health�information�should�be�linked�to�the�individual’s�health�record�by�using�the�consumer�/�patient�unique�identifier.�Instances�where�health�information�may�be�stored�elsewhere�and�should�be�linked�include:
• results�of�investigations�stored�in�a�central�file
• registration�on�tissue�/�organ�donation�banks
• rural�hospitals�attended�by�a�local�general�practitioner�where�the�GP�clinic�records�contain�further�information.
Prompt points
¼ How does the organisation identify instances where health records should be cross-referenced? How are records that should be linked identified?
¼ How is the movement of health records tracked and monitored? How are complaints from staff about clinicians who inappropriately remove records managed by the organisation? What policies are available to address these issues?
¼ How are complaints from clinical staff who are unable to locate health records / files within a record managed by the organisation?
Clinical coding and reportingSystems�should�be�in�place�that�consider�and�include�the�ICD-10-AM�codes,�the�Australian�Coding�Standards,�the�clinical�coder�workforce,�and�clinician�input,�to�ensure�that�coding�is�clinically�appropriate,�efficient,�accurate�and�timely.�
Coding�policies�and�procedures�help�to�ensure�that�data�are�accurate.�They�recognise�the�need�to�check�accuracy�and�monitor�input�for�whatever�classification�system�is�used.�National�organisations,�such�as�the�National�Casemix�and�Classification�Centre�(NCCC)6,�have�expertise�in�clinical�coding�and�can�provide�advice�on�clinical�coding�and�reporting.�Coding�performance�indicator�results�can�be�trended�and�compared�to�those�from�other�organisations�to�determine�whether�the�organisation�meets�best�practice,�and�to�identify�opportunities�for�improvement.�
Mechanisms�to�assist�staff�to�meet�internal�and�external�timelines�include:
• ongoing�coding�education�for�relevant�staff
• access�to�support�mechanisms,�such�as�standards�and�guidelines
• monitoring�coding�workload�and�the�allocation�of�resources
• monitoring�turnaround�time�and�mentoring�/�educating�staff�on�areas�of�weakness
• networking�with�other�organisations�that�use�the�same�classification�system�to�identify�alternative�mechanisms
• assisting�staff�under�time�pressures�to�prioritise�their�workloads�and�manage�their�obligations�more�effectively,�by�removing�interruptions�or�other�pressures.
Prompt points
¼ What training / qualifications are held by staff involved in clinical classification?
¼ Are relevant standards available for staff who need to code or interpret clinical data? How are they made available?
¼ How are clinicians involved in clinical classification?
seCtion 5Standards, criteria, elements and guidelinesstandard 2.3:�Information�management�systems�enable�the�organisation’s�goals�to�be�met
330 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 2.3.1
Health�records�management�systems�support�the�collection�of�information�and�meet�the�consumer�/�patient�and�organisation’s�needs.�(continued)
Staff education and trainingTraining�in�any�aspect�of�health�records�will�differ�for�administrative�staff�and�clinical�staff.�Training�needs�may�be�pre-empted�by�reviewing�position�descriptions,�the�changing�case�load�across�departments,�plans�for�new�record�systems�and�strategic�/�operational�plans.
In�each�circumstance,�the�organisation�should�consider:
• the�time�commitment�required�to�learn�a�new�system�/�task
• the�risks�associated�with�incorrect�compliance�with�records�systems�and�processes
• the�availability�of�skilled�staff�to�teach�/�mentor�staff�who�are�learning�and�monitor�their�output
• whether�there�is�the�budget�and�equipment��for�in-house�training�of�groups
• whether�there�are�suitable�outsourced�courses�available.
Relevant�staff�should�have�basic�induction�training�on�how�consumers�/�patients�can�access�their�records,�management�of�consumer�/�patient�administration�systems,�electronic�health�records,�the�management�of�paper�records,�legibility�and�completeness�of�record�keeping,�and�retention�and�disposal�of�records.�Explaining�the�reasons�for�policies�on�the�management�of�health�records�and�the�risks�associated�with�poor�record�keeping�will�assist�in�compliance.�The�goal�should�be�to�promote�responsible�health�record�keeping�as�a�cooperative�team�activity�essential�for�safe,�multidisciplinary�care,�which�may�help�to�overcome�perceptions�that�it�is�merely�a�bureaucratic�obligation.�As�with�any�other�training,�attendance�should�be�documented�in�the�relevant�personnel�files.
Prompt points
¼ What health records training needs have been identified by the organisation? What options have been investigated to meet those needs? What has been the feedback on the training undertaken so far?
¼ How is training provided at orientation? How is attendance documented?
¼ What current staff members or groups have recently received health records training?
Evidence commonly presented for this criterion
Consider whether the following will help to address criterion 2.3.1
¼ Policy / guidelines / by-laws and procedures for health records management
¼ Systems for management of health records, including:
– storage / location / security – retrieval processes – unique identifiers – use of clinical classification
¼ Health record audits
¼ Evidence of qualifications of health records management staff, including clinical coders
¼ Performance indicators
¼ Consumer / patient master index or central index
October 2010 331
Performance measurementThis�criterion�states�that:�“Health�records�management�systems�support�the�collection�of�information�and�meet�the�consumer�/�patient�and�organisation’s�needs”.�Effective,�coordinated�management�systems�are�vital�to�ensure�both�appropriate�access�to,�and�secure�storage�of,�confidential�health�information.�The�organisation�should�be�able�to�demonstrate�that�it�has�efficient,�secure�systems�of�health�records�management�in�place,�that�it�provides�all�necessary�information,�training�and�support�for�staff,�and�that�it�monitors�and�improves�the�performance�of�its�systems.
Some�common�suggested�performance�measures�as�follows:
Number�of�clinicians�/�managers�who�have�a�login�to�access�a�computer
Total number of clinicians / managers
Number�of�staff�who�receive�education�on�information�systems
Total number of staff
Number�of�clinical�staff�who�have�access�to�clinical�information�systems�
Total number of clinical staff
Comment:examplesofclinicalinformationsystemsincludeClinicalInformationAccessProgram(CIAP),Medline,etc.
Number�of�health�records�/�summaries�of�health�records�provided�to�consumers�/�patients�upon�request�within�the�allotted�time�period
Total number of health records / summaries of health records requested by consumers / patients
Number�of�health�record�duplications�identified
Total number of health records audited
seCtion 5Standards, criteria, elements and guidelinesstandard 2.3:�Information�management�systems�enable�the�organisation’s�goals�to�be�met
332 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 2.3.1
Health�records�management�systems�support�the�collection�of�information�and�meet�the�consumer�/�patient�and�organisation’s�needs.�(continued)
Records�or�parts�of�records�not�available�(within�reasonable�time�from�request)�because�they�could�not�be�located
Total number of consumers / patients admitted / seen
Comment:organisationtodefine‘reasonabletime’
Records�or�parts�of�records�not�available�(within�reasonable�time�from�request)�for�any�reason
Total number of consumers / patients admitted / seen
Comment:organisationtodefine‘reasonabletime’
References1.� Office�of�the�Federal�Privacy�Commissioner.�Stateand
territoryprivacylaws.Sydney�NSW;�Australian�Government.�Accessed�from�http://www.privacy.gov.au/aboutus/contact�on�1�September�2010.
2.� Office�of�the�Federal�Privacy�Commissioner.�Nationalprivacyprinciples(extractedfromthePrivacyAmendment(PrivateSector)Act2000).�Sydney�NSW;�Australian�Government;�2001.
3.� Office�of�the�Federal�Privacy�Commissioner.�Nationalprivacyprinciples.Private�sector�information�sheet.�Vol.�1.�Canberra�ACT;�Office�of�the�Privacy�Commissioner;�2006.
4.� Office�of�the�Federal�Privacy�Commissioner.�Nationalprivacyprinciples.�Information�sheet.�Canberra�ACT;�Office�of�the�Privacy�Commissioner;�2008.
5.� Abdelhak�M,�Grostick�S,�Hanken�MA�and�Jacobs�E.�Healthinformation:Managementofastrategicresource.Second�edn.�Philadelphia�USA;�Saunders;�2001.
6.� National�Casemix�and�Classification�Centre�(NCCC).�Homepage.�Wollongong�NSW;�University�of�Wollongong.�Accessed�from�http://nccc.uow.edu.au/index.html�on�1�September�2010.
October 2010 333
seCtion 5Standards, criteria, elements and guidelinesstandard 2.3:�Information�management�systems�enable�the�organisation’s�goals�to�be�met
334 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
IntentThe�intent�of�this�criterion�is�to�focus�on�issues�beyond�clinical�records�and�to�ensure�that�the�organisation’s�records�management�systems�facilitate�effective�management�of�the�organisation�and�associated�research�and�education�activities.�
Each�organisation�should�ensure�the�integrity,�safety,�appropriate�access�and�security�of�all�records,�including�but�not�limited�to�staff�records,�clinical�registers,�film,�prints,�financial�information�and�minutes�of�meetings.�Policy�/�guidelines�and�procedures�for�records�management�systems�should�include�the�following�areas:
• information�privacy
• management�of�updating�information,�such�as�personnel�information
• storage
• risk�minimisation
• retrieval
• retention
• destruction
• version�control�for�draft�documents.
Relationships of 2.3.2 with other criteriaEstablishing�and�maintaining�an�effective�records�management�framework�represents�a�significant�business�challenge�for�many�organisations.�This�task�is�made�more�difficult�by�changing�legislative�and�other�requirements�and�ongoing�developments�in�information�technology.
Criterion LA – Awareness sA – implementationLA plus the following
MA – evaluationSA plus the following
eA – excellenceMA plus the following
oA – LeadershipEA plus the following
Criterion 2.3.2
Corporate�records�management�systems�support�the�collection�of�information�and�meet�the�organisation’s�needs.
a)� There�is�a�corporate�records�management�policy�and�system�that�ensures:
� (i)� �the�secure,�safe�and�systematic�storage�of�data�and�records
� (ii)� �timely�and�accurate�retrieval�of�records�stored�on�or�off-site
� (iii)� �appropriate�retention�and�destruction�of�records�
� according�to�all�relevant�standards�/�legislation�/�policy�/�guidelines.
b)� Policy�/�guidelines�exist�that�define�the�governance�and�accountability�for�corporate�records�management.
c)� The�corporate�records�management�system�specifies�the�requirements�for�standardised�record�creation�and�tracking.
d)� Staff�are�made�aware�of�their�responsibilities�in�relation�to�corporate�records�management.
a)� The�corporate�records�management�system�is�managed�with�reference�to�any�relevant�standards,�legislation,�policy,�codes�of�practice�and�industry�guidelines.
b)� Corporate�records�created�by�the�organisation�are�supported�by�relevant�records�systems.
c)� Training�on�corporate�record�keeping�and�records�management�is�available�for�staff.�
a)� Corporate�records�management�systems�are�evaluated�and�improvements�are�made�as�required.
b)� Training�on�corporate�record�keeping�and�records�management�is�evaluated,�and�improved�as�required.�
c)� Corporate�records�creation�and�tracking�is�evaluated�and�improved�as�required.
a)� Corporate�records�management�systems�are�compared�internally�and�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.
a)� The�organisation�demonstrates�it�is�a�leader�in�corporate�records�management.
October 2010 335
The�management�of�corporate�records�has�some�commonalities�with�the�management�of�health�records�(Criterion�2.3.1);�both�will�be�impacted�by�systems�for�the�collection,�use�and�storage�of�data�(Criterion�2.3.3)�and�by�the�management�of�information�and�communications�technology�(Criterion�2.3.4).�Corporate�records�systems�will�in�turn�play�a�significant�role�in�many�aspects�of�the�organisation’s�governance�and�management�(Criteria�3.1.1�and�3.1.2),�human�resources�management�(Standard�2.2),�in�particular�workforce�planning�(Criterion�2.2.1),�and�orientation�and�training�(Criterion�2.2.2).�Corporate�records�management�is�a�vital�component�of�the�organisation’s�integrated�risk�management�framework�(Criterion�2.1.2).
Corporate records policy and systemsThe�records�management�policy�/�guideline�for�corporate�records�should�refer�to�AS�ISO�15489:2002�Recordsmanagement1�and�to�all�relevant�Federal,�State�and�Territory�Acts2�including�privacy�laws.�Information�on�privacy�laws�are�available�for�individual�States�/�Territories�from�the�Office�of�the�Federal�Privacy�Commissioner.2�
Criterion LA – Awareness sA – implementationLA plus the following
MA – evaluationSA plus the following
eA – excellenceMA plus the following
oA – LeadershipEA plus the following
Criterion 2.3.2
Corporate�records�management�systems�support�the�collection�of�information�and�meet�the�organisation’s�needs.
a)� There�is�a�corporate�records�management�policy�and�system�that�ensures:
� (i)� �the�secure,�safe�and�systematic�storage�of�data�and�records
� (ii)� �timely�and�accurate�retrieval�of�records�stored�on�or�off-site
� (iii)� �appropriate�retention�and�destruction�of�records�
� according�to�all�relevant�standards�/�legislation�/�policy�/�guidelines.
b)� Policy�/�guidelines�exist�that�define�the�governance�and�accountability�for�corporate�records�management.
c)� The�corporate�records�management�system�specifies�the�requirements�for�standardised�record�creation�and�tracking.
d)� Staff�are�made�aware�of�their�responsibilities�in�relation�to�corporate�records�management.
a)� The�corporate�records�management�system�is�managed�with�reference�to�any�relevant�standards,�legislation,�policy,�codes�of�practice�and�industry�guidelines.
b)� Corporate�records�created�by�the�organisation�are�supported�by�relevant�records�systems.
c)� Training�on�corporate�record�keeping�and�records�management�is�available�for�staff.�
a)� Corporate�records�management�systems�are�evaluated�and�improvements�are�made�as�required.
b)� Training�on�corporate�record�keeping�and�records�management�is�evaluated,�and�improved�as�required.�
c)� Corporate�records�creation�and�tracking�is�evaluated�and�improved�as�required.
a)� Corporate�records�management�systems�are�compared�internally�and�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.
a)� The�organisation�demonstrates�it�is�a�leader�in�corporate�records�management.
seCtion 5Standards, criteria, elements and guidelinesstandard 2.3:�Information�management�systems�enable�the�organisation’s�goals�to�be�met
336 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 2.3.2
Corporate�records�management�systems�support�the�collection�of�information�and�meet�the�organisation’s�needs.�(continued)
Records�are�an�organisation’s�corporate�memory.�They�provide�evidence�of�actions�and�decisions�and�represent�a�vital�asset�to�support�daily�functions�and�operations.�Records�support�policy�formation�and�managerial�decision�making,�protecting�the�interests�of�the�organisation�as�well�as�the�rights�of�staff�and�consumers�/�patients,�and�help�in�the�delivery�of�services�in�a�consistent�and�equitable�way.�They�also�support�consistency,�continuity,�efficiency�and�productivity�in�program�delivery,�management�and�administration.
Organisations�should�ensure�policies�/�guidelines�address�the�requirements�for�retention,�storage,�archiving�and�destruction�of�all�corporate�records,�including,�but�not�limited�to,�minutes�of�any�meetings,�personnel�records,�governance�decisions,�plans,�financial�records�and�any�other�documents�developed�and/or�received�by�the�organisation.3�Policies�should�also�give�guidance�about�the�use,�storage�and�retention�of�less�formal�means�of�internal�and�external�communication�including�hard�copy�memos�and�mail,�email�and�sms�messages.
How�corporate�records�are�managed�will�depend�on�the�type�of�record,�the�requirements�of�the�organisation�and�the�relevant�standards,�guidelines�and�Acts.�Organisational�policies�/�guidelines�and�procedures�should�address�these�issues.�For�example,�meeting�minutes�will�be�managed�in�different�ways,�and�the�type�of�meeting�will�dictate�where�and�how�the�records�need�to�be�stored,�and�how�long�they�need�to�be�retained.�Final�versions�of�key�corporate�files�such�as�Board�meeting�minutes,�annual�reports�and�policy�documents�should�be�filed�in�an�unalterable�format�and�archived�in�a�manner�that�preserves�the�content�for�long�term�storage�and�accessibility,�even�as�key�personnel�and�technology�change.�
Organisations�should�incorporate�record�retention�into�their�records�management�system.�Record�retention�requirements�should�be�documented�when�each�new�record�is�generated�and�relevant�staff�should�be�aware�of�these�requirements.4
Prompt points
¼ How are corporate records distinguished from health records in organisational policies and procedures?
¼ What are the organisation’s retention policies / procedures for tax records? Asset records such as contracts and title deeds? Financial records?
¼ Is there delineated responsibility for the management of corporate records?
Systems to ensure consistent records The�format�of�paper-based�records�and�how�they�are�created�is�often�apparent�by�their�appearance.�However,�systems�for�creation�of�legal�records,�for�example,�minutes�of�meetings�of�Boards,�may�be�subject�to�specific�processes�such�as�storage�in�a�tamper-proof�journal,�and�policy�should�address�how�these�records�are�created�and�by�whom.�In�the�case�of�electronic�records,�security�levels,�file�paths�and�access�should�be�considered�and�the�requirements�for�creation�documented.�Standardised�record�creation�and�filing,�whether�paper-based�or�electronic,�assists�in�locating�records�and�ensuring�that�retention�and�destruction�schedules�are�met.5
Records�that�leave�the�central�control�should�be�tracked�and�monitored,�so�that�the�organisation�is�aware�of�who�holds�the�record,�especially�if�it�is�a�single�copy�of�a�paper-based�record�or�if�circulation�of�the�information�could�have�legal�ramifications.
Tracking�of�the�movement�and�use�of�records�within�a�records�system�is�required�to:
• identify�outstanding�action�required
• enable�retrieval�of�a�record
• prevent�loss�of�records
• monitor�usage�for�systems�maintenance�and�security,�and�maintain�an�auditable�trail�of�records�transactions,�for�example,�capture�or�registration,�classification,�indexing,�storage,�access�and�use,�migration�and�disposition
• maintain�the�capacity�to�identify�the�operational�origins�of�individual�records�where�systems�have�been�amalgamated�or�migrated.
Tracking�mechanisms�may�record�the�item�identifier,�the�title,�the�person�or�unit�having�possession�of�the�item�and�the�time�/�date�of�movement.
October 2010 337
Adherence�to�records�management�processes�and�file�management�systems�is�required�to�control�important�documents�as�they�evolve�through�a�series�of�drafts.�Documents�emailed�outside�the�organisation�for�comment�or�editing�can�be�challenging�to�track;�a�system�for�version�control�is�necessary.�It�is�important�that�staff�approach�record�keeping�with�discipline�to�ensure�that�all�files�including�emails�and�SMS�messages�are�effectively�backed�up.
Prompt points
¼ How does the organisation ensure compliance with records management policy?
¼ What system does the organisation use to monitor and track corporate records? How is the system evaluated? What changes have been made following evaluation of the system?
Staff training and educationThere�should�be�central�control�over�what�organisationally-relevant�documents�are�stored�and�where�they�are�stored.�Policy�should�direct�staff�on�corporate�records�management.�Staff�responsibilities�should�be�highlighted�during�orientation,�and�training�should�be�provided�to�ensure�compliance�with�the�policy.
Staff�training�needs�will�differ�according�to�position�descriptions�and�individual�responsibilities�with�respect�to�access�and�management�of�corporate�records.�The�specific�documents�that�need�to�be�handled�by�an�administration�staff�member�vary�greatly�from�those�that�are�important�for�clinical�staff.
Staff�training�programs�on�record�keeping�remain�important�and�should�cover�topics�such�as:�
• what�is�a�record?
• why�records�need�to�be�kept
• record�keeping�obligations�of�all�staff
• how�to�file�records�in�corporate�record�keeping�systems
• when�and�how�to�dispose�of�records.�
Records�management�training�often�only�talks�of�records�in�general�terms,�outlining�statements�such�as�‘records�are�any�documents�that�provide�evidence�of�a�decision�or�activity’.�In�practice,�not�every�document�or�email�should�be�kept,�and�general�statements�do�little�to�help�staff�make�judgements�about�what�to�file�and�where�to�file�it.�Training�programs�need�to�be�tailored�to�ensure�all�staff�are�aware�of�the�organisation’s�expectations�and�their�own�responsibilities.
A�training�program�for�record�keeping�and�records�management�should�be�established�and�provided�for�staff�with�records�management�responsibilities,�other�staff�with�records�use�responsibilities�and�new�recruits.
Prompt points
¼ How does the organisation provide records management training to new staff? How is the training tailored to different positions?
¼ What checks are done to ensure staff are aware of their responsibilities when creating, handling, and storing records?
¼ Which, if any, corporate records are audited regularly to ensure adherence to policy and processes?
Evidence commonly presented
Consider whether the following will help to address criterion 2.3.2
¼ Policies / guidelines and procedures for corporate records management
¼ Facilities or equipment for management of corporate records, including:
– storage / location / security – file management systems – search / retrieval processes – privacy / confidentiality compliance – templates that speed recording or
structure content of records ¼ Corporate records audit results or other
performance indicators
¼ Systems for managing organisational needs, including:
– monitoring changes in legislation and tracking compliance
– asset registers – filing of contracts – financial and accounting records – corporate records – correspondence – human resources records – industrial relations records – minutes of meetings
seCtion 5Standards, criteria, elements and guidelinesstandard 2.3:�Information�management�systems�enable�the�organisation’s�goals�to�be�met
338 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
References1.� AS�ISO�15489.2:2002�Recordsmanagement:Guidelines.
2.� Office�of�the�Federal�Privacy�Commissioner.�Stateandterritoryprivacylaws.�Sydney�NSW;�Australian�Government.�Accessed�from�http://www.privacy.gov.au/aboutus/contact�on�1�September�2010.
3.� NSW�Health.�Records–Principlesforcreation,management,storageanddisposalofhealthcarerecords.�Sydney;�NSW�Health;�2005.
4.� Information�Enterprises�Australia.�Australianrecordretentionmanual.�Fremantle�WA;�Information�Enterprises�Australia;�2009.
5.� AS�ISO�15489.1:2002�Recordsmanagement:General.
Criterion 2.3.2
Corporate�records�management�systems�support�the�collection�of�information�and�meet�the�organisation’s�needs.�(continued)
Performance measurementThis�criterion�states�that:�“Corporate�records�management�systems�support�the�collection�of�information�and�meet�the�organisation’s�needs”.�The�organisation�should�be�able�to�demonstrate�both�that�it�fulfils�its�legislative�responsibilities�for�the�collection,�storage,�destruction�and�confidential�management�of�corporate�records,�and�that�it�has�systems�in�place�that�facilitate�its�need�for�efficient�operation�and�quality�service�provision.
Some�common�suggested�performance�measures�are�as�follows:
Number�of�corporate�records�that�comply�with�standards�for�such�areas�as�storage,�policies,�procedures
Total number of corporate records reviewed
Number�of�reports�to�State�/�Territory�health�departments�that�are�accurate�(i.e.�error�free)�
Total number of reports submitted to State / Territory health departments
Number�of�reporting�submissions�to�external�bodies�that�meet�timeframes
Total number of reporting submissions to external bodies
Number�of�staff�who�have�completed�education�/�training�in�corporate�records�management
Total number of staff requiring education / training in corporate records management
October 2010 339
seCtion 5Standards, criteria, elements and guidelinesstandard 2.3:�Information�management�systems�enable�the�organisation’s�goals�to�be�met
340 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion LA – Awareness sA – implementationLA plus the following
MA – evaluationSA plus the following
eA – excellenceMA plus the following
oA – LeadershipEA plus the following
Criterion 2.3.3
Data�and�information�are�collected,�stored�and�used�for�strategic,�operational�and�service�improvement�purposes.
a)� The�collection,�storage�and�use�of�data�comply�with�professional�and�statutory�requirements.
b)� Policy�/�guidelines�exist�for�the�validation�and�protection�of�data�and�information.
c)� Data�are�available�for:
� (i)� research
� (ii)� development
� (iii)� improvement�activities
� (iv)� education
� (v)� �corporate�and�clinical�decision�making.�
d)� Resources�exist�for�the�assessment,�analysis�and�use�of�data.
e)� Reference�and�resource�materials�are�available�for�use�by�staff.
a)� An�information�management�plan�is�implemented�and�identifies�the�needs�of�the�organisation�at�all�levels.
b)� A�system�is�implemented�for�validation�and�protection�of�data�and�information.
c)� Data�storage�and�retrieval�are�facilitated�through�effective�classification�and�indexing.
d)� Responsibility�and�accountability�for�action�on�data�and�information�are�clearly�delineated.
e)� Databases�are�linked�to�provide�access�within�and�across�units�and�departments.
f)� Staff�have�access�to�training�on�information�and�data�management.
g)� Liaison�with�external�bodies�improves�the�quality�of�information�supplied�and�received.
h)� The�organisation�contributes�to�external�databases�and�registers.
i)� There�are�systems�to�provide�information�for�authorised�stakeholders�that�are�consistent�with�jurisdictional�privacy�legislation.
j)� The�needs�of�staff�for�reference�and�resource�materials�are�identified,�analysed�and�prioritised.
a)� Systems�used�for�validation�and�protection�of�data�and�information�are�evaluated�and�improved�as�required.
b)� Monitoring�and�analysis�of�clinical�and�non-clinical�data�and�information�occurs�to�ensure:
� (i)� �accuracy,�integrity�and�completeness
� (ii)� �timeliness�of�information�and�reports
� (iii)� �the�needs�of�the�organisation�are�met,�
� and�improvements�are�made�as�required.
c)� Training�is�evaluated�to�ensure�it�improves�skills�in�information�and�data�management.�
d)� Data�use�and�reporting�processes�are�evaluated�and�improved�as�required.
e)� The�organisation�reviews�results�from�external�databases�and�registers�and�improves�care�and�services�as�indicated.
f)� Reference�management�and�resource�material�systems�are�evaluated�and�improved�as�required.
a)� Information�and�data�management�systems�are�compared�internally�and�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.
and/or
b)� Systems�for�the�management�of�reference�and�resource�material�are�compared�internally�and�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.�
and/or
c)� The�organisation�undertakes�research�into�information�systems�and�data�management�and�collection�systems,�and�acts�on�results.
a)� The�organisation�demonstrates�it�is�a�leader�in�the�collection,�use�and�storage�of�data�and�information.
October 2010 341
Criterion LA – Awareness sA – implementationLA plus the following
MA – evaluationSA plus the following
eA – excellenceMA plus the following
oA – LeadershipEA plus the following
Criterion 2.3.3
Data�and�information�are�collected,�stored�and�used�for�strategic,�operational�and�service�improvement�purposes.
a)� The�collection,�storage�and�use�of�data�comply�with�professional�and�statutory�requirements.
b)� Policy�/�guidelines�exist�for�the�validation�and�protection�of�data�and�information.
c)� Data�are�available�for:
� (i)� research
� (ii)� development
� (iii)� improvement�activities
� (iv)� education
� (v)� �corporate�and�clinical�decision�making.�
d)� Resources�exist�for�the�assessment,�analysis�and�use�of�data.
e)� Reference�and�resource�materials�are�available�for�use�by�staff.
a)� An�information�management�plan�is�implemented�and�identifies�the�needs�of�the�organisation�at�all�levels.
b)� A�system�is�implemented�for�validation�and�protection�of�data�and�information.
c)� Data�storage�and�retrieval�are�facilitated�through�effective�classification�and�indexing.
d)� Responsibility�and�accountability�for�action�on�data�and�information�are�clearly�delineated.
e)� Databases�are�linked�to�provide�access�within�and�across�units�and�departments.
f)� Staff�have�access�to�training�on�information�and�data�management.
g)� Liaison�with�external�bodies�improves�the�quality�of�information�supplied�and�received.
h)� The�organisation�contributes�to�external�databases�and�registers.
i)� There�are�systems�to�provide�information�for�authorised�stakeholders�that�are�consistent�with�jurisdictional�privacy�legislation.
j)� The�needs�of�staff�for�reference�and�resource�materials�are�identified,�analysed�and�prioritised.
a)� Systems�used�for�validation�and�protection�of�data�and�information�are�evaluated�and�improved�as�required.
b)� Monitoring�and�analysis�of�clinical�and�non-clinical�data�and�information�occurs�to�ensure:
� (i)� �accuracy,�integrity�and�completeness
� (ii)� �timeliness�of�information�and�reports
� (iii)� �the�needs�of�the�organisation�are�met,�
� and�improvements�are�made�as�required.
c)� Training�is�evaluated�to�ensure�it�improves�skills�in�information�and�data�management.�
d)� Data�use�and�reporting�processes�are�evaluated�and�improved�as�required.
e)� The�organisation�reviews�results�from�external�databases�and�registers�and�improves�care�and�services�as�indicated.
f)� Reference�management�and�resource�material�systems�are�evaluated�and�improved�as�required.
a)� Information�and�data�management�systems�are�compared�internally�and�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.
and/or
b)� Systems�for�the�management�of�reference�and�resource�material�are�compared�internally�and�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.�
and/or
c)� The�organisation�undertakes�research�into�information�systems�and�data�management�and�collection�systems,�and�acts�on�results.
a)� The�organisation�demonstrates�it�is�a�leader�in�the�collection,�use�and�storage�of�data�and�information.
seCtion 5Standards, criteria, elements and guidelinesstandard 2.3:�Information�management�systems�enable�the�organisation’s�goals�to�be�met
342 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 2.3.3
Data�and�information�are�collected,�stored�and�used�for�strategic,�operational�and�service�improvement�purposes.�(continued)
IntentHealth�care�is�information-dependant�and�cannot�be�provided�efficiently�without�facts;�therefore,�the�collection,�use�and�storage�of�data�are�integral�to�the�management�of�all�healthcare�organisations.�
The�intent�of�this�criterion�is�to�ensure�that�there�are�systems�in�place�for�the�collection�of�data�and�information,�that�data�and�information�are�made�available�for�use�in�a�timely�manner,�and�that�data�and�information�are�stored�safely�and�used�effectively�so�as�to�meet�the�organisation’s�needs.
Relationships of 2.3.3 with other criteriaWithin�healthcare�organisations,�the�collection,�storage�and�usage�of�data�are�most�conspicuous�in�the�creation�and�maintenance�of�consumer�/�patient�health�records�(Criterion�1.1.8)�and�the�implementation�of�systems�for�health�record�management�(Criterion�3.2.1).�However,�data�systems�also�impact�significantly�upon�the�management�of�other�important�records,�including�personnel�information�(Standard�2.2),�corporate�records�(Criterion�2.3.2)�and�all�research�documentation�(Criterion�2.5.1).�In�addition,�data�from�incidents�(Criterion�2.1.3)�and�complaints�(Criterion�2.1.4)�should�be�recorded�and�analysed�to�minimise�recurrence.
Effective�management�systems�for�information�and�communication�technology�(Criterion�2.3.4)�will�assist�organisations�to�collect,�access,�store�and�use�data�and�information.�The�organisation�must�ensure�the�security�of�all�records,�both�paper-based�and�electronic�(Criterion�3.2.5).
Data and information managementOrganisations�produce�an�overwhelming�volume�of�information�and�certain�types�of�information�need�to�be�managed�in�different�ways.�The�data�and�information�management�system�should�ensure�that�data�and�information�are�available,�accessible�and�relevant�to�the�strategic�and�operational�needs�of�the�organisation.�In�addition,�organisations�will�need�to�ensure�there�are�sufficient�resources�to�manage�this�information.
Three�major�categories�of�information�within�many�organisations�are:
• key�corporate�information�
• information�shared�within�an�organisation�
• information�communicated�externally.
Organisations�should�consider�these�categories�when�developing�information�management�plans.�File�formats,�the�storage�media�chosen,�how�the�system�is�backed�up,�access�restrictions�and�other�factors�will�be�influenced�by�legislation�governing�retention,�confidentiality�issues�and�whether�the�information�will�be�shared�with�other�departments,�organisations�and�data�systems.�
Policies�and�procedures�for�information�and�data�management�and�collection�systems�may�include:�
• identifying�and�planning�for�the�organisation’s�information�needs�
• defining�and�capturing�data�and�information�from�various�sources�and�in�compliance�with�all�statutory�requirements
• linking�and�combining�different�types�of�data�and�information�within�and�outside�the�organisation
• analysing�data�and�transforming�them�into�information�that�is�easily�interpreted�by�the�user
• transmitting�and�reporting�data�and�information�
• managing�all�types�of�records
• storing�data�and�information�so�they�are�easy�to�retrieve
• educating�and�training�users�on�the�appropriate�and�ethical�ways�of�collecting�and�using�data�and�information
• obtaining�input�from�users�to�ensure�the�data�collected�and�reported�are�useful�and�relevant�
• ensuring�data�and�information�are�available�at�points�of�care�for�care�planning�and�decision�making
• processes�to�monitor�the�quality�of�data�and�information,�including�data�reliability,�accuracy�and�validity�from�both�internal�and�external�sources
• comparing�organisational�performance�and�outcomes�internally�and�externally�with�other�healthcare�organisations�and�best-practice�standards�
• systems�and�procedures�for�managing�financial�data.�
Databases�are�used�to�store�information�in�a�predictable�structure.�Well-designed�databases�and�information�systems�can�respond�to�questioning.�Repetition�of�information�within�a�database�may�use�
October 2010 343
a�lot�of�memory,�but�when�designed�with�appropriate�links�between�key�fields,�the�capability�of�databases�can�be�expanded�in�this�way.�Similarly,�links�between�databases�can�tie�together�clinical�information�from�multiple�sources�and�sometimes�overcome�fundamental�design�differences�between�storage�systems.�Tools�such�as�HL7�may�play�a�major�role�in�achieving�these�goals�of�integrating�data�from�independent�database�sources.
Prompt points
¼ How has the organisation identified and described its needs for information management?
¼ How does the organisation provide access to data within and across all units?
¼ What training is provided to staff? How are staff requiring training identified? Are there programs to improve the generic computer skills of ‘frontline’ staff?
¼ Is training provided as part of orientation? Is training provided on the specific applications used within the organisation?
¼ What improvements have been made in response to insights gained from the collection of data and information, and their analysis?
Data collection, use, storage and retrievalData�management�should�comply�with�relevant�privacy�protocols,�such�as�the�Privacy(PrivateSector)Regulations2001�(Cth)�on�personal�privacy�protection.�Information�is�available�at�http://www.privacy.gov.au
When�data�are�collected�from�different�sources,�organisations�should�have�systems�in�place�to�reduce�the�error�rate;�the�most�effective�way�of�maintaining�data�quality�in�a�database�is�to�manage�the�data�at�the�point�of�collection�and�data�entry,�and�then�to�segregate�data.�
Having�standardised�processes�and�procedures�and�experienced�people�collecting�the�data�are�key�prerequisites.
Information�use�should�be�appropriate�and�managed�effectively.�Data�should�be�sorted�into�categories�so�that�a�problem�or�issue�can�be�understood.�Analysing�data�and�identifying�the�essential�elements�creates�information�and�helps�organisations�to�consider�what�needs�to�be�done�next.�
Healthcare�professionals�who�use�and�report�data�should�be�involved�in�its�analysis.�Responsibility�and�accountability�for�action�on�data�and�information�and�accuracy�of�data�should�be�clearly�defined�within�the�organisation�and�communicated�to�all�staff.�
Information�can�be�used�to�improve�performance,�for�research�and�development,�education�(staff�and�consumer�/�patient)�and�decision�making�(clinical�and�non-clinical).�Examples�of�uses�include:
• demographic�information�may�guide�updates�to�local�health�promotion�strategies�
• clinical�indicator�data�may�provide�insights�into�variations�in�the�effectiveness�of�care�delivery�systems�or�treatment�protocols�within�or�between�organisations
• complication�rates�or�variance�data�may�influence�the�ongoing�development�of�clinical�pathways
• incident�data�may�guide�priority�setting�when�improving�organisational�care�delivery�processes
• complaints�data�can�be�used�to�improve�care�and�services
• infection�surveillance�data�may�indicate�effectiveness�of,�or�breakdowns�in,�preventative�systems
• relative�utilisation�rates�can�be�used�to�assess�appropriateness�of�services
• Diagnosis�Related�Group�(DRG)�information�may�highlight�local�demand�and�assist�the�planning�of�new�services.
The�ways�in�which�data�and�information�are�stored�will�depend�on�the�type�of�data�or�information,�as�well�as�the�media�in�which�they�are�held.�Organisations�should�ensure�that�there�is�policy�addressing�the�methods�of�data�collection,�use�and�storage,�depending�on�the�form�the�information�takes.�Policy�should�consider1:
• the�clinical�and�business�data�that�is�most�sensitive�from�the�perspectives�of�the�organisation’s�consumers�/�patients,�clinicians,�and�the�administrators�
• where�the�most�sensitive�clinical�data�resides
• the�origin�and�nature�of�any�risks.
The�organisation�should�determine�what�controls�will�best�manage�the�risks�and�protect�sensitive�and�critical�data.�Security�of�data�should�be�managed�centrally�and�security�systems�should�be�regularly�tested.�
seCtion 5Standards, criteria, elements and guidelinesstandard 2.3:�Information�management�systems�enable�the�organisation’s�goals�to�be�met
344 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 2.3.3
Data�and�information�are�collected,�stored�and�used�for�strategic,�operational�and�service�improvement�purposes.�(continued)
Prompt points
¼ How does the organisation ensure compliance with regulatory and professional standards?
¼ How are staff notified of lines of responsibility for data and information management?
¼ How does the organisation ensure staff understand the meaning of data and what its purpose is?
Validation and protectionThere�should�be�processes�for�confirming�the�accuracy�of�all�data�used�to�support�decisions,�reports�and�funding.�Validating�the�data�at�time�of�entry�into�the�organisation’s�systems�is�undoubtedly�the�best�and�most�efficient�means�of�maintaining�quality.�In�doing�so,�organisations�will�reduce�the�need�for�validation�tools,�and�the�time�and�resources�allocated�for�costly�manual�inspection�of�data,�rectification�at�source�and�rework�in�a�second�collation.
Data�validation�is�often�a�multi-step�process�where�a�small�sample�of�data�is�closely�examined,�and�depending�on�whether�the�quality�is�within�acceptable�levels�of�tolerance�(i.e.�the�examination�of�a�pre-agreed�sample�size�yields�more�or�less�errors�than�a�benchmark),�a�decision�may�be�made�to�extend�the�sample,�or�instead�test�all�the�data�for�one�or�more�characteristics.�This�recognises�how�commonly�data�may�be�problematic.�Irregular�data�have�a�high�probability�of�also�being�inaccurate,�particularly�if�collected�by�different�personnel�or�through�different�processes,�and�must�be�rechecked�before�the�irregularity�is�confirmed�as�a�characteristic.
Prompt points
¼ How is the policy for validation and protection of data and information implemented? How is this system evaluated?
¼ How does the organisation address rating reliability?
External databases Data�and�information�that�are�available�from�other�clinical�information�systems,�either�internally�or�externally,�can�be�utilised�in�conjunction�with�health�record�data�as�long�as�any�ethical�and�privacy�concerns�are�addressed.�Having�timely�information�from�these�sources�can�enhance�care.�Examples�of�these�types�of�clinical�information�systems�include:
• pathology�and�radiology�results�by�secure�or�encrypted�phone�/�fax�/�computer�/�email
• external�pharmacy�data
• films,�images,�graphs�and�prints
• clinical�pathway�variance�data
• Clinical�Information�Access�Program�(CIAP)
• Doctors�reference�site
• Cochrane�Library�database
• Medline.
Each�organisation�should�be�aware�of�mandatory�external�data�collection�and�reporting�requirements.�
To�meet�these�requirements,�data�should�be�accessible�and�reporting�timelines�and�mechanisms�identified.�Some�of�these�data�collections�include:�
• inpatient�statistics�collection
• infectious�disease�notification�
• jurisdictional�data�collections
• cancer�notifications
• midwives�data�collection�
• suspected�child�abuse�/�domestic�violence
• deaths�/�coroner’s�cases�
• victims�of�crime
• other�clinical�registries�including�those�monitoring�stroke�patients�(AuSCR),�clinical�trials,�rehabilitation�outcomes�(AROC),�cardiac�procedures�(ACPR),�burns,�femoral�neck�fractures�(NOffRA)2,�and�cancer�registries�(AIHW)
• employer�responsibilities�to�the�relevant�Taxation�Act,�such�as�social�service�garnishees,�payment�of�group�tax,�tax�status�
• payroll�information,�such�as�income�tax,�leave�entitlements,�superannuation�payments,�etc.
October 2010 345
External�entities�often�use�an�organisation’s�information.�Organisations�should�ensure�that�there�is�a�system�in�place�to�produce�such�information�for�external�entities�and�that�they�have�the�authority�to�access�and�use�the�information�in�compliance�with�Commonwealth�and�State�/�Territory�legislation�and�other�requirements.�These�external�entities�include:
• Departments�of�Health
• funders�of�health�care
• insurers
• accreditation�and�certification�agencies�
• legislators
• coroners
• courts�of�law
• media
• stakeholders
• local�government�
• benchmarking�groups
• local�community.
Prompt points
¼ What external databases does the organisation contribute to? How does the organisation coordinate data submission to external databases?
¼ Is secure messaging used to transfer data to external sources?
¼ How has the quality of information collected by the organisation improved through liaison with external bodies?
References and resources for staffStaff�access�to,�and�utilisation�of,�reference,�research�and�other�resource�materials3�are�of�crucial�importance�in�supporting�evidence-based�practice�and�improving�quality�programs�and�services�in�health�care.�
An�organisation’s�processes�for�managing�reference,�research�and�other�resource�materials�should�be�based�on�current�and�future�needs�and�utilise�links�with�relevant�external�databases,�information�networks,�bodies�of�expert�help�and�administrative�or�research�knowledge.�
New�staff�are�likely�to�require�training�in�order�to�understand�the�information�available�to�them�and�to�become�efficient�and�effective�in�accessing�information�when�it�is�most�needed.
Evaluation�of�information�materials�should�consider�the�cost�effectiveness�of�different�options�for�information�provision.�Any�evaluation�should�also�identify�which�information�is�absolutely�key�for�safe�practice�and�ensure�that�alternative�access�in�cases�of�electronic�systems�failure�is�considered.
Prompt points
¼ How are the needs of staff for reference and resource tools identified?
¼ How are reference and resource materials made available to staff? What is the use rate by staff?
¼ How is usage and cost effectiveness of information provision analysed?
Evidence commonly presented
Consider whether the following will help to address criterion 2.3.3
¼ Information management strategic plan
¼ Types of data collected and the utilisation of data
¼ Evidence of data linkages
¼ Evidence of training for staff in data management
¼ Reported errors in coding
¼ Reported errors in records
¼ Satisfaction with financial reports and budget development
¼ Evaluation of data collected
¼ Systems to manage information on:
– document control – relevant monitoring – validation and protection of data
¼ Evaluation of systems
¼ Policies and procedures such as mandatory reporting, accountability, etc.
seCtion 5Standards, criteria, elements and guidelinesstandard 2.3:�Information�management�systems�enable�the�organisation’s�goals�to�be�met
346 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 2.3.3
Data�and�information�are�collected,�stored�and�used�for�strategic,�operational�and�service�improvement�purposes.�(continued)
Performance measurementThis�criterion�states�that:�“Data�and�information�are�collected,�stored�and�used�for�strategic,�operational�and�service�improvement�purposes”.�Safe,�high�quality�health�care�is�information-dependent,�and�organisations�should�be�able�to�demonstrate�that�they�have�systems�for�managing�the�collection�and�use�of�data�to�support�all�facets�of�their�operation.
Some�common�suggested�performance�measures�are�as�follows:
Number�of�staff�satisfied�with�computer�access
Total number of staff
Number�of�staff�who�have�completed�education�/�training�in�data�/�information�collection�and�storage
Total number of staff requiring education / training in data / information collection and storage
Number�of�staff�who�have�undertaken�training�courses�to�improve�their�computer�skills
Total number of staff invited to undertake training to improve their computer skills
Number�of�pathology,�imaging,�etc.�reports�received�within�X�hours,�that�enable�clinical�decision�and�appropriate�care
Total number of requests for pathology, imaging, etc. reports
Comment:theorganisationtodefine‘X’
Number�of�incidents�that�relate�to�problems�with�delivery�of�service�due�to�lack�of�information
Total number of incidents that relate to problems with delivery of service
Number�of�users�satisfied�with�information�provided�in�reports
Total number of users surveyed
October 2010 347
References1.� RSA�Security�and�Frost�&�Sullivan.�Informationrisk
managementforhealthcareorganizations:Sixbestpracticesforprotectingyourhealthinformation.Palo�Alto�USA;�Frost�&�Sullivan;�2008.
2.� Australian�Commission�on�Safety�and�Quality�in�Health�Care�(ACSQHC).�Australianclinicalqualityregistries.Sydney�NSW;�ACSQHC.�Accessed�from�http://www.health.gov.au/internet/safety/publishing.nsf/Content/PriorityProgram-08_CQRegistries�on�28�June�2010.
3.� Health�Libraries�Australia.�GuidelinesforAustralianhealthlibraries.4th�edn.�Canberra�ACT;�Australian�Library�&�Information�Association�(ALIA);�2008.
seCtion 5Standards, criteria, elements and guidelinesstandard 2.3:�Information�management�systems�enable�the�organisation’s�goals�to�be�met
348 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
IntentInformation�management�is�a�term�used�to�encompass�all�of�the�systems�and�processes�for�the�creation�and�use�of�information�within�an�organisation.�In�a�technological�context,�information�management�is�a�collective�term�that�includes�electronic�systems�designed�to�facilitate�communication�and�the�flow�of�information.�These�technologies�include�personal�computers,�the�internet,�email,�videoconferencing,�telehealth�and�mobile�technologies�such�as�handheld�or�tablet�computers.�
The�intent�of�this�criterion�is�to�ensure�that�the�organisation’s�information�and�communication�technology�needs�are�met�through�appropriate�use�and�management�of�technology.�
Relationships of 2.3.4 with other criteriaInformation�and�communication�technology�(I&CT)�within�healthcare�organisations�supports�many�areas�of�service�delivery,�including�health�record�content�(Criterion�1.1.8),�and�the�management�of�health�records�(Criterion�2.3.1),�corporate�records�(Criterion�2.3.2)�and�human�resources�records�(Standard�2.2).�All�data�collected,�stored�and�used�within�the�organisation�(Criterion�2.3.3)�must�be�managed.�Many�medical�devices�and�other�clinical�equipment�also�rely�upon�software�and�technology�(Criterion�3.2.2).�
Correct�and�responsible�use�of�I&CT�should�be�addressed�during�staff�orientation�(Criterion�2.2.2).�Where�organisations�rely�upon�external�service�providers�and�operators�of�sections�of�their�I&CT�strategic�development�and�service�delivery,�appropriate�and�detailed�service�agreements�will�be�required�(Criterion�3.1.4).�The�organisation’s�approach�to�planning,�use�and�management�of�I&CT�is�an�aspect�of�its�integrated�risk�management�framework�(Criterion�2.1.2)�and�of�organisational�security�(Criterion�3.2.5).
Criterion LA – Awareness sA – implementationLA plus the following
MA – evaluationSA plus the following
eA – excellenceMA plus the following
oA – LeadershipEA plus the following
Criterion 2.3.4
The�organisation�has�an�integrated�approach�to�the�planning,�use�and�management�of�information�and�communication�technology�(I&CT).
a)� There�is�effective�governance�of�I&CT�that�is�supported�by�policy�and�procedure.
b)� Licences�are�purchased�as�required.
c)� A�system�of�I&CT�operational�support�exists.�
d)� There�is�a�documented�plan�for�managing�I&CT�risks�and�crises.
a)� A�strategy�for�current�and�future�I&CT�needs�is�implemented.
b)� Strategies�for:
� (i)� backup
� (ii)� security�
� (iii)� protection�of�privacy
� (iv)� virus�detection
� are�implemented�and�used.
c)� There�is�a�planned�system�for�preventative�maintenance�for�I&CT.
d)� A�strategy�and�plan�for�disaster�recovery�/�business�continuity�is�implemented.
e)� The�integrated�I&CT�system�supports�the�collection,�aggregation�and�analysis�of�data.�
a)� The�I&CT�system,�including�compliance�with�I&CT�policy�and�procedures,�is�evaluated�and�improved�as�required.
b)� The�preventative�maintenance�and�repair�system�for�I&CT�is�evaluated�regularly�and�improved�as�required.
c)� The�risk�and�crisis�management�system�for�I&CT�is�evaluated�regularly�and�improved�as�required.
a)� The�I&CT�system�is�compared�with�external�systems�and�improvements�are�made�to�ensure�better�practice.
and/or
b)� The�preventative�maintenance�system�is�compared�with�external�systems�and�improvements�are�made�to�ensure�better�practice.
and/or
c)� Risk�and�crisis�management�systems�are�compared�with�external�systems�and�improvements�are�made�to�ensure�better�practice.
and/or
d)� The�organisation�undertakes�research�into�I&CT�systems�and�implements�improved�systems.
a)� The�organisation�demonstrates�it�is�a�leader�in�the�planning,�use�and�management�of�I&CT.
October 2010 349
Policies and proceduresAn�I&CT�plan�supported�by�policy�and�procedures�for�all�aspects�of�I&CT�management�is�required.�This�will�develop�the�organisation’s�capacity�to�effectively�manage�I&CT�applications�and�infrastructures�to�support�the�organisation’s�operations�and�business.�The�plan�should�be�proportionate�to�the�size,�role�and�complexity�of�the�organisation�and�similarly,�to�the�range�and�programs�of�I&CT�in�the�organisation.
The�I&CT�plan�should�include�(but�not�be�limited�to):
• communications�technologies�(voice,�video,�data)
• applications�and�services
• integration�with�the�current�infrastructure
• management�of�data,�information�and�knowledge
• change�management�and�workflow�redesign
…�and�should�consider:
• ongoing�maintenance,�updating�and�development�of�I&CT�for�the�organisation
• organisational�strategic�and�investment�plans
• the�national�e-health�strategy�
• planned�outcomes�from�future�investment�in�I&CT.
To�achieve�the�outcomes�proposed�within�the�I&CT�plan,�there�will�need�to�be�clear�governance�and�accountability�over�a�number�of�key�areas�including:
• oversight�of�the�vision�and�its�alignment�with�jurisdictional�and�national�health�objectives
• maintenance,�implementation�and�ongoing�review�
• information�management�and�technology�policies,�principles�and�standards
• funding,�to�ensure�long-term�sustainability�
• common�expectations,�including�implementation�of�and�compliance�with�policies,�protocols�and�standards�within�the�organisation
• personal�use�of�IC&T
• inappropriate�use�of�IC&T.
Criterion LA – Awareness sA – implementationLA plus the following
MA – evaluationSA plus the following
eA – excellenceMA plus the following
oA – LeadershipEA plus the following
Criterion 2.3.4
The�organisation�has�an�integrated�approach�to�the�planning,�use�and�management�of�information�and�communication�technology�(I&CT).
a)� There�is�effective�governance�of�I&CT�that�is�supported�by�policy�and�procedure.
b)� Licences�are�purchased�as�required.
c)� A�system�of�I&CT�operational�support�exists.�
d)� There�is�a�documented�plan�for�managing�I&CT�risks�and�crises.
a)� A�strategy�for�current�and�future�I&CT�needs�is�implemented.
b)� Strategies�for:
� (i)� backup
� (ii)� security�
� (iii)� protection�of�privacy
� (iv)� virus�detection
� are�implemented�and�used.
c)� There�is�a�planned�system�for�preventative�maintenance�for�I&CT.
d)� A�strategy�and�plan�for�disaster�recovery�/�business�continuity�is�implemented.
e)� The�integrated�I&CT�system�supports�the�collection,�aggregation�and�analysis�of�data.�
a)� The�I&CT�system,�including�compliance�with�I&CT�policy�and�procedures,�is�evaluated�and�improved�as�required.
b)� The�preventative�maintenance�and�repair�system�for�I&CT�is�evaluated�regularly�and�improved�as�required.
c)� The�risk�and�crisis�management�system�for�I&CT�is�evaluated�regularly�and�improved�as�required.
a)� The�I&CT�system�is�compared�with�external�systems�and�improvements�are�made�to�ensure�better�practice.
and/or
b)� The�preventative�maintenance�system�is�compared�with�external�systems�and�improvements�are�made�to�ensure�better�practice.
and/or
c)� Risk�and�crisis�management�systems�are�compared�with�external�systems�and�improvements�are�made�to�ensure�better�practice.
and/or
d)� The�organisation�undertakes�research�into�I&CT�systems�and�implements�improved�systems.
a)� The�organisation�demonstrates�it�is�a�leader�in�the�planning,�use�and�management�of�I&CT.
seCtion 5Standards, criteria, elements and guidelinesstandard 2.3:�Information�management�systems�enable�the�organisation’s�goals�to�be�met
350 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 2.3.4
The�organisation�has�an�integrated�approach�to�the�planning,�use�and�management�of�information�and�communication�technology�(I&CT).�(continued)
Prompt points
¼ How is I&CT governed? Who has ultimate responsibility for I&CT?
¼ How is compliance with the I&CT policy ensured?
¼ What checks are made to determine whether the organisation’s system meets requirements for both appropriate access and privacy of different classes of records?
Strategic planningEffective�use�of�I&CT�requires�an�integrated�approach�to�the�planning�and�use�of�technology.�Planning�helps�to�ensure�that�I&CT�improves�the�effectiveness�and�efficiency�of�the�organisation’s�management�of�information�via�collection,�aggregation�and�analysis�of�data.�
Larger�organisations�often�develop�a�separate�information�technology�plan�as�an�integral�part�of�their�information�management�plan.�Smaller�organisations�may�include�information�management�and�I&CT�within�the�overall�strategic�and�business�plans.�
It�may�also�be�useful�to�consider�the�following�issues:�
• responsibility�for�management�of�the�organisation’s�information�technology�
• users’�needs�and�expectations
• the�form�in�which�information�will�be�kept,�for�example,�electronic�or�microfilm�
• the�relationship(s)�between�information�held�in�various�forms�
• how�systems�will�be�linked�and�work�together,�including�support�for�management�of�the�systems
• data�uniformity�through�the�definition�of�key�data�elements�
• standard�operating�environment�across�the�whole�organisation
• version�control�of�documents
• State�/�Territory,�national�and�international�guidelines�and�standards
• legal�issues,�such�as�legally�authorised�use�of�software�
• confidentiality�issues
• I&CT�purchases�requiring�consultation�with�key�personnel,�purchasing�against�set�criteria�related�to�business�requirements
• applications�and�infrastructure
• coordination�of�service-specific�databases
• education�for�relevant�staff�in�I&CT�use,�organisational�policy�and�staff�responsibilities
• management�if�systems�are�upgraded�/�changed�to�ensure�access�to�existing�data
• the�need�for�specific�types�of�management�planning�systems�to�enhance�the�organisation’s�I&CT�systems,�such�as�behaviour�management,�cost�management,�I&CT�change�management,�I&CT�project�management,�availability�management�and�capacity�management.
Prompt points
¼ How are the organisation’s I&CT needs decided? Who is involved in this?
¼ How are anticipated future needs decided and documented?
Systems maintenance and operational supportSoftware�licensing�and�copyright�regulations�are�obligatory�to�ensure�that�intellectual�property�rights�and�title�to�products�are�retained�by�product�owners.�Organisations�should�ensure�that�there�are�appropriate�licences�for�all�software�being�used�on�their�computers.�Staff�should�be�made�aware�of�the�need�to�operate�systems�within�the�legal�requirements�of�the�respective�licence�arrangements.�Policy�should�list�approved�software�and�include�procedures�for�the�review�and�introduction�of�other�software.�
Logical�security�comprises�security�features�that�are�built�into�communications,�information�technology�(IT)�and�other�information�management�(IM)�systems.�Secure�data�storage�is�of�the�utmost�importance�in�a�healthcare�setting.�Compliance�with�the�National�Privacy�Principles�(NPP)1-3�and�the�relevant�State�/�Territory�legislation�should�be�considered�at�all�times.�The�paper-based�sections�of�records,�both�consumer�/�patient�health�records�and�corporate�records,�must�be�stored�securely.
October 2010 351
Organisations�should�have�reliable�back-up�systems�for�electronic�data�and�a�disaster�recovery�plan.�All�computer�terminals�should�have�secure�access�with�screensavers�and�default�to�standby�if�the�terminal�is�left�unattended�for�a�certain�period�of�time.�Firewalls�and�other�relevant�security�systems�should�be�installed�on�all�computers�and�servers�as�planned.�Consideration�should�be�included�in�these�aspects�of�the�plan�for�extended�and�all-hours�actions�in�the�case�of�problems�with�data�management.
There�should�be�a�Help�Desk�or�other�service�to�ensure�that�users�of�I&CT�have�reliable�and�timely�support,�especially�when�problems�arise�that�could�undermine�the�effective�management�and�use�of�data�and�information.�
Prompt points
¼ How does the organisation decide licence requirements for software? How are allocated licences registered / documented? What procedures are followed if additional licences are needed?
¼ How often are backup strategies and disaster plans tested? When was the last time they were tested? How well did the system work and what changes were needed?
Staff education and trainingHealth�is�a�technology-reliant�industry�prone�to�incidents.4�One�of�the�greatest�contributors�to�incidents�is�human�error�and�in�the�case�of�technology,�specifically�operator�error.
Training�in�I&CT�is�an�important�activity�undertaken�to�ensure�staff�at�all�levels�have�the�necessary�skills�to�carry�out�their�roles�effectively.�Training�is�particularly�important�as�part�of�orientation�to�the�organisation�and�should�be�reinforced�with�follow-up�training�and/or�retraining�where�necessary.�
Organisations�should�decide�what�training�is�needed�for�staff,�how�the�training�will�be�carried�out,�how�the�organisation�will�evaluate�the�effectiveness�of�its�education�and�training�activities�and�what�processes�will�be�put�in�place�to�improve�the�delivery�and�effectiveness�of�I&CT�education�and�training�programs.�This�should�then�be�documented�and�incorporated�into�the�orientation�program.�
Prompt points
¼ What types of data are collected by the organisation? Who is allowed to enter the data?
¼ What training is provided to data entry staff? Who interprets the data?
Risk management and crisis planningAs�with�all�systems�in�health�care,�organisations�should�consider�a�risk�management�framework�that�includes�a�prioritisation�schedule�when�addressing�risks�to�I&CT.�This�should�include:
• emergency�operating�procedures
• a�recovery�plan(s)�with�systems�priority
• disaster�and�contingency�planning
• software,�hardware,�telecommunication�networks�
• technical�expertise�to�control�and�maintain�operational�processes
• planned�preventative�maintenance�processes�
• security�and�processes�to�manage�breaches�of�security;�protecting�security�of�data�by�controlling�file�access.�Data�should�be�securely�available�to�authorised�users�while�denied�to�others.�Security�passwords�can�be�used�on�stand-alone�computers.�Passwords�and�security�access�levels�can�be�used�on�networked�systems.�Security�should�be�considered�when�data�are�transferred�from�one�system�to�another
• use�of�firewalls�and�other�electronic�devices�which�control�the�flow�of�data�in�and�out�of�the�organisation
• remote�access�procedures
• regular�backup�processes�and�storage�of�backup,�for�example,�away�from�electromagnetic�sources�or�off-site�
• accidental�and�deliberate�corruption�or�sabotage
• security�of�faxes,�email�and�telephones,�including�mobile�phones,�and�the�preservation�of�confidentiality.�Policy�and�procedures�for�sending�faxes�and�emails�that�contain�sensitive�information�help�minimise�risk.�
seCtion 5Standards, criteria, elements and guidelinesstandard 2.3:�Information�management�systems�enable�the�organisation’s�goals�to�be�met
352 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 2.3.4
The�organisation�has�an�integrated�approach�to�the�planning,�use�and�management�of�information�and�communication�technology�(I&CT).�(continued)
Reviewing�records�of�equipment�purchase�and�maintenance,�and�the�monitoring�of�system�and�technology�failures�and�costs,�assist�in�the�development�of�strategies�to�ensure�systems�are�protected�and�operate�effectively.�Data�on�failures�and�resource�utilisation�can�be�used�to�monitor�performance.�Preventative�maintenance�reduces�downtime�and�the�need�for�crisis�maintenance.��It�also�can�increase�users’�satisfaction.
Prompt points
¼ Where is the risk and crisis management plan stored? How often is it reviewed? Who contributed to the plan?
¼ What protective actions help to protect I&CT security for the organisation?
I&CT support for data processingOne�way�that�organisations�can�support�the�collection,�aggregation�and�analysis�of�data�is�through�providing�sufficient�numbers�of,�and�ease�of�access�to,�computers�that�have�up-to-date�and�appropriate�programs�for�analysis�of�data.�Staff�should�be�provided�with�training�and�support�to�perform�their�tasks.�
Within�the�organisation’s�I&CT�policy,�instructions�and�contact�details�should�be�provided�on�how�to�access�and�receive�operational�support�both�within�the�organisation�and�from�external�locations.�The�data�management�policy�should�also�outline�the�system�for�the�validation�and�protection�of�data.�Poorly�collected�data�that�are�subsequently�used�by�managers�to�guide�decision�making�can�have�devastating�consequences.�Unexpected�clinical�data�should�not�be�acted�upon�without�further�review,�as�many�non-clinical�factors�can�impact�measurements,�for�example,�from�medical�devices.�
For�these�reasons,�data�entry�should�be�performed�by�trained�staff.�Although�all�staff�may�access�data,�only�appropriate�staff�should�update�or�make�changes�to�the�data.�
The�system�used�for�the�validation�and�protection�of�data�and�information�will�be�reviewed�through�its�inclusion�in�the�data�management�policy,�which�should�be�evaluated�and�improved�as�part�of�the�Continuous�Quality�Improvement�policy�review�plan.�
Prompt points
¼ What training is provided to staff? Following I&CT training, how is the competency of staff using the systems reviewed?
¼ How does the organisation decide what training to provide in-house? How does it decide what training is provided externally?
¼ How often is I&CT training reviewed? What were the results of the last review? What changes were made in response to these findings?
Evidence commonly presented
Consider whether the following will help to address criterion 2.3.4
¼ Policies, including all aspects of information handling
¼ Maintenance schedules of information technology hardware
¼ Contingency plans for emergencies or disasters
¼ Evidence of licences for software
¼ Evidence of consultation with staff / relevant stakeholders to determine current and future needs for hardware / software
¼ Risk management strategies
¼ Evidence of monitoring of downtime and disasters
¼ Schedule for maintenance of systems
¼ Evaluation of systems
October 2010 353
Performance measurementThis�criterion�states�that:�“The�organisation�has�an�integrated�approach�to�the�planning,�use�and�management�of�information�and�communication�technology�(I&CT)”.�The�organisation�should�be�able�to�demonstrate�effective�and�integrated�management�of�information�technology,�as�well�as�the�provision�of�appropriate�training,�to�ensure�that�it�achieves�its�goals�for�the�safe�use�of�medical�devices,�data�storage,�and�health�and�corporate�records�management�and�security.
Some�common�suggested�performance�measures�are�as�follows:
Number�of�staff�for�whom�the�level�of�I&CT�access�is�appropriate
Total number of staff
Number�of�staff�whose�IT�training�needs�were�identified�and�met
Total number of staff
Number�of�requests�for�IT�assistance�that�were�resolved�within�X�minutes
Total number of requests for IT assistance
Comment:theorganisationtodefine‘X’
Number�of�hours�of�system�downtime�per�week�/�month
Total number of user hours per week / month
Number�of�programs�for�which�there�is�a�valid�licence
Total number of programs
Number�of�complaints�received�related�to�IT�privacy�breaches
Total number of complaints received
seCtion 5Standards, criteria, elements and guidelinesstandard 2.3:�Information�management�systems�enable�the�organisation’s�goals�to�be�met
354 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
References1.� Office�of�the�Federal�Privacy�Commissioner.�National
privacyprinciples(extractedfromthePrivacyAmendment(PrivateSector)Act2000).Sydney�NSW;�Australian�Government;�2001.
2.� Office�of�the�Federal�Privacy�Commissioner.�Nationalprivacyprinciples.Private�sector�information�sheet.�Vol.�1.�Canberra�ACT;�Office�of�the�Privacy�Commissioner;�2006.
3.� Office�of�the�Federal�Privacy�Commissioner.�Nationalprivacyprinciples.Information�sheet.�Canberra�ACT;�Office�of�the�Privacy�Commissioner;�2008.
4.� Institutes�of�Medicine�Committee�on�Quality�of�Health�Care�in�America.�Toerrishuman:buildingasaferhealthsystem.�Washington�DC�USA;�National�Academy�Press;�2000.
Relevant standardsAS�2828:1999Paper-basedhealthcarerecords.Second�edn.
AS�13335.3:2003�Informationtechnology–GuidelinesforthemanagementofITsecurity.
AS�ISO�18308:2005�Healthinformatics–Requirementsforanelectronichealthrecordarchitecture.
AS�ISO�15489.2:2002RecordsManagement:Guidelines.
AS/NZS�13594:1998�Informationtechnology–Lowerlayerssecurity.
AS/NZS�4444.2:2000�Informationsecuritymanagement–specificationforinformationsecuritymanagementsystems.
AS�ISO�20514:2005�Healthinformatics–Electronichealthrecord–definition,scopeandcontext.
Criterion 2.3.4
The�organisation�has�an�integrated�approach�to�the�planning,�use�and�management�of�information�and�communication�technology�(I&CT).�(continued)
Number�of�FTE�staff�involved�in�IT�planning
Total number of FTE staff
Comment:FTE=full-timeequivalent
Number�of�staff�satisfied�with�IT�services�/�equipment
Total number of staff surveyed
October 2010 355
2.4�Population�Health�Standard
The�standard�is:�The organisation promotes the health of the population.
The�intent�of�this�standard�is�to�ensure�that�all�healthcare�organisations�take�responsibility�for�promoting�the�health�and�wellness�of�the�Australian�population,�in�some�way.�The�extent�of�this�responsibility�is�dependent�on�the�size�and�type�of�organisation�and�on�the�location�of�the�service.
There�is�one�criterion�in�this�standard.�This�is:
2.4.1� �Better�health and wellbeing is promoted�by�the�organisation�for�consumers�/�patients,�staff,�carers�and�the�wider�community.�
This�standard�and�criterion�focus�on�three�main�aspects�of�population�health:�
• health�promotion
• health�protection
• surveillance.
A�great�deal�of�progress�has�been�made�in�improving�the�health�of�the�population�over�the�past�20�years�through�a�combination�of�improving�social�and�environmental�conditions,�providing�a�wider�range�of�prevention�services�and�public�education.�Healthcare�organisations,�the�community,�government�and�public�and�private�institutions�cannot�however�become�complacent.�
During�this�time,�the�burden�has�shifted�from�communicable�diseases�to�non-communicable�diseases�such�as�heart�disease,�chronic�respiratory�disease,�diabetes�type�2�and�mental�health�problems.�New�diseases,�new�threats�to�health�and�new�health�challenges�constantly�emerge�and�need�to�be�managed�in�effective�and�innovative�ways.�Increasing�health�inequalities�will�have�a�significant�effect�on�population�health�status�in�a�range�of�ways.�At�the�same�time,�the�demography�of�the�Australian�population�is�changing,�bringing�new�resources,�opportunities�and�issues.�All�healthcare�organisations�have�roles�to�play�in�the�process�of�improving�population�health.
seCtion 5Standards, criteria, elements and guidelines
seCtion 5Standards, criteria, elements and guidelinesstandard 2.4:�The�organisation�promotes�the�health�of�the�population
356 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
IntentThe�intent�of�this�criterion�is�to�ensure�that�all�healthcare�organisations�take�some�measure�of�responsibility�for�promoting�the�health�and�wellbeing�of�the�Australian�population.�The�organisation�should�demonstrate�that�it�has�delineated�its�responsibility�in�this�respect�via�consideration�of�its�consumer�/�patient�population,�and�its�size,�services�and�location.
Relationships of 2.4.1 with other criteriaThe�organisation�has�an�obligation�to�provide�safe,�high�quality�care�(Standard�1.5).�Many�of�the�programs�by�which�the�organisation�regulates�and�improves�aspects�of�its�care,�including�those�addressing�medication�safety�(Criterion�1.5.1),�infection�control�(Criterion�1.5.2),�falls�prevention�(Criterion�1.5.4)�and�nutritional�needs�(Criterion�1.5.7),�can�be�adapted�for�inclusion�in�preventive�health�programs�for�the�broader�community.�Population�health�initiatives�are�more�likely�to�be�effective�if�the�community�is�involved�in�their�planning,�delivery�and�evaluation�(Criterion�1.6.1).�They�should�also�consider�the�diverse�needs�and�diverse�backgrounds�of�those�within�the�community�(Criterion�1.6.3).
Criterion LA – Awareness sA – implementationLA plus the following
MA – evaluationSA plus the following
eA – excellenceMA plus the following
oA – LeadershipEA plus the following
Criterion 2.4.1
Better�health�and�wellbeing�is�promoted�by�the�organisation�for�consumers�/�patients,�staff,�carers�and�the�wider�community.
a)� Staff�and�other�key�stakeholders�are�informed�of�population�health�principles�and�participate�in�evidence-based�health�promotion�strategies.
b)� The�organisation�is�aware�of�the�current�and�emerging�health�priority�areas.
c)� The�organisation�is�aware�of�its�statutory�requirements�for�reporting�public�health�matters.
a)� Policy�/�guidelines�are�implemented�that�are�consistent�with�health�promotion�programs�and�interventions�and�reflect�jurisdictional�priorities.
b)� The�organisation�works�collaboratively�and�has�partnerships�in�place�to�utilise�resources�effectively,�to�support�health�promotion�activities.
c)� The�organisation�optimises�the�delivery�of�health�promotion�programs�and�interventions�to�consumers�/�patients�and�carers.
d)� Training�and�resources�are�available�for�staff�to�support�the�development�of�evidence-based�health�promotion�and�interventions�to�consumers�/�patients,�carers�and�the�wider�community.
e)� Opportunistic�health�promotion�/�education�strategies�are�undertaken�in�partnership�with�consumers�/�patients,�carers,�staff�and�the�wider�community.�
f)� Health�surveillance�data�is�appropriate�to�the�organisation.
a)� The�outcomes�of�health�promotion�programs�and�interventions�are�evaluated�for�their�effectiveness�in�improving�the�health�and�wellbeing�of�consumers�/�patients,�staff,�carers�and�the�wider�community,�and�improved�as�required.
b)� Performance�measures�are�developed,�and�quantitative�or�qualitative�data�collected,�to�evaluate�the�effectiveness�/�outcomes�of�health�promotion�programs�and�interventions�implemented�by�the�organisation.
a)� Health�promotion�programs�and�interventions�together�with�results�are�compared�with�similar�programs�internally�and�externally,�and�improvements�are�made�to�ensure�better�practice.
and/or
b)� Strategic�plans�are�informed�by�relevant�population�health�data�and�reflect�current�jurisdictional�priorities.
and/or
c)� Research�is�undertaken�into�population�health�programs�and�interventions�and�results�are�published�in�peer�review�journals.
a)� The�organisation�demonstrates�it�is�a�leader�in�health�promotion.
October 2010 357
The�organisation�also�has�a�responsibility�for�the�health�and�wellbeing�of�its�staff,�and�health�promotion�within�the�organisation�should�be�integrated�with�other�staff�support�services�(Criterion�2.2.5).
As�with�all�programs�implemented,�the�organisation’s�health�promotion�strategies�should�be�evaluated�for�their�appropriateness�(Criterion�1.3.1)�and�effectiveness�(1.4.1).
Public health prioritiesHealth�promotion�is�the�process�of�enabling�consumers�/�patients�to�increase�control�over,�and�to�improve,�their�health.1�It�is�described�as�the�use�of�activities�that�are�designed�to�advance�health�status.�Health�promotion�is�concerned�not�only�with�strengthening�the�skills�and�capabilities�of�individuals�but�also�with�actions�directed�towards�changing�social,�environmental�and�economic�conditions�in�order�to�improve�population�and�individual�health.2
Criterion LA – Awareness sA – implementationLA plus the following
MA – evaluationSA plus the following
eA – excellenceMA plus the following
oA – LeadershipEA plus the following
Criterion 2.4.1
Better�health�and�wellbeing�is�promoted�by�the�organisation�for�consumers�/�patients,�staff,�carers�and�the�wider�community.
a)� Staff�and�other�key�stakeholders�are�informed�of�population�health�principles�and�participate�in�evidence-based�health�promotion�strategies.
b)� The�organisation�is�aware�of�the�current�and�emerging�health�priority�areas.
c)� The�organisation�is�aware�of�its�statutory�requirements�for�reporting�public�health�matters.
a)� Policy�/�guidelines�are�implemented�that�are�consistent�with�health�promotion�programs�and�interventions�and�reflect�jurisdictional�priorities.
b)� The�organisation�works�collaboratively�and�has�partnerships�in�place�to�utilise�resources�effectively,�to�support�health�promotion�activities.
c)� The�organisation�optimises�the�delivery�of�health�promotion�programs�and�interventions�to�consumers�/�patients�and�carers.
d)� Training�and�resources�are�available�for�staff�to�support�the�development�of�evidence-based�health�promotion�and�interventions�to�consumers�/�patients,�carers�and�the�wider�community.
e)� Opportunistic�health�promotion�/�education�strategies�are�undertaken�in�partnership�with�consumers�/�patients,�carers,�staff�and�the�wider�community.�
f)� Health�surveillance�data�is�appropriate�to�the�organisation.
a)� The�outcomes�of�health�promotion�programs�and�interventions�are�evaluated�for�their�effectiveness�in�improving�the�health�and�wellbeing�of�consumers�/�patients,�staff,�carers�and�the�wider�community,�and�improved�as�required.
b)� Performance�measures�are�developed,�and�quantitative�or�qualitative�data�collected,�to�evaluate�the�effectiveness�/�outcomes�of�health�promotion�programs�and�interventions�implemented�by�the�organisation.
a)� Health�promotion�programs�and�interventions�together�with�results�are�compared�with�similar�programs�internally�and�externally,�and�improvements�are�made�to�ensure�better�practice.
and/or
b)� Strategic�plans�are�informed�by�relevant�population�health�data�and�reflect�current�jurisdictional�priorities.
and/or
c)� Research�is�undertaken�into�population�health�programs�and�interventions�and�results�are�published�in�peer�review�journals.
a)� The�organisation�demonstrates�it�is�a�leader�in�health�promotion.
seCtion 5Standards, criteria, elements and guidelinesstandard 2.4:�The�organisation�promotes�the�health�of�the�population
358 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 2.4.1
Better�health�and�wellbeing�is�promoted�by�the�organisation�for�consumers�/�patients,�staff,�carers�and�the�wider�community.�(continued)
Health�promotion�programs�often�focus�action�on�the�reduction�of�levels�of�major�non-communicable�diseases,�such�as�cardiovascular�diseases,�cancer,�chronic�respiratory�diseases�and�diabetes,�and�communicable�diseases,�through�coordinated,�comprehensive�health�promotion�and�disease�prevention�measures.�The�aim�is�to�promote�healthier�lifestyles�in�communities�and�to�prevent�and�control�common�risk�factors,�such�as�hypertension,�lipaemia,�obesity,�smoking,�alcohol�abuse,�unhealthy�diet�and�sedentary�lifestyle.�
This�criterion�includes�elements�that�focus�on�the�three�main�aspects�of�population�health:
• health�promotion
• health�protection
• surveillance.
Government�priorities�may�influence�resource�allocation�in�health�prevention�and�treatment.�Because�planning�is�undertaken�by�people�with�specialist�expertise,�and�greater�funding�is�likely�to�be�available,�these�should�be�considered�as�priorities�by�the�majority�of�organisations.�Government�priority�setting�should�not�be�based�solely�on�incidence�or�severity�of�a�health�problem,�but�should�reflect�available�evidence�on�the�cost-effectiveness�of�interventions,�particularly�preventative�measures.3�Additionally,�organisations�will�understand�the�demographics�of�their�local�area�and�its�populations,�which�will�shape�their�response�to�national�and�jurisdictional�priorities.�
To�assess�the�determinants�of�health�in�its�local�area,�the�organisation�should�ask�the�following�questions�and�monitor�the�answers�over�time:
• Are�the�factors�determining�good�health�changing�for�the�better?
• Where�and�for�whom�are�these�factors�changing?
• Is�it�the�same�for�everyone?
As�Australia�entered�the�21st�century,�seven�National�Health�Priority�Areas�were�chosen�for�focused�attention�at�a�national�level�because�of�their�significant�contribution�to�the�burden�of�illness�and�injury�in�the�Australian�community.�The�National�Health�Priority�Areas�identified�by�government�are4:
• arthritis�and�musculoskeletal�conditions�
• asthma�
• cancer�control�
• cardiovascular�health�
• diabetes�mellitus�
• injury�prevention�and�control�(national)�
• mental�health.�
The�National�Chronic�Disease�strategy�provides�guidance�on�government�planning�and�an�overarching�framework�to�manage�these�conditions4,�while�the�Australian�Institute�of�Health�and�Welfare�coordinates�activity�in�this�area�across�the�States�and�Territories�of�Australia.5
A�number�of�Australian�population�groups�are�also�seen�to�be�of�special�interest�from�a�health�perspective�because�of�their�high�incidence�of�health�problems�compared�to�the�remainder�of�the�population6,�7:
• people�with�a�disability
• socioeconomically�disadvantaged�Australians
• indigenous�people
• people�living�in�rural�and�remote�areas
• prisoners
• veterans.
Health�outcomes�for�indigenous�people�are�so�different�from�the�remainder�of�the�Australian�population�that�they�are�now�separately�monitored.�Membership�of�the�‘indigenous�population’�is�determined�by�participating�individuals�–�inclusion�relies�on�self�identification�by�Aboriginal�and�Torres�Strait�Islanders�who�should�be�asked�for�this�information�according�to�guidelines.8
October 2010 359
Planning�in�larger�public�organisations�should�draw�on�the�multifaceted�approach�of�the�World�Health�Organization’s�Ottawa�Charter�for�Health�Promotion9,�developed�in�1986.�This�remains�the�basis�upon�which�population�health�strategies�are�developed.�It�has�six�key�components:
• building�healthy�public�policy
• creating�supporting�environments
• supporting�and�strengthening�community�action
• developing�personal�self�care�skills
• reorienting�health�services
• promoting�health�promotion�in�other�health�and�disability�services.
Prompt points
¼ What jurisdictional and national priorities for health promotion are reflected in the organisation’s planning?
¼ What local demographics influence the selection of appropriate health promotion messages and messaging?
Staff education and training Because�of�the�time�pressures�on�many�clinical�staff,�organisations�may�need�to�ensure�their�staff�are�validated�in�preventative�health�action�and�have�access�to�tools�for�efficiently�educating�their�consumers�/�patients,�providing�relevant�information�and�taking�opportunities�for�referral�to�other�providers.�
Opportunities�for�staff�training�in�preventative�health�actions�and�resources�might�be�built�into:
• orientation�programs
• training�focused�on�access�to�information�resources�(particularly�where�these�are�located�on�organisation�intranets)
• performance�and�education�discussions�with�managers
• formal�or�informal�mentoring�contexts.�
Encouraging�staff�members�to�become�involved�in�broader�health�promotion�committees�and�programs�can�help�to�build�internal�capacity�and�organisational�awareness�of�projects�and�new�initiatives.�There�are�sometimes�opportunities�for�organisations�to�participate�in�research�and�pilot�studies�that�will�build�staff�knowledge�and�may�provide�unique�opportunities�for�consumers�/�patients.�
Organisations�might�choose�to�pursue�new�ties�with�relevant�Federal�and�jurisdictional�governments,�professional�bodies�or�universities,�ideally�facilitated�through�the�professional�networks�of�key�staff.�
Ongoing�education�and�networking�through�attendance�at�conferences�and�scanning�relevant�journals�may�alert�the�organisation�to�effective�projects�undertaken�by�similar�organisations.�Relevant�groups�involved�in�health�promotion�include:�
• Public�Health�Association�of�Australia��http://www.phaa.net.au
• Australian�Health�Promotion�Association��http://www.healthpromotion.org.au/
• Australasian�Faculty�of�Public�Health�Medicine�http://www.racp.edu.au/page/racp-faculties/australasian-faculty-of-public-health-medicine/
• Nutrition�Society�of�Australia��http://www.nsa.asn.au/
• Australian�Diabetes�Educators�Association��http://www.adea.com.au/.�
Recognising�the�limited�opportunities�for�advanced�training�in�nutrition�at�many�institutions,�the�Australian�Public�Health�Nutrition�Academic�Collaboration�(APHNAC)�offers�special�public�health�nutrition�units�by�distance�education.10�These�can�be�included�in�specified�undergraduate�and�postgraduate�programs�at�a�number�of�Australian�universities.
Staff�training�to�improve�preventative�health�awareness�and�opportunistic�health�promotion�skills�among�clinical�staff�could�be�achieved�through�onsite�programs�or�by�sending�staff�to�professional�development�programs,�such�as�those�offered�by�many�State�/�Territory�Departments�of�Health.�
Prompt points
¼ Is the organisation aware of staff members with further training in public health / preventative medicine training? Are any staff currently involved in further study in this area?
¼ What training or mentoring is available to improve clinicians’ skills in opportunistic health promotion?
seCtion 5Standards, criteria, elements and guidelinesstandard 2.4:�The�organisation�promotes�the�health�of�the�population
360 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 2.4.1
Better�health�and�wellbeing�is�promoted�by�the�organisation�for�consumers�/�patients,�staff,�carers�and�the�wider�community.�(continued)
Surveillance and reportingSurveillance�is�defined�as�the�ongoing,�systematic�collection,�analysis�and�interpretation�of�health-related�data�essential�to�the�planning,�implementation�and�evaluation�of�public�health�practice11,�and�is�closely�integrated�with�the�timely�dissemination�of�these�data�to�those�responsible�for�prevention�and�control.�
All�healthcare�organisations�should�be�aware�of�their�legislated�obligations�in�relation�to�surveillance�and�for�the�reporting�of�infectious�diseases.�This�is�addressed�within�criterion�1.5.2.�
In�addition,�public�facilities�will�have�State�/�Territory�government�obligations�for�the�reporting�of�information�about�service�provision,�such�as�emergency�department�waiting�times,�elective�surgery�lists�and�other�indicators.�In�some�States�/�Territories,�a�more�regulated�framework�for�reporting�has�been�introduced12;�the�Clinical�Excellence�Commission�in�NSW�has�developed�a�‘Quality�Systems�Assessment’�program,�and�the�Queensland�Health�and�Quality�Complaints�Commission�has�released�statutory�standards�under�section�20�of�the�HealthQualityandComplaintsCommissionAct2006(Qld),�with�which�it�is�the�legal�duty�of�providers�to�comply.
Performance�measures�for�health�promotion�need�to�be�carefully�reviewed�to�determine�their�relevance�to�the�organisation;�the�selection�process�should�include�consideration�of�the�purpose�of�monitoring�performance�and�whether�action�could�be�taken�if�performance�deteriorated�or�was�considered�to�be�inadequate.�Using�measures�that�are�submitted�externally�(such�as�jurisdictional�health�department�data�or�ACHS�clinical�indicators)�will�provide�opportunities�to�benchmark�performance�against�similar�organisations.�
Prompt points
¼ How is the organisation’s health surveillance data captured, collated and reported? In addition to meeting statutory obligations, how is the data used by the organisation in promoting public health?
¼ What measures are being / have been used to review recent health promotion activities undertaken by the organisation? How were the outcomes of projects reviewed? What occurred following the review of this data?
Health promotion activitiesAny�healthcare�admission�may�provide�an�opportunity�for�promoting�good�health�practices�for�consumers�/�patients.�In�both�formal�and�informal�contexts,�consumers�/�patients�and�their�families�can�be�made�aware�of�health�and�wellness�strategies�they�may�adopt�to�improve�their�health�and�wellbeing.�Advice�and�recommendations�from�a�healthcare�professional�can�make�a�significant�contribution�to�behaviour�change.�There�is�significant�evidence�that�confirms�the�effectiveness�of�professional�advice�in�driving�smoking�cessation.13
Areas�where�planned�and�structured�health�promotion�strategies�targeting�consumers�/�patients�have�proven�effective�include�changing�nutrition�(folate�for�pregnant�women),�promoting�exercise,�encouraging�longer�periods�of�breastfeeding,�promoting�weight�loss,�and�in�cessation�of�smoking.�It�is�not�suggested�that�all�healthcare�organisations�should�be�providing�programs�in�these�areas,�but�if�they�are�available�locally,�that�the�organisation�knows�how�and�where�to�access�them.�
Health�promotion�and�protection�strategies�are�also�important�for�staff;�examples�include�immunisation,�stress�management,�occupational�health�risk�management,�smoking�cessation�and�exercise�programs.�
Opportunistic�health�promotion�may�be�initiated�by�any�healthcare�provider�as�part�of�general�discussions�with�consumers�/�patients�and�their�carers.�It�may�be�fundamental�to�and�directly�linked�with�the�reason�for�admission,�or�an�incidental�discussion�point.�
October 2010 361
Specialist�organisations,�such�as�day�procedure�centres,�might�demonstrate�their�health�promotion�commitments�through�education�and�information�on�ongoing�care�for�the�conditions�that�they�treat.�For�example,�an�organisation�that�works�in�macular�degeneration�might�educate�consumers�/�patients�and�provide�visual�test�cards�so�that�consumers�/�patients�could�distribute�them�to�family�members�for�screening.�They�could�promote�information�evenings�offered�by�branches�of�the�Royal�Blind�Society,�which�might�assist�consumers�/�patients�to�better�manage�their�deteriorating�vision�and�avoid�other�injuries.
Prompt points
¼ How does the organisation work with the community to develop health promotion programs?
¼ Describe a health promotion program undertaken by this organisation that has been evaluated? Based on the evaluation, if the organisation were to repeat the program, what would be done differently?
¼ How has the organisation optimised a program to get the best achievable outcomes for its consumer / patient population?
Collaborative work and partnershipsWithin�Australia,�there�are�many�member�organisations�and�charities�doing�valuable�work�in�health�promotion.�Groups�that�focus�on�the�government’s�priority�disease�areas�include:
• Heart�Foundation�of�Australia��http://www.heartfoundation.org.au
• Cancer�Council�of�Australia��http://www.cancer.org.au/
• Diabetes�Australia��http://www.diabetesaustralia.com.au/
• Arthritis�Australia��http://www.arthritisaustralia.com.au/
• Asthma�Australia��http://www.asthmaaustralia.org.au/
• Mental�health�groups�including�SANE�Australia,�the�Black�Dog�Institute,�PANDA�and�Beyond�Blue.
The�initiatives�of�these�and�many�other�groups�in�fundraising,�education,�research�and�community�outreach�provide�many�opportunities�for�collaborative�activities.�As�a�starting�point�for�discussions,�these�groups�provide�excellent�information�resources�for�clinicians�and�consumers�/�patients,�which�can�be�considered�for�use�within�healthcare�organisations.�
Prompt points
¼ What collaborative links and partnerships does the organisation use to support its health promotion activities?
¼ What challenges does the collaboration present for the organisation? Has the collaboration facilitated more effective, timely and cost-effective delivery of programs?
Evidence commonly presented
Consider whether the following will help to address criterion 2.4.1
¼ Health protection programs, including staff vaccination records
¼ Declared commitment / philosophy / policy
¼ Survey data regarding disease prevalence
¼ Evidence of staff education programs
¼ Health promotion programs and information available on relevant programs for consumers / patients
¼ Review of care plans / pathways
¼ Evaluation of discharge plans
¼ Policies and procedures on:
– reporting infectious diseases – management of consumers / patients with
infectious diseases
seCtion 5Standards, criteria, elements and guidelinesstandard 2.4:�The�organisation�promotes�the�health�of�the�population
362 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 2.4.1
Better�health�and�wellbeing�is�promoted�by�the�organisation�for�consumers�/�patients,�staff,�carers�and�the�wider�community.�(continued)
Performance measurementThis�criterion�states�that:�“Better�health�and�wellbeing�is�promoted�by�the�organisation�for�consumers�/�patients,�staff,�carers�and�the�wider�community”.�The�organisation�should�be�able�to�demonstrate�its�health�promotion�activities�with�respect�to�each�of�these�target�population�groups,�and�that�it�supports�and�facilitates�staff�involvement�in�health�promotion�activities.
Some�common�suggested�performance�measures�are�as�follows:
Number�of�health�promotion-related�policies�/�by-laws�/�guidelines�/�procedures�that�reflect�national,��State�/�Territory�and�local�priorities�for�health�promotion
Total number of health promotion-related policies / by-laws / guidelines / procedures
Number�of�clinical�staff�with�tertiary�qualifications�in�health�promotion
Total number of clinical staff
Number�of�clinical�staff�who�have�received�training�in�population�health�principles�and�development�of�evidence-based�health�promotion�and�interventions
Total number of clinical staff
Number�of�clinical�staff�who�have�received�training�or�mentoring�in�opportunistic�health�promotion
Total number of clinical staff
Number�of�health�promotion�strategies�that�address�at�least�one�of�the�six�key�Ottowa�Charter�components
Total number of health promotion strategies
Number�of�health�promotion�initiatives�that�are�developed�and�implemented�in�partnership�with�other�organisations
Total number of health promotion initiatives developed and implemented
October 2010 363
Number�of�health�promotion�initiatives�that�target�high-risk�population�groups
Total number of health promotion initiatives
Comment:organisationtonominatehigh-riskpopulationgroup
Number�of�prevention�and�early�intervention�initiatives�that�focus�on�children�and�young�people
Total number of prevention and early intervention initiatives
Number�of�consumers�/�patients�whose�self�identified�program�goals�were�met
Total number of consumers / patients who set goals at the commencement of a specific health promotion program
Number�of�the�eligible�population�screened�for�a�specific�medical�condition�(e.g.�breast�cancer,�bowel�cancer)
Total number of eligible population
Number�of�consumers�/�patients�who�are�smokers,�and�to�whom�a�smoking�cessation�program�has�been�actively�promoted
Total number of consumers / patients who are smokers
Number�of�children�whose�vaccination�status�was�checked�when�seen�/�admitted
Total number of children seen / admitted
Number�of�consumers�/�patients�who�receive�follow�up�/�recall�requests�following�screening�/�assessment,�and�who�return�to�the�service
Total number of consumers / patients who receive follow up / recall requests following screening / assessment
Number�of�staff�enrolled�in�health�promotion�programs�promoted�through�the�organisation
Total number of staff eligible for enrolment in health promotion programs promoted through the organisation
seCtion 5Standards, criteria, elements and guidelinesstandard 2.4:�The�organisation�promotes�the�health�of�the�population
364 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 2.4.1
Better�health�and�wellbeing�is�promoted�by�the�organisation�for�consumers�/�patients,�staff,�carers�and�the�wider�community.�(continued)
References1.� World�Health�Organization�(WHO).�Healthpromotion
glossary.Geneva�CH:�WHO;�1998.�Accessed�from�http://www.who.int/hpr/NPH/docs/hp_glossary_en.pdf�on�1�September�2010.�
2.� World�Health�Organization�–�Europe.�Standardsforhealthpromotioninhospitals.Copenhagen�DK;�WHO;�2004.
3.� Segal�L�and�Chen�Y.Prioritysettingmodelsforhealth–Theroleforprioritysettingandacritiqueofalternativemodels.Melbourne�VIC;�Centre�for�Health�Program�Evaluation;�2001.
4.� National�Health�Priority�Action�Council�(NHPAC).�Nationalchronicdiseasestrategy.Canberra�ACT;�Australian�Health�Ministers’�Advisory�Council�(AHMAC);�2005.
5.� Australian�Institute�of�Health�&�Welfare�(AIHW).�Chronicdisease:Nationalchronicdiseasestrategy.�Canberra�ACT;�AIHW.�Accessed�from�http://www.health.gov.au/internet/main/publishing.nsf/Content/pq-ncds-strat�on�17�August�2010.
6.� Australian�Institute�for�Health�and�Welfare�(AIHW).�Australia’shealth.Australia’s�health�series�no�12.�Canberra�ACT;�AIHW;�2010.
7.� Allen�Consulting�Group.�Fairhealthfacts.�Melbourne�VIC;�Department�of�Human�Services;�2009.
���
8.� Victorian�Department�of�Health�and�Victorian�Aboriginal�Community�Controlled�Health�Organisation.�Aboriginalhealthpromotionandchroniccarepartnershipprogramguidelines.�Melbourne�VIC;�Dept�of�Health;�2005.
9.� World�Health�Organization.�Ottawa�Charter�for�health�promotion.�Firstinternationalconferenceonhealthpromotion.�Ottawa�Canada,�21�November�1986.�Accessed�from�http://www.who.int/hpr/NPH/docs/ottawa_charter_hp.pdf�on�1�September�2010.
10.� Australian�Public�Health�Nutrition�Academic�Collaboration�(APHNAC).�WelcometoAPHNAC.Accessed�from�http://www.new.webtemplate.com.au/bridgehead/Aphnac/default.php�on�1�July�2010.
11.� World�Health�Organization�(WHO).Publichealthsurveillance.Geneva�CH;�WHO.�Accessed�from�http://www.who.int/immunization_monitoring/burden/routine_surveillance/en/index.html�on�2�September�2010.
12.� Australian�Commission�on�Safety�and�Quality�in�Health�Care�(ACSQHC).�DevelopingasafetyandqualityframeworkforAustralia.�Sydney�NSW;�ACSQHC;�2008.
13.� Zwar�NA,�Richmond�R,�Borland�R�etal.�SmokingcessationguidelinesforAustraliangeneralpractice:Practicehandbook.�Sydney�NSW;�RACGP�Guideline�Development�Group;�2004.
October 2010 365
2.5�Research�Standard
The�standard�is:�The organisation encourages and adequately governs the conduct of health and medical research to improve the safety and quality of health care.
The�intent�of�the�Research�standard�is�two-fold:
• to�encourage�organisations�to�participate�in�research�to�further�the�evidence�available�to�health�care�organisations�for�providing�high�quality�care
• to�ensure�that�if�health�care�organisations�engage�in�clinical�or�health�services�research,�the�research�is�governed�effectively,�in�accordance�with�acceptable�guidelines�and�standards.
There�is�one�criterion�in�this�standard.�This�is:
2.5.1� �The�organisation’s�research program develops�the�body�of�knowledge,�protects�staff�and�consumers�/�patients�and�has�processes�to�appropriately�manage�the�organisational�risk�associated�with�research.
Most�organisations�have�developed�and�implemented�policies�and�systems�for�clinical�and�corporate�risk�management,�human�resources�and�information�management�and�for�managing�the�environment�in�which�health�care�is�provided.�Organisations�should�understand�their�responsibilities�for�the�management�or�governance�of�research,�and�this�responsibility�should�not�rest�with�a�human�research�ethics�committee�(HREC).
seCtion 5Standards, criteria, elements and guidelines
seCtion 5Standards, criteria, elements and guidelinesstandard 2.5:�The�organisation�encourages�and�adequately�governs�the�conduct�of�health�and�medical�research�to�improve�the�safety�and�quality�of�health�care
366 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
IntentThe�intent�of�this�criterion�is�to�encourage�participation�in�research,�in�order�to�further�the�knowledge�and�evidence�available�to�healthcare�organisations;�and�to�ensure�that�when�organisations�do�engage�in�clinical�or�health�services�research,�there�is�appropriate�oversight�and�that�the�participating�consumers�/�patients�and�staff�are�protected.
Relationships of 2.5.1 with other criteriaResearch,�whether�medical,�scientific�or�informational,�is�undertaken�in�order�to�increase�knowledge�and,�ultimately,�to�improve�the�care�given�to�the�consumer�/�patient�and�to�have�a�positive�impact�on�the�community�as�a�whole.�The�proper�conduct�of�research�requires�that�participating�consumers�/�patients�are�informed�of�their�rights�and�responsibilities�(Criterion�1.6.2),�and�that�they�are�able�to�give�informed�consent�(Criterion�1.1.3).�The�organisation�must�manage�any�risks�involved�in�the�research�(Criterion�2.1.2),�and�failure�to�do�so�may�lead�to�incidents�and�complaints�(Criteria�2.1.3�and�2.1.4).�The�research�program�requires�organisational�oversight�and�governance�(Criterion�3.1.2).�External�organisations�that�manage�research,�and�Human�Research�Ethics�Committees�and�Animal�Ethics�Committees�from�other�bodies,�are�external�service�providers�(Criterion�3.1.4).
Criterion LA – Awareness sA – implementationLA plus the following
MA – evaluationSA plus the following
eA – excellenceMA plus the following
oA – LeadershipEA plus the following
Criterion 2.5.1
The�organisation’s�research�program�develops�the�body�of�knowledge,�protects�staff�and�consumers�/�patients�and�has�processes�to�appropriately�manage�the�organisational�risk�associated�with�research.
a)� The�organisation�fosters�and�encourages�clinical�and�health�services�research.
b)� Research�policy�/�guidelines�is�consistent�with:
� (i)� key�NHMRC�statements
� (ii)� jurisdictional�legislation
� (iii)� codes�of�conduct.
c)� The�governing�body�demonstrates�its�responsibility�for�the�governance�of�research.
d)� The�research�policy�/�guidelines�define�which�research�requires�ethics�approval�and�under�what�conditions�ethics�approval�will�apply.
e)� Staff�are�aware�of�the�research�policy�/�guidelines.
f)� Formal�agreements�exist�with�collaborating�agencies.
a)� The�research�policy�/�guideline�is�implemented.
b)� Scientific�review�standards�of�research�are�applied�and�demonstrated�within�the�body�of�work.
c)� The�respective�responsibilities�of�all�parties�involved�in�research�are�identified�and�documented.
d)� The�role�and�reporting�lines�of�the�organisation’s�human�research�ethics�committee�(HREC)�are�clearly�defined.
e)� The�HREC�is�adequately�resourced.
f)� Ethics�approval�processes�are�timely,�transparent�and�effective.
g)� Consumers�and�researchers�work�in�partnership�to�make�decisions�about�research�priorities,�policy�and�practices.
a)� Performance�measures�are�used�to�evaluate�the�effectiveness�of�the�governance�of�research.
b)� The�system�for�ensuring�effective�research�governance�is�evaluated,�and�is�improved�as�required.
a)� Research�outcomes�are�implemented�in�the�organisation�and�are�used�to�demonstrate�improvements�in�health�care.
and/or
b)� The�organisation�participates�voluntarily�in�a�regular�external�evaluation�of�research�governance.
a)� The�organisation�demonstrates�that�it�is�a�leader�in�research�risk�management.
October 2010 367
Addressing this criterionResearch�involves�a�systematic�and�rigorous�inquiry�or�investigation,�to�discover�or�confirm�facts�or�principles.�The�ultimate�purpose�of�healthcare�research�is�to�improve�consumer�/�patient�care.�Advances�in�surgical�technique,�the�development�of�new�drugs,�new�or�improved�treatment�options�and�refinements�to�treatment�regimes�rely�on�research.
However,�it�is�imperative�that�where�research�requires�the�participation�of�consumers�/�patients�/�subjects,�they�are�not�placed�at�risk�by�a�research�experiment,�or�at�no�greater�risk�than�that�posed�by�their�disease�condition,�no�matter�how�laudable�the�anticipated�research�outcome.�
Research�projects�undertaken�in�healthcare�settings�take�a�range�of�formats:
• organisations�may�have�dedicated�research�facilities�where�much�of�the�primary�work�may�not�involve�human�subjects
• organisations�may�trial�new�procedures�as�part�of�a�project�coordinated�by�their�owners,�the�WHO�or�a�government�body�
• clinicians�at�a�facility�may�recruit�and�monitor�consumers�/�patients�as�part�of�a�clinical�trial�managed�for�a�pharmaceutical�company�or�university
• organisations�may�have�researching�clinicians�who�undertake�and�publish�primary�research�within�their�own�specialty�area
• organisations�may�undertake�investigations�to�compare�different�approaches�to�providing�clinical�care,�usually�within�the�facility�(many�Quality�Improvement�projects�are�of�this�type).
Criterion LA – Awareness sA – implementationLA plus the following
MA – evaluationSA plus the following
eA – excellenceMA plus the following
oA – LeadershipEA plus the following
Criterion 2.5.1
The�organisation’s�research�program�develops�the�body�of�knowledge,�protects�staff�and�consumers�/�patients�and�has�processes�to�appropriately�manage�the�organisational�risk�associated�with�research.
a)� The�organisation�fosters�and�encourages�clinical�and�health�services�research.
b)� Research�policy�/�guidelines�is�consistent�with:
� (i)� key�NHMRC�statements
� (ii)� jurisdictional�legislation
� (iii)� codes�of�conduct.
c)� The�governing�body�demonstrates�its�responsibility�for�the�governance�of�research.
d)� The�research�policy�/�guidelines�define�which�research�requires�ethics�approval�and�under�what�conditions�ethics�approval�will�apply.
e)� Staff�are�aware�of�the�research�policy�/�guidelines.
f)� Formal�agreements�exist�with�collaborating�agencies.
a)� The�research�policy�/�guideline�is�implemented.
b)� Scientific�review�standards�of�research�are�applied�and�demonstrated�within�the�body�of�work.
c)� The�respective�responsibilities�of�all�parties�involved�in�research�are�identified�and�documented.
d)� The�role�and�reporting�lines�of�the�organisation’s�human�research�ethics�committee�(HREC)�are�clearly�defined.
e)� The�HREC�is�adequately�resourced.
f)� Ethics�approval�processes�are�timely,�transparent�and�effective.
g)� Consumers�and�researchers�work�in�partnership�to�make�decisions�about�research�priorities,�policy�and�practices.
a)� Performance�measures�are�used�to�evaluate�the�effectiveness�of�the�governance�of�research.
b)� The�system�for�ensuring�effective�research�governance�is�evaluated,�and�is�improved�as�required.
a)� Research�outcomes�are�implemented�in�the�organisation�and�are�used�to�demonstrate�improvements�in�health�care.
and/or
b)� The�organisation�participates�voluntarily�in�a�regular�external�evaluation�of�research�governance.
a)� The�organisation�demonstrates�that�it�is�a�leader�in�research�risk�management.
seCtion 5Standards, criteria, elements and guidelinesstandard 2.5:�The�organisation�encourages�and�adequately�governs�the�conduct�of�health�and�medical�research�to�improve�the�safety�and�quality�of�health�care
368 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 2.5.1
The�organisation’s�research�program�develops�the�body�of�knowledge,�protects�staff�and�consumers�/�patients�and�has�processes�to�appropriately�manage�the�organisational�risk�associated�with�research.�(continued)
The�types�and�scale�of�the�research�projects�being�undertaken�by�an�organisation�will�determine�which�elements�of�this�criterion�are�applicable�to�its�circumstances.�From�an�organisational�perspective,�research�activity�offers�both�benefits�and�risks,�and�presents�logistical�and�managerial�challenges.�
When�responding�to�this�criterion,�an�organisation�should�consider�the�types�of�research�it�undertakes�and�the�implications�of�that�research�in�terms�of:
• organisational�governance�(financial�and�legal�implications,�clinical�and�ethical�risks,�benefits�to�society)
• ethics
• risks�to,�and�obligations�to,�participating�consumers�/�patients�/�subjects
• day-to-day�administration�and�management�(research�may�cause�surges�of�activity,�competing�for�resources�with�other�consumers�/�patients�or�staff)
• researchers�and�research�staff�(who�require�training�and�may�be�diverted�from�other�tasks)
• other�staff,�particularly�liaison�people�such�as�those�at�reception�(who�should�be�aware�of�the�project,�if�not�all�its�details)
• the�local�and�broader�community.
Where�a�project�has�implications�in�a�limited�number�of�these�areas,�it�may�be�possible�to�claim�‘Not�Applicable’�status�for�some�elements.�Organisations�should�discuss�these�issues�with�their�Customer�Service�Manager.�
All�EQuIP�member�organisations�are�expected�to�be�monitoring�the�quality�of�their�care�delivery�and�continually�improving�their�processes.�Small�research�projects�will�be�used�to�test�and�monitor�improvements�as�they�are�introduced,�through�the�process�of�continuous�quality�improvement�(CQI).�If�CQI�is�the�only�form�of�research�undertaken�by�the�organisation,�the�organisation�may�be�able�to�claim�an�exemption�from�this�criterion.
Which�QI�projects�are�defined�as�research�to�fulfil�the�requirements�of�this�criterion?�The�answer�should�be�determined�by�the�scale�and�risk�associated�with�the�project.�Quality�Improvement�projects�with�at�least�two�of�these�features:
1.� Funding�by�a�body�outside�the�organisation
2.� Approval�of�the�project�by�a�Human�Research�Ethics�Committee�(HREC)
3.� An�objective�to�develop�a�marketable�product�that�might�be�adopted�by�other�organisations�(e.g.�a�wound�care�solution,�alternative�bandaging�technique,�software�tool)
4.� Coordination�by�a�central�agency,�such�as�a�State�/�Territory�health�department�or�the�Australian�Commission�on�Safety�and�Quality�in�Health�Care
5.� Planning�for�publication�in�a�peer-reviewed�journal
6.� Impact�on�non-participating�staff�and/or�consumers�/�patients
...�would�be�considered�to�have�the�scale�and�reach�both�within�and�beyond�the�organisation�to�be�counted�as�research�for�the�purposes�of�this�criterion.
October 2010 369
Types of research undertaken within healthcare settings
Potential for direct risk to participating consumer / patient / subject
experiment description
impact of experiment on consumer / patient’s treatment
Components of research: considering research projects in terms of their various aspects may assist in responding to the element(s)
Governance awareness
organisational management awareness
ethics Committee (eC) review
Consumer / patient education and consent
Research team training
other staff informed of the project
Higher Clinical�trial�or�other�controlled�experiment�where�treatment�of�individual�consumers�/�patients�is�varied�for�the�purpose�of�the�research
Selection�of�treatment�pathway�determined�by�experimental�profile�which�may�be�randomised
Yes Sometimes HREC Yes Yes General�awareness,�with�more�information�as�appropriate
Only�variations�to�normal�treatment�are�through�additional�sample�collection�(tissues,�blood,�urine,�etc.),�measurements�or�imaging�
Inconvenience�to�consumer�/�patient
Small�risks�associated�with�some�sample�collection�(e.g.�biopsy,�radiography)
Yes Sometimes HREC Yes Yes As�appropriate
Variations�to�process�that�have�no�direct�clinical�ramifications�(e.g.�administration�of�admission�processes,�number�or�type�of�staff�assigned�to�a�task)
Minimal�physical�risk;�Potential�for�inconvenience
Where�scale�is�very�large�or�project�prestigious‡
Where�scale�is�large
HREC Yes** Yes As�appropriate
Low Only�variations�to�normal�treatment�and�process�are�through�observation�or�survey�/�interview
Minimal�physical�risk;�Potential�for�inconvenience
Where�scale�is�very�large�or�project�prestigious‡
Where�scale�is�large
HREC Yes** Yes As�appropriate,�but�usually�no
Retrospective�study�of�records�with�or�without�consumer�/�patient�contact
No�physical�risk
Almost�never Where�there�are�staffing�or�operational�risks
HREC*� No†† Yes Usually�no
Nil Animal�studies Not�applicable Yes No Animal�EC Not�applicable
Yes No
Basic�research:�Non-living�substrates,�single�celled�organisms�or�cell�cultures
Not�applicable Yes No Only�in�exceptional�circum-stances†
Not�applicable
Yes No
*� Where�record�is�used�outside�its�original�clinical�context†� Genetically�engineered�organisms,�use�of�embryonic�tissue,�etc.‡� Project�would�need�to�have�the�potential�to�impact�the�organisation�through�cost,�risk,�consumer�/�patient�or�staff�
dissatisfaction�or�damaged�reputation�with�collaborators�(funding�bodies�or�participating�organisations)
**� Except�where�experimental�success�depends�on�a�naive�participant.�However,�permission�to�use�any�recordings��and�observations�is�highly�likely.
††� Study�would�be�explained�at�time�of�follow-up�contact
seCtion 5Standards, criteria, elements and guidelinesstandard 2.5:�The�organisation�encourages�and�adequately�governs�the�conduct�of�health�and�medical�research�to�improve�the�safety�and�quality�of�health�care
370 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 2.5.1
The�organisation’s�research�program�develops�the�body�of�knowledge,�protects�staff�and�consumers�/�patients�and�has�processes�to�appropriately�manage�the�organisational�risk�associated�with�research.�(continued)
Governance of researchWhere�research�is�a�significant�activity�for�an�organisation,�it�would�be�anticipated�that�there�is�a�framework�within�which�it�is�undertaken.�The�framework�is�a�construct�of�governance;�it�considers�current�and�existing�research�results,�and�organisational�expertise�and�experience,�and�uses�these�to�guide�new�and�relevant�research�activities.�The�framework�will�assist�the�organisation�to�facilitate�good�research�concepts,�and�to�direct�project�planning�and�applications�for�funding.�Performance�measures�may�relate�to�funding�achievements,�publication�in�peer-reviewed�journals,�or�commercialisation�of�developments�realised�through�research.
As�part�of�its�commitment�to�fostering�and�encouraging�research,�the�management�of�the�organisation�should�appropriately�support�the�use�of�the�organisation’s�resources�by�those�carrying�out�the�research,�and�ensure�the�implementation�of�the�policies�and�guidelines�under�which�the�research�is�to�be�conducted.�The�purpose�of�research�governance�is�to�ensure�research�integrity�through�accountability,�transparency�and�responsibility.1,�2�The�three�key�components�of�research�governance�are:
• the�protection�of�consumers�/�patients,�carers�and�staff�involved�in�research:�this�includes�such�matters�as�consent,�the�provision�of�appropriate�and�safe�facilities�in�which�clinical�research�may�be�undertaken,�and�the�monitoring�of�consumers�/�patients’�wellbeing
• the�protection�of�researchers:�this�includes�training,�facilities,�processes�for�the�proper�conduct�of�research,�and�appropriate�employment�arrangements
• the�protection�of�the�organisation:�this�includes�matters�that�might�pose�a�risk�to�the�organisation�or�bring�the�organisation�into�disrepute,�for�example,�the�risk�to�the�reputation�of�that�organisation�posed�by�dishonest�research,�financial�risk,�intellectual�property�risk,�commercial�arrangements,�and�liability�with�regard�to�consumer�/�patient�harm.
It�is�important�that�the�need�for�review�by�a�Human�Research�Ethics�Committee�(HREC)�is�not�confused�with�the�need�for�research�governance.�The�organisation’s�management�should�be�aware�of�research�that�presents�specific�risks�or�opportunities�for�the�organisation.�In�addition�to�the�researcher’s�responsibility,�organisations�should�aim�to�ensure�that�projects�receive�appropriate�HREC�oversight.�This�requires�their�understanding�that�if�the�organisation�is�engaged�in�clinical�or�health�services�research,�the�governing�body�is�responsible�for�the�governance�of�that�research.�In�relation�to�clinical�research,�the�responsibility�does�not�rest,�by�default�or�any�other�means,�with�the�HREC.�Such�committees�have�a�different�role�that�is�related�to�the�research,�but�it�is�not�for�the�governance�of�the�research.�In�this�respect,�the�role�of�the�HREC�should�be�clearly�defined�within�the�organisation’s�policies�and�guidelines.�Similarly,�governance�bodies�that�do�not�have�an�organisational�HREC�should�consider�access�in�advance�of�the�need�arising�–�even�low-risk�quality�projects�undertaken�in�healthcare�organisations�will�frequently�draw�upon�health�records�or�require�cooperation�from�consumers�/�patients�to�complete�surveys�or�interviews.
In�the�absence�of�an�HREC,�organisations�should�have�a�designated�executive�member�/�group�that�is�familiar�with�the�NationalStatementonEthicalConductinHumanResearch3,�and�can�review�any�research�project�proposal,�and�assist�in�determining�the�need�for�HREC�involvement.
Organisations�should�review�and�revise�their�policies�and�performance�measures�at�regular�intervals,�and�make�improvements�according�to�available�evidence�and�their�performance�outcomes.�There�is�no�formal�body�that�does�external�evaluations�of�research�governance�for�health�facility�research.�Organisations�should�look�to�peers�to�assist�with�this.
Smaller�organisations�that�undertake�only�low-risk�projects�and�do�not�have�or�need�an�HREC�might�consider�evaluating�their�research�governance�through:
• recording�and�monitoring�consultations�about�research�projects�with�the�designated�executive�member�/�group�
• monitoring�the�executive�member�/�group’s�knowledge�of�relevant�parts�of�the�National�Statement.
October 2010 371
Prompt points
¼ How does the organisation demonstrate its commitment to fostering and encouraging research?
¼ What is an example of a research project undertaken within this organisation?
¼ How often are the governance policies and performance measures reviewed? What changes have been made in response to a review of policies or performance measures?
Policies, guidelines and standardsClinical�research�involving�human�subjects,�and�the�organisational�policies�that�govern�it,�should�be�consistent�with�the�key�National�Health�and�Medical�Research�Council�(NHMRC)�statements.�These�are:
• NationalStatementonEthicalConductinHumanResearch.The�Australian�Government�National�Health�and�Medical�Research�Council,�2007�(incorporating�all�updates�as�of�September�2009)3�
• TheAustralianCodefortheResponsibleConductofResearch.�Developed�and�issued�jointly�by�the�National�Health�and�Medical�Research�Council,�the�Australian�Research�Council�and�Universities�Australia,�20071
• ValuesandEthics:GuidelinesforEthicalConductinAboriginalandTorresStraitIslanderHealthResearch.�The�Australian�Government�National�Health�and�Medical�Research�Council,�2003.2
In�addition�to�these�three�key�statements,�research�is�governed�by�laws�(Federal�and/or�State�/�Territory),�and�by�other�guidelines�and�codes�of�conduct,�which�deal�with�matters�such�as�privacy,�confidentiality,�consent,�biosafety�and�professional�standards.
The�research�policy�/�guidelines�adopted�by�an�organisation�would�be�expected�to�be�appropriate�for,�and�congruent�with,�the�level�of�risk�associated�with�research�activities�undertaken�by�the�organisation.�The�application�of�a�standard�across�research�practices�will�provide�many�benefits�to�all�involved.4�
These�include:
• enhanced�contribution�to�organisational�goals,�culture�and�knowledge
• best-practice�performance
• increased�efficiency�in�bringing�safe�and�effective�new�therapies�and�organisational�improvements�to�and�for�the�consumer
• external�recognition�as�an�organisation�that�adheres�to�best-practice�standards�through�self�regulation
• enhanced�standards�within�clinical�research
• confidence�in�the�competence�and�level�of�expertise�of�employees
• a�benchmark�for�the�content�of�education�and�training�programs�for�researchers
• increased�marketability�for�an�individual�clinical�research�professional.
Prompt points
¼ How does the organisation ensure widespread awareness of, and alignment with, legislated requirements and the standards developed by the NHMRC?
¼ Is the organisation involved in collaborative research?
¼ What formal research agreements has the organisation entered into?
Ethical review and approval of researchMany�organisations�conduct�basic�health�research�that�does�not�involve�human�or�even�animal�subjects;�this�may�have,�for�example,�a�biological,�engineering,�statistical�or�literature�review�focus.�Fundamental�research�such�as�this�usually�does�not�require�ethical�review.�However,�the�organisation’s�managers�should�be�aware�of�the�broad�areas�of�research�undertaken�and�any�risks�associated�with�them.�Those�organisations�housing�research�involving�genetically�modified�organisms�(GMOs)�will�require�a�licence�and�pre-certified�facilities,�and�the�research�will�be�administered�through�the�Office�of�the�Gene�Technology�Regulator5�and�monitored�by�a�local,�often�institutional,�Biosafety�Committee.�Organisations�with�facilities�that�operate�in�this�sector�should�be�aware�of�the�GeneTechnologyAct2000�(Cth)�and�its�associated�regulations.
seCtion 5Standards, criteria, elements and guidelinesstandard 2.5:�The�organisation�encourages�and�adequately�governs�the�conduct�of�health�and�medical�research�to�improve�the�safety�and�quality�of�health�care
372 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 2.5.1
The�organisation’s�research�program�develops�the�body�of�knowledge,�protects�staff�and�consumers�/�patients�and�has�processes�to�appropriately�manage�the�organisational�risk�associated�with�research.�(continued)
Research�that�involves�humans�and�that�has�any�risk�of�causing�harm�physically,�psychologically�or�spiritually,�or�that�potentially�could�breach�confidentiality�or�privacy,�must�always�be�submitted�to�a�properly�constituted�HREC.�This�includes�research�where�members�of�the�organisation’s�staff�are�the�participants.
Some�organisations�in�which�human�research�is�conducted�will�have�their�own�HREC,�and�it�is�the�responsibility�of�the�establishing�organisation�to�ensure�that�its�committee�is�adequately�resourced.�Other�organisations,�which�choose�not�to�establish�their�own�committee�or�in�which�the�establishment�of�such�a�committee�would�be�impractical,�may�make�use�of�the�services�of�another�organisation’s�committee,�usually�upon�payment�of�an�appropriate�fee.�The�website�of�the�NHMRC�provides�an�overview�of�HRECs,�including�a�comprehensive�state-by-state�list�of�all�registered�HRECs�and�information�on�such�issues�as�fees.6
Prompt points
¼ Does the organisation have its own HREC? How is the body constituted within organisational policy?
¼ If the organisation does not have its own HREC, where are human research proposals submitted for review?
¼ Does the organisation have an internal review committee? How does the organisation ensure that committee members are familiar with the requirements of the NHMRC’s National Standard on Ethical Conduct in Human Research?
¼ Does the organisation conduct animal-based medical research? To what Animal Ethics Committee does it submit its research proposals? Where does it display its project approval numbers?
Participation in researchAll�participants�in�research,�including�participating�consumers�/�patients,�bear�a�degree�of�responsibility�for�the�correct�conduct�of�the�research.�An�organisation�that�intends�to�undertake�research�must�first�put�in�place�a�research�policy�that�will�frame�and�support�the�correct�management�of�any�research�program�it�undertakes�or�collaborates�in.�In�addition�to�covering�organisational�risk�management�and�project�management,�the�research�policy�should�outline�minimum�standards�for�the�protection�of�research�subjects�/�participants,�staff�assisting�with�the�research�project�and�other�organisational�staff,�including:
• the�responsibilities�of�all�parties
• participant�indemnity
• participant�consent�processes
• the�protection�and�support�of�researchers�and�assisting�staff
• management�of�inquiries�and�complaints.
In�the�interest�of�transparency,�the�organisation’s�research�policy�should�be�made�available�to�consumers�/�patients,�staff,�and�any�other�interested�party.
In�December�2004,�the�NHMRC�published�a�model�framework�for�consumer�and�community�participation�in�health�and�medical�research7�and�a�resource�pack�to�assist�in�the�implementation�of�the�framework.8�These�documents�are�important�references�for�organisations�undertaking�research�and�should�be�incorporated�into�organisational�research�policy.�They�provide�advice�for�organisations�on�why�consumer�and�community�participation�in�research�is�important,�what�is�meant�by�‘involvement’�and�‘participation’,�and�how�to�achieve�it�at�various�levels�of�research.�It�is�relevant�to�many�different�types�of�research�and�the�governance�thereof.�
As�with�many�specialised�work�areas,�the�purposes�and�processes�of�research�may�not�be�evident�to�the�community,�or�even�to�uninvolved�staff�within�the�organisation.�By�including�staff�and�members�of�the�public�in�open�discussion�and�planning,�the�goals,�techniques�and�successes�of�research�may�be�better�communicated,�and�any�misunderstandings�overcome�by�building�networks,�expanding�knowledge�and�raising�levels�of�awareness.�The�organisation�may�arrange�‘Open�Days’�to�publicise�its�research�program(s)�and�its�achievements,�or�deliver�education�sessions�through�community�groups�or�other�public�forums.�The�NHMRC�documents7,�8�are�also�effective�education�tools�for�consumers�and�researchers.�
October 2010 373
Prompt points
¼ How is the organisation’s research policy accessible to staff? How is the community made aware of research undertaken by the organisation? How can community members access the organisation’s research policy?
¼ How are consumers / patients and/or members of the community involved with research undertaken by the organisation?
Evidence commonly presented
Consider whether the following will help to address criterion 2.5.1
¼ Policies on research
¼ Involvement in research programs
¼ Evidence of ethics approval processes
¼ Evidence of awareness of research in relevant areas
¼ Evidence of qualifications for roles undertaken
¼ Evidence of consumer / patient participation in research
¼ Evidence of formal agreements or contracts
¼ Minutes from meetings
Performance measurementThis�criterion�states�that:�“The�organisation’s�research�program�develops�the�body�of�knowledge,�protects�staff�and�consumers�/�patients�and�has�processes�to�appropriately�manage�the�organisational�risk�associated�with�research”.�It�is�important�that�the�organisation�be�able�to�demonstrate�that�it�encourages�and�governs�health�and�medical�research�to�improve�the�safety�and�quality�of�health�care,�while�effectively�managing�the�associated�risk.
Some�common�suggested�performance�measures�are�as�follows:
Number�of�research�projects�approved�(HREC,�AEC,�internal�committee)
Total number of research projects submitted for approval
Number�of�staff�participating�in�research�projects�or�activities�during�the�previous�twelve�months
Total number of staff
Number�of�research-related�incidents
Total number of research projects or activities
Number�of�research�projects�amended�or�stopped�due�to�animal�welfare�issues
Total number of animal-based research projects
seCtion 5Standards, criteria, elements and guidelinesstandard 2.5:�The�organisation�encourages�and�adequately�governs�the�conduct�of�health�and�medical�research�to�improve�the�safety�and�quality�of�health�care
374 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
References1.� National�Health�and�Medical�Research�Council�(NHMRC),�
Australian�Research�Council�(ARC)�and�Universities�Australia.�Australiancodefortheresponsibleconductofresearch.�Melbourne�VIC;�NHMRC;�2007.
2.� National�Health�and�Medical�Research�Council�(NHMRC).�Valuesandethics:GuidelinesforethicalconductinAboriginalandTorresStraitIslanderhealthresearch.�Melbourne�VIC;�NHMRC;�2003.
3.� National�Health�and�Medical�Research�Council�(NHMRC),�Australian�Research�Council�(ARC)�and�Australian�Vice-Chancellors’�Committee.�Nationalstatementonethicalconductinhumanresearch.Canberra�ACT;�Australian�Government;�2007.
4.� Institute�for�Clinical�Research�(ICR).�Clinicalresearchprofessionalstandardsforprofessionalpractice:Raisingthestandardsforclinicalresearch.�Bourne�End�UK;�ICR;�2005.
5.� Office�of�the�Gene�Technology�Regulator�(OGTR).�WelcometotheOfficeoftheGeneTechnologyRegulatorwebsite.�Canberra�ACT;�Australian�Department�of�Health�and�Ageing.�Accessed�from�http://www.ogtr.gov.au/internet/ogtr/publishing.nsf/Content/home-1�on�13�August�2010.
6.� National�Health�and�Medical�Research�Council�(NHMRC).�Overviewofhumanresearchethicscommittees.�Melbourne�VIC;�NHMRC.�Accessed�from�http://www.nhmrc.gov.au/health_ethics/hrecs/overview.htm�on�29�June�2010.
7.� National�Health�and�Medical�Research�Council�(NHMRC)�Amodelframeworkforconsumerandcommunityparticipationinhealthandmedicalresearch.�Canberra�ACT;�Australian�Government;�2004.
8.� National�Health�and�Medical�Research�Council�(NHMRC).�Resourcepackforconsumerandcommunityparticipationinhealthandmedicalresearch.Canberra�ACT;�Australian�Government;�2004.
Standards and guidelinesUnited�States�Department�of�Health�and�Human�Services.�Protectionofhumansubjects.�Code�of�Federal�Regulations:�Public�Welfare�Part�46.�Washington�DC�USA;�Dept�of�Health�and�Human�Services;�2009.
Further readingMonash�University.�Aguidetogoodresearchpractice.Melbourne�VIC;�Faculty�of�Medicine,�Nursing�and�Health�Services�at�Monash�University;�2003.
Jackson�CL,�Nicholson�C,�Doust�J�etal.�Seriously�working�together:�integrated�governance�models�to�achieve�sustainable�partnerships�between�health�care�organisations.�MedJAust2008;�188(8Suppl):�S57-S60.
Katz�SJ�and�Martin�BR.�Whatisresearchcollaboration?Research�Policy.�Brighton�UK;�University�of�Sussex;�1995.
National�Health�and�Medical�Research�Council�(NHMRC).�Removingthebarriers–Outcomespaper.�National�Clinical�Research�Forum.�Sydney;�NSW�Ministry�for�Science�and�Medical�Research;�2005.
Australian�Commission�on�Safety�and�Quality�in�Health�Care�(ACSQHC).�Researchframeworkprinciples.�Sydney�NSW;�ACSQHC;�2008.
Criterion 2.5.1
The�organisation’s�research�program�develops�the�body�of�knowledge,�protects�staff�and�consumers�/�patients�and�has�processes�to�appropriately�manage�the�organisational�risk�associated�with�research.�(continued)
Number�of�consumers�/�patients�experiencing�an�adverse�event�during�or�as�a�result�of�participation�in�a�research�project
Total number of consumers / patients enrolled in research projects
October 2010 375
3.1�Leadership�and�Management�Standard
The�standard�is:�The governing body leads the organisation’s strategic direction to ensure the provision of quality, safe services.
The�intent�of�this�standard�is�to�ensure�that�an�organisation�is�aware�of�and�manages�all�the�key�components�of�governance�of�a�healthcare�organisation.�The�standards�and�criteria�contained�in�this�functional�area�provide�guidance�on�how�healthcare�organisations�can�achieve�effective�corporate�and�clinical�governance.�
There�are�five�criteria�in�this�standard.�They�are:
3.1.1� �The�organisation�provides�quality,�safe�health�care�and�services�through�strategic and operational planning and development.
3.1.2� Governance�is�assisted�by�formal�structures�and�delegation�practices�within�the�organisation.
3.1.3 Processesfor credentialling and defining the scope of clinical practicesupportsafe,qualityhealthcare.
3.1.4� External�service�providers�are�managed�to�maximise�quality,�safe�health�care�and�service�delivery.
3.1.5� Documented corporate and clinical policies and proceduresassisttheorganisationtoprovidequality,safehealthcare.
These�standards�and�criteria�emphasise�the�need�for�strong�leadership,�governance�and�direction.�
seCtion 5Standards, criteria, elements and guidelines
seCtion 5Standards, criteria, elements and guidelinesstandard 3.1:�The�governing�body�leads�the�organisation’s�strategic�direction�to�ensure�the�provision�of�quality,�safe�services
376 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
IntentThe�intent�of�this�criterion�is�to�ensure�that�healthcare�organisations�have�an�integrated�planning�process�that�begins�at�the�strategic�level�and�guides�everyday�work�through�operational�planning.�A�well-articulated�strategic�plan�that�is�supported�by�a�detailed�operational�plan(s)�allows�everyone�to�work�towards�the�same�vision,�mission�and�values,�while�providing�clear�direction�regarding�each�unit,�team�or�individual’s�role�in�the�achievement�of�the�organisation’s�strategic�objectives�and�service�development.
Relationships of 3.1.1 with other criteriaThe�organisation’s�strategic�and�operational�planning�should�articulate�its�commitment�to�the�delivery�of�safe,�high�quality�care�(Standard�1.1),�continuous�quality�improvement�(Criterion�2.1.1),�the�management�of�risk�(Criterion�2.1.2)�and�consumer�participation�(Criterion�1.6.1).�The�planning�will�consider�all�operational�aspects�of�the�organisation,�including�human�resources�(Standard�2.2),�information�technology�(Criterion�2.3.4),�governance�(Criterion�3.1.2)�and�the�safety�of�consumers�/�patients,�visitors�and�staff�(Standard�3.2).
Criterion LA – Awareness sA – implementationLA plus the following
MA – evaluationSA plus the following
eA – excellenceMA plus the following
oA – LeadershipEA plus the following
Criterion 3.1.1
The�organisation�provides�quality,�safe�health�care�and�services�through�strategic�and�operational�planning�and�development.
a)� An�organisational�strategic�plan�has�been�developed�and�includes�values,�vision�and�mission.
b)� Service�delivery�needs�of�the�communities�are�analysed�and�considered�when�developing�strategic�and�operational�plans.
c)� There�is�recognition�of�the�need�to�develop�relationships�with�relevant�organisations�and�communities�to�achieve�organisational�and�strategic�objectives.
d)� There�is�a�planned�approach�to�the�development�of�facilities�and�services.
e)� Operational�plans�are�developed�to�achieve�the�organisation’s�goals�and�objectives�and�guide��day-to-day�activities.
f)� The�activities�of�the�organisation�are�covered�by�appropriate�by-laws,�articles�of�association�and/or�policies�and�procedures.
a)� Organisational�and�service�planning�aligns�with�strategic�objectives.
b)� Clinical�and�non-clinical�service�planning�reflects�projected�service�demands.
c)� Planning�identifies�priority�areas�for�care�/�service�development�and�the�most�efficient�use�of�resources
d)� Stakeholders�and�where�appropriate,�consumers�/�patients�and�carers�are�involved�in�the�development�and�implementation�of�plans.
e)� Relationships�with�relevant�external�organisations�are�formally�recognised�in�the�planning�process.
f)� Change�and�risk�management�strategies�are�documented�to�achieve�the�objectives�of�the�strategic�and�operational�plans.
g)� Planned�changes�are�clearly�communicated�to�relevant�stakeholders.
a)� The�governing�body�evaluates�progress�towards�achieving�the�vision,�goals�and�strategic�objectives�of�the�strategic�plan,�and�takes�remedial�action�as�required.
b)� Changes�driven�by�the�strategic�plan�are�evaluated�in�consultation�with�relevant�stakeholders.
a)� The�process�of�service�planning�and�development�is�compared�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.
and/or
b)� Achievement�against�strategic�objectives�is�compared�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.
a)� The�organisation�demonstrates�it�is�a�leader�in�providing�quality,�safe�care�and�services�through�strategic�and�operational�planning�and�development.
October 2010 377
Organisational planningStrategic�planning�is�a�process�that�articulates�the�organisation’s�vision�and�mission,�its�values,�and�planned�objectives;�what�it�intends�to�achieve�for�its�community.�The�process�of�strategic�planning�is�a�function�of�the�governing�body�but�ideally�involves�staff,�stakeholders�and�consumers�as�well.
Organisational�strategy�defines�what�an�organisation�seeks�to�do�and�how�it�plans�to�do�it.�While�a�formal�plan�may�guide�overall�direction,�strategy�development�is�a�continuous�process,�enabling�the�organisation�to�respond�to�changes�in�its�environment�as�appropriate.1�Strategic�planning�is�a�management�tool�that�helps�an�organisation�to�assess�and�adjust�the�organisation’s�direction�in�response�to�a�changing�environment�–�to�focus�its�energy,�and�to�ensure�that�members�of�the�organisation�are�working�toward�the�same�goals.2
The�outcome�of�effective�health�service�strategic�planning�is�clarity�of�direction�for�service�development�and�resource�investment.�This�direction�should�be�evidence-based�and�reflect�strategic�objectives,�service�policies�and�population�needs�and�priorities.�Planning�is�developed�through�consumer,�clinician�and�stakeholder�consultation,�and�needs�to�acknowledge�affordability�and�the�workforce�necessary�to�deliver�the�plan.�Therefore,�planning�must�consistently�be�tested�against�the�strategic�direction�of�the�system�and�the�health�needs�of�the�population�served.3
Criterion LA – Awareness sA – implementationLA plus the following
MA – evaluationSA plus the following
eA – excellenceMA plus the following
oA – LeadershipEA plus the following
Criterion 3.1.1
The�organisation�provides�quality,�safe�health�care�and�services�through�strategic�and�operational�planning�and�development.
a)� An�organisational�strategic�plan�has�been�developed�and�includes�values,�vision�and�mission.
b)� Service�delivery�needs�of�the�communities�are�analysed�and�considered�when�developing�strategic�and�operational�plans.
c)� There�is�recognition�of�the�need�to�develop�relationships�with�relevant�organisations�and�communities�to�achieve�organisational�and�strategic�objectives.
d)� There�is�a�planned�approach�to�the�development�of�facilities�and�services.
e)� Operational�plans�are�developed�to�achieve�the�organisation’s�goals�and�objectives�and�guide��day-to-day�activities.
f)� The�activities�of�the�organisation�are�covered�by�appropriate�by-laws,�articles�of�association�and/or�policies�and�procedures.
a)� Organisational�and�service�planning�aligns�with�strategic�objectives.
b)� Clinical�and�non-clinical�service�planning�reflects�projected�service�demands.
c)� Planning�identifies�priority�areas�for�care�/�service�development�and�the�most�efficient�use�of�resources
d)� Stakeholders�and�where�appropriate,�consumers�/�patients�and�carers�are�involved�in�the�development�and�implementation�of�plans.
e)� Relationships�with�relevant�external�organisations�are�formally�recognised�in�the�planning�process.
f)� Change�and�risk�management�strategies�are�documented�to�achieve�the�objectives�of�the�strategic�and�operational�plans.
g)� Planned�changes�are�clearly�communicated�to�relevant�stakeholders.
a)� The�governing�body�evaluates�progress�towards�achieving�the�vision,�goals�and�strategic�objectives�of�the�strategic�plan,�and�takes�remedial�action�as�required.
b)� Changes�driven�by�the�strategic�plan�are�evaluated�in�consultation�with�relevant�stakeholders.
a)� The�process�of�service�planning�and�development�is�compared�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.
and/or
b)� Achievement�against�strategic�objectives�is�compared�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.
a)� The�organisation�demonstrates�it�is�a�leader�in�providing�quality,�safe�care�and�services�through�strategic�and�operational�planning�and�development.
seCtion 5Standards, criteria, elements and guidelinesstandard 3.1:�The�governing�body�leads�the�organisation’s�strategic�direction�to�ensure�the�provision�of�quality,�safe�services
378 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 3.1.1
The�organisation�provides�quality,�safe�health�care�and�services�through�strategic�and�operational�planning�and�development.�(continued)
Major�strategic�planning�activities�include:�
• strategic�analysis�(see�Strategic�/�needs�analysis�section�below)
• seizing�the�future�and�being�responsive�to�the�environment�in�which�the�organisation�operates
• setting�strategic�directions
• being�clear�about�the�organisation’s�objectives�
• being�aware�of�the�organisation’s�resources
• action�planning.1
Long-�and�short-term�objectives�are�essential�for�effective�management�of�the�organisation.�Action�planning�is�carefully�laying�out�how�the�strategic�objectives�will�be�accomplished�using�the�identified�methods�or�strategies.�This�often�includes�declaring�specific�results�for�each�objective.�Reaching�a�strategic�objective�typically�involves�accomplishing�a�set�of�results,�or�milestones,�along�the�way.1
Therefore,�the�strategic�plan�establishes�an�organisation’s�overall�strategic�objectives,�is�organisation-wide�and�is�responsive�to�the�organisation’s�risks.�It�identifies�the�organisation’s�long-term�direction,�where�resources�are�to�be�allocated,�what�services�are�available�and�what�is�needed.�The�governing�body�approves�the�plan,�which�is�then�implemented�and�revised�as�necessary.
The�operational�plan�is�a�short-term�plan�that�details�the�methods�or�strategies�by�which�the�strategic�plan�will�be�accomplished,�and�can�be�developed�for�specific�sites�/�areas�/�programs�/�services.�It�identifies�responsibilities�and�timeframes�in�a�format�that�can�be�easily�understood.�The�strategic�plan�and�operational�plans�can�be�aligned�using�performance�indicators.�Performance�improvement,�change�management�and�risk�management�processes�should�also�be�included�to�ensure�the�achievement�of�outcomes�identified�in�the�strategic�plan.�
In�summary,�the�organisation’s�strategic�and�operational�plans�should�be�integrated,�responsive�to�the�needs�of�the�community�and�developed�cooperatively�by�management,�staff�and�the�community,�along�with�other�relevant�health�service�providers�and�stakeholders.�Operational�plans�should�be�aligned�with�the�strategic�plan�and�performance�indicators�used�to�facilitate�monitoring�and�progress�towards�achievement�of�strategic�objectives.�
Prompt points
¼ What are the organisation’s vision, mission, strategic objectives and values and how do these guide planning?
¼ How are these made known to all stakeholders?
¼ What framework and processes does the organisation use to develop strategic and operational plans?
¼ What role do stakeholders play in strategic and operational planning?
¼ What evidence of identified needs, priorities, appropriateness and effectiveness is used to guide planning?
¼ How are areas for care / service development prioritised?
¼ How is action planning undertaken?
¼ What strategies are in place to achieve the organisation’s objectives?
¼ What change or risk management strategies are documented?
¼ How do operational plans achieve the organisation’s objectives and guide day-to-day activity?
¼ How does the organisation ensure that operational plans guide performance improvement and the management of change and risk?
¼ How is progress monitored against objectives outlined in the strategic and operational plans, and corrective action taken if necessary?
October 2010 379
Strategic / needs analysisStrategic�or�needs�analysis�includes�conducting�a�scan,�or�review,�of�the�organisation’s�environment,�for�example,�of�the�political,�social,�economic�and�technical�environment.�Various�driving�forces�in�the�environment�should�be�carefully�considered,�such�as�increasing�competition,�change�in�policy�direction,�changing�demographics,�etc.1�As�healthcare�organisations�operate�within�a�complex�local�and�national�political�context,�it�is�important�to�bring�an�understanding�of�the�climate�and�culture�both�within�the�organisation�and�in�the�wider�health�and�community�environment�into�the�planning�process.�Being�attuned�to�health�strategy�and�policy�at�a�national�and�local�level�and�being�able�to�plan�ahead�in�a�way�that�takes�account�of�these�factors�is�necessary�for�the�delivery�of�appropriate,�quality�care.�This�includes�recognition�that�the�boundaries�between�organisations�are�not�important,�that�services�should�work�across�boundaries,�and�that�no�one�organisation�in�the�health�service�can�‘stand�alone’.4
The�focus�on�continuous�improvement�in�provision�of�health�care�requires�leaders�who�stay�aware�of�best�clinical�and�management�practice.�Being�aware�of�practice�elsewhere�enables�them�to�replicate�or�improve�upon�it�in�their�own�organisations�and�across�the�health�community.�Leaders�are�held�accountable�for�service�delivery�in�their�own�organisation.�Thus,�they�need�to�understand�how�services�are�being�delivered�to�consumers�/�patients,�to�pick�up�early�warning�signs�of�difficulty,�and�to�seize�opportunities�to�improve�the�consumer�/�patient�experience.4�
Identifying�and�planning�for�possible�internal�and�external�challenges�assists�the�organisation�to�be�prepared.�An�external�challenge�could�be�described�as�a�challenge�imposed�on�an�organisation�by�external�forces,�or�the�‘rules�of�success’.�These�could�include:
• changes�in�legislation�or�regulation�
• technological�advances
• government�department�restructures�
• governing�organisation�restructures�or�takeover�
• national�workforce�shortages
• external�disasters�such�as�earthquakes,�transport�accidents�or�bushfires
• outside�competition
• change�in�government�policy�that�may�impact�on�the�organisation.�
An�internal�challenge�may�be�described�as�a�challenge�within�the�organisation,�and�could�include:�
• recruitment�issues
• technological�crises
• the�Emergency�Department�being�full�to�capacity
• an�unavailability�of�beds�in�the�organisation�
• a�continuing�adverse�financial�trend.�
Prompt points
¼ What processes are used to determine and analyse key factors in the external environment?
¼ How does the organisation anticipate and ensure adaptability to changing circumstances?
¼ How are internal and external challenges addressed?
¼ How is projected demand for clinical and non-clinical services incorporated into planning processes?
¼ What evidence is used to support provision (or non-provision) of particular services?
Building relationships and collaboration in planningTo�ensure�a�comprehensive�approach�to�planning,�it�is�crucial�for�strategic�and�operational�planning�processes�to�incorporate�formal�consideration�and�recognition�of�the�relationships�that�exist,�or�need�to�be�developed,�between�the�healthcare�organisation�and�other�bodies,�such�as�other�health�services,�community�organisations,�health�funds�and�government�bodies.�Broad�consultation�will�help�to�identify�and�address�the�needs�and�expectations�of�the�organisation’s�internal�and�external�customers.�The�involvement�of�managers,�staff�and�the�community�in�strategic�and�operational�planning,�as�well�as�the�implementation�of�those�plans,�will�ensure�that�needs,�expectations�and�opportunities�are�determined�and�considered.�
Healthcare�organisations�should�define�their�communities,�or�the�populations�they�serve.�These�are�the�people�and�groups�who�have�an�interest�in�the�organisation,�and�its�outcomes,�or�who�are�affected�in�some�way�by�its�activities.5�Organisations�will�identify�their�communities,�as�discussed�within�criterion�1.2.1,�in�order�to�meet�their�needs.�They�may�also�find�it�useful�to�analyse�the�influence�of�various�stakeholders�associated�with�the�organisation,�and�the�impact�such�influence�may�have�on�planning.5�
seCtion 5Standards, criteria, elements and guidelinesstandard 3.1:�The�governing�body�leads�the�organisation’s�strategic�direction�to�ensure�the�provision�of�quality,�safe�services
380 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 3.1.1
The�organisation�provides�quality,�safe�health�care�and�services�through�strategic�and�operational�planning�and�development.�(continued)
Consumer�participation�should�occur�at�multiple�levels�of�the�organisation�through�activities�such�as�consumer�partnership�in�governance�and�management�committees�and�within�improvement�initiatives�or�clinical�risk�management�activities,�as�well�as�broader�community�consultation.�Consumer�participation�should�be�actively�sought�in�planning,�and�the�utilisation�of�consumer�/�patient�complaints,�compliments,�surveys�and�Freedom�of�Information�(FOI)�requests�should�inform�improvements.�Strategies�should�be�in�place�to�ensure6,�7:
• consumers�participate�in�planning,�improvement�and�monitoring�organisational�processes�
• there�is�clear,�open�and�respectful�communication�between�consumers�and�the�organisation�at�all�levels,�including�strategically�
• services�respond�with�humanity�to�the�diverse�needs�of�consumers�/�patients�and�the�community�
• services�learn�from�consumer�/�patient�feedback�on�clinical�care�and�service�delivery.�
Once�the�composition�of�a�healthcare�organisation’s�community�is�determined,�how�representatives�are�actively�sought�for�participation�in�planning�will�vary.�For�example,�one�organisation�may�hold�focus�groups�comprised�of�referring�practitioners�to�obtain�their�input,�while�another�may�invite�consumers�through�a�local�advertising�campaign�to�apply�for�positions�on�its�governing�body.
Prompt points
¼ How are the views of diverse stakeholders incorporated into planning processes?
¼ How is consumer participation encouraged and supported in planning activities?
¼ How is stakeholder influence acknowledged, balanced and managed?
¼ How does the organisation actively create conditions for successful partnership work?
¼ How are partnerships utilised to support planning for ‘joined up’ or integrated care?
¼ What communication and distribution channels are utilised for informing management, staff and the community of plans and any changes?
¼ How is the quality and effectiveness of collaborative partnerships evaluated?
Change managementChange�management�is�the�process�of�managing�the�effective�implementation�of�organisational�strategies,�ensuring�that�permanent�changes�in�objectives,�behaviours,�relationships,�processes�and�systems�are�achieved�to�the�organisation’s�advantage.�Change�management�has�been�recognised�as�a�complex,�dynamic�process,�during�which�unanticipated�events�and�behaviours�may�emerge.�Change�is�seen�as�a�learning�process�that�is�not�linear�and�sequential,�but�a�continuous�process�of�transition�involving�continual�adjustment�of�objectives,�unanticipated�events�and�disruption.8�An�organisation’s�willingness�and�ability�to�adapt�to�changing�circumstances,�along�with�the�development�of�flexible�strategies,�assist�the�organisation�to�continue�to�achieve�its�overall�strategic�objectives�and�mission.�
Communicating�the�vision�and�rationale�for�change�and�service�improvement,�and�engaging�and�facilitating�others�to�work�collaboratively�to�achieve�real�improvement,�are�essential�components�when�instituting�change.�Leadership�is�critical�in�establishing�the�organisational�climate�that�people�experience,�whether�the�context�is�a�hospital,�a�community�setting�or�a�network.�How�prepared�people�are�to�expend�the�extra�effort�required�to�implement�change�is�impacted�by�this�climate.�Strong�and�clear�leadership�is�critical�in�inspiring�people�to�make�changes�and�in�getting�diverse�stakeholders�to�work�effectively�together.�As�health�services�become�more�integrated�with�other�agencies,�it�is�also�critical�that�leaders�provide�clarity�about�individual�and�team�roles.4
A�change�leader�needs�to4:
• manage�the�team
• secure�the�right�resources�and�support
• create�the�right�team�conditions
• articulate�a�compelling�vision�of�change
• mobilise�people’s�energy�and�commitment
• make�change�inclusive�and�effective.
October 2010 381
While�changing�organisational�structure�is�a�popular�thing�to�do,�much�research�suggests�that�this�often�results�in�poor�outcomes,�with�the�benefits�sought�by�those�who�initiate�restructuring�only�rarely�being�achieved.�Instead,�there�are�strong�arguments�for�making�improvements�to�systems�and�cultures.�This�means�striving�to�influence�and�shape�how�people�tackle�change,�their�behaviours�and�practices,�attitudes�and�values,�which�are�the�fundamental�building�blocks�of�successful�and�sustainable�change.�
Utilising�an�interactive,�problem-solving�approach�along�with�a�range�of�tools�helps�to�promote�change�and�measure�progress.9
In�summary:
• establish�a�change�agenda�and�improvement�program
• anticipate�change�and�be�responsive�in�a�planned�manner
• communicate�vision�and�rationale�for�change
• engage�and�facilitate�others�to�work�collaboratively
• prioritise�effort�to�get�the�best�outcomes
• focus�on�making�improvements�to�systems�and�cultures,�rather�than�structure�alone
• involve�relevant�staff�and�consumers�throughout�the�design,�implementation�and�evaluation�phases
• utilise�an�interactive,�problem-solving�approach,�along�with�a�range�of�tools
• secure�resources�and�support
• support�staff�through�change�processes
• be�open�and�transparent�in�communication�with�stakeholders:
– internal�stakeholders�such�as�staff,�visiting�medical�officers
– the�wider�community
– external�service�providers,�such�as�local�government�community�services�and�general�practitioners
– external�stakeholders,�such�as�State�/�Territory�government,�corporate�office,�etc.�
• identify�and�measure�the�outcomes�of�any�significant�change�process;�review�and�evaluation�of�achievement�against�planned�outcomes�feeds�back�into�the�planning�process.
Prompt points
¼ How does the organisation strategically anticipate and plan for change?
¼ How are opportunities likely to achieve the greatest outcomes determined?
¼ Are there examples where challenges were overcome and change management strategies were effectively used? Were these documented?
¼ Was the organisation able to direct efforts to improving systems or cultures?
¼ What approach was taken?
¼ How was the vision and rationale for change communicated?
¼ How did the organisation ensure collaborative stakeholder engagement throughout?
¼ How were risks identified, documented and managed?
¼ What evaluation strategies were built in and how are changes evaluated?
¼ What examples demonstrate that evaluation findings have resulted in changes to clinical and non-clinical areas?
¼ How have findings been utilised to further refine the strategy, or inform other activities?
seCtion 5Standards, criteria, elements and guidelinesstandard 3.1:�The�governing�body�leads�the�organisation’s�strategic�direction�to�ensure�the�provision�of�quality,�safe�services
382 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 3.1.1
The�organisation�provides�quality,�safe�health�care�and�services�through�strategic�and�operational�planning�and�development.�(continued)
Evidence commonly presented
Consider whether the following will help to address criterion 3.1.1
¼ Framework and process for developing strategic and operational plans including categories for participants
¼ Vision, mission, strategic objectives and value statements
¼ Strategic and operational plans with objectives and targets and links to other plans
¼ Legislative compliance activities – team reviews, audits, mortality and morbidity review meetings, etc.
¼ Examples of internal and external challenges that have been addressed
¼ Examples of issues where change management strategies are used
¼ Communication and distribution channels for informing management, staff and the community of plans and any changes
¼ Reports of progress to objectives and targets in the strategic and operational plans
¼ Reports of evaluation of changes to the organisation’s systems, culture, services, structures or practices
Performance measurementThis�criterion�states�that:�“The�organisation�provides�quality,�safe�health�care�and�services�through�strategic�and�operational�planning�and�development”.�All�aspects�of�the�organisation’s�operation�must�be�addressed�within�its�processes�for�planning�and�development.�The�organisation�should�be�able�to�demonstrate�how�these�processes�facilitate�effective�care�outcomes�and�continuous�quality�improvement.
Some�common�suggested�performance�measures�are�as�follows:
Number�of�documented�strategic�/�operational�/�departmental�objectives�achieved�annually
Total number of documented strategic / operational / departmental objectives
Number�of�staff�educated�about�legislation�related�to�their�area�of�responsibility
Total number of staff in a particular area
Number�of�department�/�unit�plans�that�are�deployed�from�organisational�operational�/�strategic�plans
Total number of department / unit plans
Number�of�operational�/�strategic�plans�developed�with�stakeholder�involvement
Total number of operational / strategic plans
October 2010 383
References1.� McNamara�C.�Basicdescriptionofstrategicplanning
(includingkeytermstoknow).�Minneapolis�USA;�Authenticity�Consulting.�Accessed�from�http://www.managementhelp.org/plan_dec/str_plan/basics.htm�on�3�March�2010.
2.� Bryson�JM.�Strategicplanningforpublicandnonprofitorganizations:Aguidetostrengtheningandsustainingorganizationalachievement.3rd�edn.�San�Francisco�USA;�Jossey�Bass;�2004.
3.� NSW�Health.�PolicyDirective:Areahealthcareservicesplans–NSWHealthguidefordevelopment.Sydney;�NSW�Health;�2005.
4.� National�Health�Service�(NHS).�Institute�for�Innovation�and�Improvement.�NHSleadershipqualitiesframework.London�UK;�NHS;�2006.
5.� Maddern�J,�Courtney�M,�Montgomery�J�and�Nash�R.�Strategy�and�organisational�design�in�health�care.�In:�Harris�MG�(ed.)�Managinghealthservices:conceptsandpractice.�2nd�edn.�Sydney�NSW;�Elsevier�Australia;�2006.
6.� Victorian�Rural�and�Regional�Health�and�Aged�Care�Services�Division.�Doingitwithus,notforus:Strategicdirection2010–13.�Melbourne;�Victorian�Department�of�Health;�2009.
7.� KPMG�Australia.�ReviewofthecurrentstateofclinicalgovernanceinVictoria.�Melbourne�VIC;�KPMG;�2008.
8.� Telford�K,�Maddock�A,�Isam�C�and�Kralik�D.�Managing�change�in�the�context�of�a�community�health�organisation.�AustJPrimHealth�2006;�12(2):�156-166.
9.� Braithwaite�J.�An�empirical�assessment�of�social�structural�and�cultural�change�in�clinical�directorates.�HealthCareAnal2006;�14(4):�185-193.
Number�of�operational�/�strategic�plans�that�formally�recognise�relationships�with�external�organisations
Total number of operational / strategic plans
Number�of�consumers�/�consumer�representatives�who�contributed�to�operational�/�strategic�planning
Total number of individuals / groups who contributed to operational / strategic planning
Number�of�strategic�objectives�achieved�per�planning�cycle
Total number of objectives in strategic plan per planning cycle
Number�of�documented�change�management�and�risk�management�strategies�for�strategic�objectives
Total number of objectives in operational / strategic plan
Number�of�communications�from�governing�body�/�leadership�team�that�convey�vision�and�rationale�for�change
Total number of changes implemented
Number�of�outcome�measures�met�with�respect�to�specific�changes
Total number of outcome measures set for specific changes
seCtion 5Standards, criteria, elements and guidelinesstandard 3.1:�The�governing�body�leads�the�organisation’s�strategic�direction�to�ensure�the�provision�of�quality,�safe�services
384 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion LA – Awareness sA – implementationLA plus the following
MA – evaluationSA plus the following
eA – excellenceMA plus the following
oA – LeadershipEA plus the following
Criterion 3.1.2
Governance�is�assisted�by�formal�structures�and�delegation�practices�within�the�organisation.
a)� The�governing�body�is�aware�of�its�role�for�strategy�and�monitoring.
b)� The�governing�body’s�duties�and�responsibilities�are�defined,�documented�and�comply�with�relevant�legislation.�
c)� Leaders�and�managers�understand�their�role�as�promoters�of�organisational�culture.
d)� Terms�of�reference,�membership�and�procedures�are�in�place�for�meetings�of�the�governing�body.�
e)� A�formal�delegation�system�exists.
f)� A�formal�system�to�appoint�senior�managers�exists�that�identifies�the�accountability�of�managers�for�the�safe�provision�of�services.�
g)� A�system�exists�to�govern�decision�making�with�ethical�implications.
h)� There�are�records�of�ethical�decisions�that�have�been�referred�by�a�clinician�to�the�nominated�consultative�body�for�ethical�decision�making.
i)� Financial�processes�are�consistent�with�legislative�and�government�requirements.
j)� The�organisation�has�a�budget�development�and�review�process.
k)� Allocation�of�resources�is�based�on�the�service�requirements�identified�in�the�strategic�and�operational�planning�processes.
a)� Members�of�the�governing�body�receive�formal�orientation�and�ongoing�education�regarding�their�role.
b)� The�vision,�mission�and�values�are�demonstrated�through�the�culture�of�the�organisation.
c)� Leaders�and�managers�are�educated�in�their�role�as�promoters�of�organisational�culture.
d)� The�governing�body�ensures�that�committees�have�access�to�terms�of�reference,�membership�and�procedures.
e)� Minutes,�decisions�and�actions�of�committee�and�governing�body�meetings�are�recorded�and�confirmed.
f)� Decisions�of�the�governing�body�are�implemented.
g)� The�governing�body�receives,�monitors�and�assesses�issues�referred�for�ethical�consideration.�
h)� The�organisation�has�sound�financial�management�practices�that�ensure�its�ongoing�financial�viability.
i)� Useful,�timely�and�accurate�financial�reports�are�provided�to�the�governing�body�and�managers�with�delegated�financial�authority.
j)� The�governing�body�regularly�shares�information�about�its�activities�and�decisions�with�relevant�stakeholders.
a)� The�vision,�mission�and�values�of�the�organisation�are�evaluated�and�changes�are�made�as�required.
b)� The�governing�body�assesses�its�performance,�and�the�performance�of�its�members,�and�improvements�are�made�as�required.
c)� The�governing�body�receives,�evaluates�and�takes�action�to�respond�to�reports�on�the�quality�of�care�and�services.
d)� The�outcomes�of�clinical�ethical�issues�are�reviewed�and�improvements�are�made�as�required.
e)� Organisational�structures�and�processes�are�reviewed�to�ensure�quality�services�are�delivered.
f)� Compliance�with�delegations�is�monitored�and�evaluated�and�improved�as�required.
g)� The�effectiveness�of�formally�constituted�committees�is�monitored,�regularly�evaluated�and�improved�as�required.
h)� By-laws,�operating�requirements�and�management�requirements�are�regularly�reviewed�to�reflect�current�requirements.
i)� Financial�performance�is�evaluated�and�improved�as�required.
a)� All�members�of�the�governing�body�have�qualifications�in�governance.
and/or
b)� The�organisation�demonstrates�that�its�governance�enables�a�culture�that�results�in�good�clinical�outcomes,�as�demonstrated�through�clinical�indicator�and�business�performance�data.�
and/or
c)� Governance�structures�are�compared�with�external�systems�and�models,�and�improvements�are�made�to�ensure�better�practice.�
and/or
d)� Delegations�are�compared�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.
and/or�
e)� Financial�management�performance�indicators�are�compared�with�external�organisations,�and�improvements�are�made�to�ensure�better�practice.
a)� The�organisation�demonstrates�it�is�a�leader�in�governance�assisted�by�formal�structures�and�delegation�practices.
October 2010 385
Criterion LA – Awareness sA – implementationLA plus the following
MA – evaluationSA plus the following
eA – excellenceMA plus the following
oA – LeadershipEA plus the following
Criterion 3.1.2
Governance�is�assisted�by�formal�structures�and�delegation�practices�within�the�organisation.
a)� The�governing�body�is�aware�of�its�role�for�strategy�and�monitoring.
b)� The�governing�body’s�duties�and�responsibilities�are�defined,�documented�and�comply�with�relevant�legislation.�
c)� Leaders�and�managers�understand�their�role�as�promoters�of�organisational�culture.
d)� Terms�of�reference,�membership�and�procedures�are�in�place�for�meetings�of�the�governing�body.�
e)� A�formal�delegation�system�exists.
f)� A�formal�system�to�appoint�senior�managers�exists�that�identifies�the�accountability�of�managers�for�the�safe�provision�of�services.�
g)� A�system�exists�to�govern�decision�making�with�ethical�implications.
h)� There�are�records�of�ethical�decisions�that�have�been�referred�by�a�clinician�to�the�nominated�consultative�body�for�ethical�decision�making.
i)� Financial�processes�are�consistent�with�legislative�and�government�requirements.
j)� The�organisation�has�a�budget�development�and�review�process.
k)� Allocation�of�resources�is�based�on�the�service�requirements�identified�in�the�strategic�and�operational�planning�processes.
a)� Members�of�the�governing�body�receive�formal�orientation�and�ongoing�education�regarding�their�role.
b)� The�vision,�mission�and�values�are�demonstrated�through�the�culture�of�the�organisation.
c)� Leaders�and�managers�are�educated�in�their�role�as�promoters�of�organisational�culture.
d)� The�governing�body�ensures�that�committees�have�access�to�terms�of�reference,�membership�and�procedures.
e)� Minutes,�decisions�and�actions�of�committee�and�governing�body�meetings�are�recorded�and�confirmed.
f)� Decisions�of�the�governing�body�are�implemented.
g)� The�governing�body�receives,�monitors�and�assesses�issues�referred�for�ethical�consideration.�
h)� The�organisation�has�sound�financial�management�practices�that�ensure�its�ongoing�financial�viability.
i)� Useful,�timely�and�accurate�financial�reports�are�provided�to�the�governing�body�and�managers�with�delegated�financial�authority.
j)� The�governing�body�regularly�shares�information�about�its�activities�and�decisions�with�relevant�stakeholders.
a)� The�vision,�mission�and�values�of�the�organisation�are�evaluated�and�changes�are�made�as�required.
b)� The�governing�body�assesses�its�performance,�and�the�performance�of�its�members,�and�improvements�are�made�as�required.
c)� The�governing�body�receives,�evaluates�and�takes�action�to�respond�to�reports�on�the�quality�of�care�and�services.
d)� The�outcomes�of�clinical�ethical�issues�are�reviewed�and�improvements�are�made�as�required.
e)� Organisational�structures�and�processes�are�reviewed�to�ensure�quality�services�are�delivered.
f)� Compliance�with�delegations�is�monitored�and�evaluated�and�improved�as�required.
g)� The�effectiveness�of�formally�constituted�committees�is�monitored,�regularly�evaluated�and�improved�as�required.
h)� By-laws,�operating�requirements�and�management�requirements�are�regularly�reviewed�to�reflect�current�requirements.
i)� Financial�performance�is�evaluated�and�improved�as�required.
a)� All�members�of�the�governing�body�have�qualifications�in�governance.
and/or
b)� The�organisation�demonstrates�that�its�governance�enables�a�culture�that�results�in�good�clinical�outcomes,�as�demonstrated�through�clinical�indicator�and�business�performance�data.�
and/or
c)� Governance�structures�are�compared�with�external�systems�and�models,�and�improvements�are�made�to�ensure�better�practice.�
and/or
d)� Delegations�are�compared�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.
and/or�
e)� Financial�management�performance�indicators�are�compared�with�external�organisations,�and�improvements�are�made�to�ensure�better�practice.
a)� The�organisation�demonstrates�it�is�a�leader�in�governance�assisted�by�formal�structures�and�delegation�practices.
seCtion 5Standards, criteria, elements and guidelinesstandard 3.1:�The�governing�body�leads�the�organisation’s�strategic�direction�to�ensure�the�provision�of�quality,�safe�services
386 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 3.1.2
Governance�is�assisted�by�formal�structures�and�delegation�practices�within�the�organisation.�(continued)
IntentThe�intent�of�this�criterion�is�to�ensure�that�the�required�structures�and�processes�are�in�place�for�effective�management�of�the�organisation,�that�individual�roles�and�responsibilities�are�understood,�and�that�there�are�clear�channels�of�communication�and�accountability.�
Relationships of 3.1.2 with other criteriaThe�delivery�of�care�that�is�high�quality�(Standard�1.1)�and�safe�(Standard�1.5)�relies�on�robust�governance�structures�and�delegations.
Formal�governance�structures,�leadership�and�delegation�practices�are�necessary�to�action�strategic�and�operational�plans�(Criterion�3.1.1),�to�support�and�drive�organisational�commitment�to�improving�performance�and�the�management�of�corporate�and�clinical�risk�(Standard�2.1),�and�to�successfully�manage�and�support�a�skilled�and�competent�workforce�(Standard�2.2).�Structures�must�also�be�in�place�to�govern�research�and�research�ethics�(Criterion�2.5.1),�which�is�distinct�from�general�decision�making�with�ethical�implications.
GovernanceGovernance�is�the�system�by�which�organisations�are�directed�and�controlled.1�In�healthcare,�it�is�a�leadership�responsibility�to�set�organisational�agendas�for,�and�monitor,�both�corporate�and�clinical�governance.�The�governing�body�and�senior�managers�need�to�ensure�that�the�organisation�is�performing�effectively,�that�services�are�being�delivered�according�to�predefined�standards�and�that�mechanisms�are�in�place�to�take�remedial�action�when�problems�are�encountered.2�Having�adequate�reporting�mechanisms�and�reviewing�clinical�and�organisational�performance�through�accurate�interpretation�of�data�on�a�regular�basis�are�preconditions�to�effective�governing�body�and�executive�leadership.
In�addressing�this�criterion,�organisations�should�define�which�body�carries�legal�accountability�and/or�scope�of�organisational�responsibility�for�the�functions�covered.�Governance�structures�vary�from�context�to�context,�jurisdiction�to�jurisdiction�and�organisation�to�organisation.�In�the�case�of�the�small�private�organisation,�the�governing�body�may�be�an�individual�owner�or�a�group�of�senior�managers.�Public�organisations�may�have�a�governing�body�of�
directors,�a�Board,�a�group�of�senior�managers�and/or�a�chief�executive�appointed�by�a�government�agency.�Some�operate�under�an�arrangement�whereby�aspects�of�governance�responsibilities,�such�as�those�relating�to�human�resources,�finance�or�information�communication�technology,�are�split�between�the�organisation�and�a�central�corporate�body;�this�is�common�for�organisations�that�are�members�of�a�large�private�company�or�an�Area�Health�Service.�Where�organisations�are�distanced�from�a�Board�or�central�decision-making�authority,�the�executive�management�group�may�make�governance�decisions�within�a�framework�provided�by�the�central�authority.�In�smaller�jurisdictions�such�as�the�Australian�Capital�Territory�or�Northern�Territory,�responsibility�for�certain�aspects�may�rest�outside�the�organisation�within�a,�or�across�a�number�of,�government�departments�or�entities.�
The�corporate�and�clinical�functions�of�the�governing�body�have�been�defined�as:�
Corporategovernance–�“The�processes�by�which�the�organisation�is�directed,�controlled�and�held�to�account.�It�encompasses�the�systems,�processes�and�arrangements�by�which�authority,�accountability,�stewardship,�leadership,�direction�and�control�are�exercised�in�an�organisation”.3�It�influences�how�the�objectives�are�set�and�achieved,�how�risk�is�monitored�and�assessed�and�how�performance�is�optimised.4�
Clinicalgovernance�–�the�system�by�which�the�governing�body,�managers�and�clinicians�share�responsibility,�and�are�held�accountable�for�consumer�/�patient�safety,�minimising�risks�to�consumers�and�for�continuously�monitoring�and�improving�the�quality�of�clinical�care.5
Leadership and organisational cultureOrganisational�culture�refers�to�the�prevailing�pattern�of�beliefs,�attitudes,�values�and�behaviours�within�an�organisation6,�which�is�often�built�upon�underlying�assumptions.�Culture�incorporates�a�set�of�structures,�routines,�rules�and�norms�which�guide�and�constrain�behaviour.�It�is�shaped�by�relations�between�the�governing�body�and�management7,�as�well�as�broader�leadership�behaviour,�and�is�constantly�created�and�enacted�through�human�interactions.8
Strong�cultures�are�built�on�consistent,�visible�role�modelling�and�leadership,�consistent�feedback�on�both�positive�and�negative�performance,�and�constant�communication�and�sharing�of�experiences�around�what�is�important�to�the�organisation.9�For�example,�the�governing�body�may�lead�and�develop�a�culture�where�open�disclosure,�reporting�and�learning�from�errors�and�adverse�events,�and�clear�accountability�for�and�participation�in�safety�improvement�are�
October 2010 387
embedded�and�rewarded.�The�governing�body�and�senior�management�support�this�culture�by�resourcing�and�encouraging�Root�Cause�Analyses,�systems�review,�and�implementation�of�best�practice,�as�well�as�appropriate�education�and�training.10�This�may�be�reflected�in�the�development�of�a�‘just’�culture11,�a�values-supportive�model�of�shared�accountability�that�encourages�individuals�to�report�mistakes�so�that�the�precursors�to�errors�can�be�better�understood�in�order�to�fix�the�system�issues.�A�just�culture�holds�organisations�accountable�for�the�systems�they�design�and�for�how�they�respond�to�staff�behaviours�in�fair�and�just�ways.�In�turn,�staff�are�accountable�for�the�quality�of�their�choices�and�for�reporting�both�their�errors�and�system�vulnerabilities.
Prompt points
¼ How does the governing body set the tone of the organisational culture?
¼ What development opportunities are provided for leaders and managers and how do these support their role in promulgating organisational culture? Are cultural surveys administered regularly? How are results utilised to improve organisational culture?
¼ How is organisational culture measured and improvements made?
¼ How is application of the organisational culture by committees or other groups monitored? What documentation is audited?
¼ How are complaints from staff or consumers / patients regarding episodes that do not reflect organisation values managed?
¼ Are ‘whistleblower’ and respectful behaviour policies in place? How are staff protected?
Roles and responsibilities Governing�bodies�within�the�healthcare�context�are�responsible�for�both�corporate�and�clinical�governance.�The�governing�body�should�lead�an�effective�system�of�corporate�and�clinical�governance,�preferably�using�an�integrated�governance�model,�to�facilitate�quality�care�delivery�and�continuous�improvement�in�the�safety�and�quality�of�care.�The�governing�body�makes�certain�that�accountability�is�clear�and�creates�a�‘just’�culture�that�is�able�to�embrace�reporting�and�support�improvement.12�
Clinical�care�should�be�addressed�with�the�same�rigour�as�financial�and�business�issues�are�addressed�by�corporate�governance.�Clinical�governance�should�be�“rigorous�in�its�application,�organisation-wide�in�its�emphasis,�accountable�in�its�delivery,�developmental�in�its�thrust,�and�positive�in�its�connotations”.13�It�should�also�strive�to�balance�both�clinical�and�management�imperatives�with�a�focus�on�the�consumer�/�patient.�
The�governing�body�is�assisted�in�meeting�its�responsibilities�by�committees�and�appropriate�delegations.
Prompt points
¼ Which body carries legal accountability and/or scope of organisational responsibility for the governance functions? If this is shared, how are accountability and the various responsibilities delineated?
¼ How does the organisation ensure that roles, duties and responsibilities of the governing body are clearly defined and effective?
¼ How does the organisation ensure that the governing body members remain up-to-date and comply with relevant legislation?
¼ Does the organisation produce reports of reviews of governing body compliance with legislation?
¼ What methods does the governing body utilise to regularly and transparently communicate with stakeholders regarding non-confidential matters?
¼ How does the organisation evaluate the performance of the governing body and its members?
Orientation and education for the governing bodyTo�fulfil�their�responsibilities,�governing�body�members�need�to�exercise�care,�diligence�and�skill,�through�actions�such�as14:�
• taking�reasonable�steps�to�guide�and�monitor�the�management�of�the�organisation�including�its�approach�to�risk�management
• becoming�familiar�with�the�business�of�the�organisation�and�how�it�is�operated
• applying�their�minds�to�the�overall�position�of�the�organisation.�
seCtion 5Standards, criteria, elements and guidelinesstandard 3.1:�The�governing�body�leads�the�organisation’s�strategic�direction�to�ensure�the�provision�of�quality,�safe�services
388 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 3.1.2
Governance�is�assisted�by�formal�structures�and�delegation�practices�within�the�organisation.�(continued)
Members�should�also�be�oriented�regarding�appropriate�governance�dynamics�and�relations�that�support�constructive�interaction.�This�includes�governance�relations:
• amongst�governing�body�members�
• between�the�governing�body,�management7�and�senior�clinicians
• between�the�governing�body�and�members�of�external�governing�bodies�or�networks�to�facilitate�coordinated�planning�or�service�delivery.
Formal�orientation�and�ongoing�education�for�the�governing�body�will�assist�its�members�to�better�understand�their�governance�role�and�responsibilities.�As�many�governing�bodies�have�focused�largely�on�financial�performance�and�access�issues,�orientation�and�ongoing�education�should�focus�on�developing�the�broader�skills�needed�to�develop�the�specific�expertise�needed�in�risk�management,�quality�and�consumer�/�patient�safety�and�to�assume�a�more�‘corporate’�role.�Orientation�processes�should�introduce�a�new�member�to�the�roles�outlined�and�their�associated�responsibilities,�in�addition�to�the�more�subtle�politics,�influences�and�contexts�that�the�organisation�operates�within.�
Prompt points
¼ How does the organisation ensure that appropriate orientation and education is provided to governing body members?
¼ How are the requirements for ongoing education determined? Is a training needs analysis undertaken to identify gaps? How often does this occur?
¼ How does the content of orientation and education programs assist governing body members to undertake their role?
Governance structuresThe�governance�structure�specifies�the�distribution�of�rights�and�responsibilities�among�different�participants�of�the�organisation�such�as�governing�body�members,�managers�and�shareholders.1
Formal�organisational�structures�include:
• clarity�regarding�composition,�such�as�appointments�of�senior�managers�and�clinicians,�representation�of�disciplines,�professional�bodies�and�committee�structures
• delegation�of�authority�appropriate�to�individual�roles�and�responsibilities�within�the�organisation�for�the�operation�of�clinical�and��non-clinical�services
• linkages�with�stakeholders�and�facilities
• effective�clinical�governance�that15:�
– provides�an�environment�that�fosters�quality�
– monitors�the�quality�of�care�
– provides�a�regular�report�to�the�governing�body�on�the�quality�of�care�
– identifies�and�minimises�the�risk�of�deficiencies�in�the�quality�of�care�
– effectively�addresses�and�overcomes�these�deficiencies
• reporting�mechanisms�to�the�governing�body,�internally�within�the�organisation�and�to�stakeholders.
Organisations�should�regularly�review�their�governance�and�assurance�arrangements�to�assess�if�all�the�threads�of�quality,�performance�and�governance�are�aligned�and�integrated.�Consideration�should�be�given�to�whether�committee�structures,�their�terms�of�reference,�relationships�and�their�‘supports’�(staff,�advisors,�systems�and�processes)�are�all�fit�for�the�purpose�and�flexible�enough�to�cope�with�changing�priorities�and�risks.16�Steps�should�also�be�taken�to�assess�and�monitor�that�the�quality�of�meeting�minutes�and�other�documentation�supports�effective,�informed�and�meaningful�information�flow�and�decision�making.�
October 2010 389
Prompt points
¼ What is in place to guide the governing body’s structure, roles and responsibilities, terms of reference, subcommittees, minutes of meetings and use of attendance registers?
¼ What Key Performance Indicators are in place and documented for the governing body, executive team, subcommittees, working groups, ‘meetings’ and advisory boards, etc.? How is progress measured and deficiencies addressed?
¼ How are committee structures, terms of reference and reporting lines determined and clearly defined? How are meeting minutes shared and with whom?
¼ How does the organisation ensure that governing body and committee meeting minutes are of high quality and comprehensively reflect discussions and decisions made?
¼ In what ways do the organisation’s annual reports reflect the organisation’s direction and activities?
Effective governance for quality and safetyWith�respect�to�safety�and�quality�of�care�in�healthcare�organisations,�ultimate�responsibility�and�authority�lies�with�the�governing�body.17�The�focus�of�the�governing�body�should�be�on�inquiry,�use�of�the�best�available�evidence,�innovation�and�systems�improvement.�
An�integrated�system�of�governance�can�be�utilised�to�actively�manage�consumer�/�patient�safety�and�quality�risks.�To�facilitate�this,�the�governing�body�should18:
• clearly�articulate�organisational�and�individual�accountabilities�for�safety�and�quality�throughout�the�organisation
• implement�planning�and�review�of�integrated�governance�systems�for�consumer�/�patient�safety�and�quality
• implement�and�maintain�systems,�materials,�education�and�training,�which�ensures�that�safe,�effective�and�reliable�health�care�is�delivered�
• facilitate�compliance�and�manage�performance�across�the�organisation�and�within�individual�areas�of�responsibility�
• model�behaviours�that�optimise�safety�and�high�quality�care�as�part�of�the�implementation�of�a�safety�culture�within�the�organisation
• consider�safety�and�quality�implications�in�decision-making�processes
• support�consumers�/�patients�to�exercise�their�healthcare�rights.
Structures�such�as�a�quality�committee�should�be�in�place,�along�with�associated�plans,�performance�measurement�and�monitoring�systems,�to�improve�quality�of�care�and�facilitate�the�management�and�reduction�of�serious�risks.10�To�facilitate�active�leadership�around�quality�and�safety,�the�governing�body�should�receive�and�consider�meaningful�reporting10�on�matters�such�as:
• progress�against�a�safety�and�quality�plan�
• adverse�events�and�progress�on�Root�Cause�Analysis�associated�with�sentinel�events�
• appropriateness�issues�such�as�overuse,�underuse�and�misuse�of�care,�including�utilisation�rates�for�high-volume,�high-cost�and�high-complaint�areas.�
The�governing�body�then�utilises�this�information�to�take�informed�and�appropriate�action.�
Prompt points
¼ What specific expertise in quality improvement and consumer / patient safety in health care or another industry is incorporated into membership of the governing body? If this capacity is lacking, what steps are being taken to attract and appoint members with such expertise?
¼ How does the organisation build and nurture effective relationships between the governing body, clinical staff and senior leadership?
¼ How is a quality and safety plan created?
¼ How does the organisation ensure that the governing body receives meaningful information, including trended and/or benchmarked performance reporting, on quality and consumer / patient safety?
seCtion 5Standards, criteria, elements and guidelinesstandard 3.1:�The�governing�body�leads�the�organisation’s�strategic�direction�to�ensure�the�provision�of�quality,�safe�services
390 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 3.1.2
Governance�is�assisted�by�formal�structures�and�delegation�practices�within�the�organisation.�(continued)
Delegation and accountabilityAppropriate�delegation�to�senior�executives�and�managers�for�the�operation�of�clinical�and�non-clinical�services�assists�them�to�fulfil�their�duties�and�meet�expectations�regarding�their�roles�and�the�implementation�of�governing�body�decisions.�Expectations�regarding�accountability�for�safety�and�quality�within�specified�areas�of�responsibility�should�be�clearly�outlined�and�linked�to�performance�measures.�A�formal�delegation�system�ensures�that�clear�lines�of�accountability�exist,�particularly�where�temporary�delegations�are�enacted.
Delegation�policies�may�include,�as�a�minimum:
• the�limits�of�delegation
• the�instrument�of�delegation
• how�the�policy�was�formulated
• implementation�and�compliance�monitoring.
Prompt points
¼ Is there a formal delegation system in operation? How are clear areas and scope of responsibility defined and documented, particularly for temporary delegations?
¼ When was the delegation system last reviewed, and what recommendations were implemented? Has this resulted in improvements?
¼ How is accountability monitored and addressed if standards are not being upheld? Is this undertaken within a climate of support and accountability?
¼ How does the governing body monitor implementation of its decisions?
¼ If there are delays in executing long-term governing body decisions, how does the organisation demonstrate that planning is underway?
Financial management The�organisation’s�financial�management�process�will�usually�include:
• appropriate�delegation�of�responsibility�for�the�management�of�financial�affairs
• planning�and�budget�preparation�with�the�participation�of�senior�management�and�staff
• a�risk�management�and�insurance�program�that�includes�appropriate�insurance�cover
• monitoring�of�financial�and�productivity�measures
• reporting�the�relationship�between�budget�and�actual�experience
• comprehensive�reporting�to�the�governing�body�and�senior�managers
• analysing�the�results�of�financial�reports
• internal�control
• preparation�of�accounts�that�meet�statutory�requirements
• independent�audit�if�required�by�statute
• management�follow-up�on�recommendations,�reports�and�related�feedback.
While�the�allocation�of�resources�may�not�be�determined�at�the�organisational�level�in�all�cases,�the�governing�body�has�responsibility�to�utilise�all�resources,�including�funding,�staff,�facilities�and�available�equipment�to�ensure�the�delivery�of�quality�and�safe�care�according�to�identified�service�requirements�and�in�line�with�strategic�and�operational�plans.�
Prompt points
¼ How are finances managed to facilitate the achievement of organisational goals, including the ability to provide quality care?
¼ What organisational values shape behaviour regarding financial management?
¼ How does the budget development and review process ensure the most equitable / just, efficient and effective use of resources?
October 2010 391
Ethical oversightEthical�decision�making�refers�to�the�way�in�which�an�organisation’s�ideals,�values�and�ethos�–�the�sum�of�ideals�which�define�an�overall�culture�–�are�translated�into�everyday�practice�through�the�actions�and�behaviour�of�people.19�
Ethical�issues�that�may�need�to�be�addressed�include:
• equity�of�access�to�services
• marketing�of�services
• recognition�of�cultural�or�religious�beliefs�that�affect�the�provision�of�care
• allocation�of�scarce�resources
• billing�and�charging�policies
• organ�donation
• withdrawal�/�continuation�of�life�support
• trialling�of�new�drugs�or�procedures
• conflicts�of�interest.
As�policies,�procedures�and�codes�of�conduct�may�not�always�provide�adequate�guidance�in�resolving�ethical�issues,�staff�may�need�a�more�formal�mechanism�to�govern�decision�making�with�ethical�implications.�This�promotes�a�consistent�approach�throughout�the�organisation�and�provides�staff�with�appropriate�support.�An�example�may�be�a�forum�where�staff�can�informally�discuss�and�explore�the�ethical�dimension�of�their�work�and�seek�collegial�guidance�and�support�not�only�for�clearly�contentious�decisions�that�may�carry�significant�associated�risk,�but�also�for�the�everyday�ethical�challenges�encountered�by�individual�staff.
Prompt points
¼ What ethical decision-making mechanism(s) is available to both clinical and non-clinical staff, particularly for everyday ethical challenges? How is this made known and promoted?
¼ How does the governing body receive, monitor and assess issues referred for ethical consideration?
¼ What arrangements are in place to address unanticipated ethical challenges, should they arise?
¼ How are the outcomes of clinical ethical issues reviewed and improvements made?
Evidence commonly presented
Consider whether the following will help to address criterion 3.1.2
¼ Measurement of and improvements to organisational culture
¼ Orientation and education program content and attendances by members of the governing body
¼ The structure of the governing body, its roles and responsibilities, terms of reference, minutes of meetings, attendance registers
¼ Organisational structure or chart
¼ Structures of committees, terms of reference, reporting lines, minutes of meetings
¼ Annual reports
¼ Reports of reviews of governing body compliance with legislation in its responsibilities
¼ Delegation documents or instruments
¼ Reports of reviews of the delegation documents
¼ Position descriptions
¼ Policies and procedures for budget development reviews
¼ Policies and procedures for financial management
¼ Reports of reviews of the financial system’s compliance with legislation
¼ Independent audit / sign-off of financial records, particularly matters that may be considered commercial-in-confidence
¼ Easy availability of ethical facts and information
¼ A forum where staff can discuss ethical issues, or a referral process for issues to be considered by the governing body
seCtion 5Standards, criteria, elements and guidelinesstandard 3.1:�The�governing�body�leads�the�organisation’s�strategic�direction�to�ensure�the�provision�of�quality,�safe�services
392 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 3.1.2
Governance�is�assisted�by�formal�structures�and�delegation�practices�within�the�organisation.�(continued)
Performance measurementThis�criterion�states�that:�“Governance�is�assisted�by�formal�structures�and�delegation�practices�within�the�organisation”.�The�organisation�should�be�able�to�demonstrate�that�it�has�a�structure�and�processes�in�place�to�ensure�effective�management,�delegation�and�communication,�and�that�these�support�the�delivery�of�quality�care�within�a�safe�and�ethical�culture.
Some�common�suggested�performance�measures�are�as�follows:
Number�of�new�governing�body�members�who�have�attended�an�orientation�program
Total number of new governing body members
Number�of�governing�body�members�educated�in�governance
Total number of governing body members
Number�of�recommendations�from�the�governing�body�implemented
Total number of recommendations from the governing body
Number�of�senior�management�and�staff�on�policy-making�and�organisational�committees
Total number of staff on policy-making and organisational committees
Number�of�committees�that�undertake�evaluation�by�members
Total number of committees
Number�of�committees�that�review�their�membership�every�X�years
Total number of committees
Comments:theorganisationtodefine‘X’
Number�of�committees�with�approved�terms�of�reference
Total number of committees
October 2010 393
Number�of�communications�from�governing�body�/�leadership�team�highlighting�teamwork�/�quality�improvements�/�staff�successes
Total number of communications from governing body / leadership team
Number�of�complaints�receiving�highlighting�issues�in�violation�of�the�organisation’s�values
Total number of complaints received
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Further reading1.� National�Health�Service�(NHS).�Institute�for�Innovation�
and�Improvement.NHSleadershipqualitiesframework.London�UK;�NHS;�2006.
2.� Accreditation�Canada.�SustainableGovernance(Qmentumstandards).�Ottawa�Ontario;�Accreditation�Canada.�Accessed�from�http://www.accreditation.ca/accreditation-programs/qmentum/standards/sustainable-governance/�on�24�August�2010.
seCtion 5Standards, criteria, elements and guidelinesstandard 3.1:�The�governing�body�leads�the�organisation’s�strategic�direction�to�ensure�the�provision�of�quality,�safe�services
394 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion LA – Awareness sA – implementationLA plus the following
MA – evaluationSA plus the following
eA – excellenceMA plus the following
oA – LeadershipEA plus the following
Criterion 3.1.3
Processesforcredentiallinganddefiningthescopeofclinicalpracticesupportsafe,qualityhealthcare.
this is a mandatory criterion
a)� The�governing�body�is�aware�of�its�responsibilities�for�ensuring�services�are�provided�by�competent�clinicians.
b)� There�is�an�organisational�policy�for�credentialling�clinicians�within�the�organisation.
c)� There�is�an�organisational�policy�for�defining�the�scope�of�clinical�practice�of�all�clinicians�within�the�organisation.
d)� Policy�exists�for�the�safe�introduction�of�new�interventions�and�treatments.
a)� There�is�a�credentialling�system�to�confirm�the�formal�qualifications,�training,�experience�and�clinical�competence�of�clinicians.
b)� The�process�for�assessing�the�credentials�of�applicants�is�consistent�with�national�standards�and�guidelines,�and�with�organisation�policy.
c)� Ongoing�monitoring�and�review�of�clinicians’�performance�is�linked�to�the�credentialling�system.
d)� The�process�for�recommending�the�scope�of�clinical�practice�is�consistent�with�national�standards�and�guidelines�and�organisation�policy.
e)� The�process�of�defining�the�scope�of�clinical�practice�is�organisation�or�facility�specific�and�relates�to�the�role�and�capabilities�of�the�organisation.
f)� A�process�for�reviewing�the�scope�of�clinical�practice�is�in�place�and�is�defined�as�part�of�the�appointment�process.
g)� Ongoing�monitoring�and�review�of�clinicians’�performance�is�linked�to�the�system�for�defining�the�scope�of�clinical�practice.
h)� A�system�exists�for�the�safe�introduction�of�new�interventions�and�treatments.
i)� The�clinician’s�credentials�are�reviewed�prior�to�the�introduction�of�new�services,�procedures�or�other�interventions.
a)� The�system�for�credentialling�clinicians�is�reviewed,�evaluated�and�improved�as�required.
b)� The�system�for�defining�the�scope�of�clinical�practice�for�clinicians�is�reviewed,�evaluated�and�improved�as�required.
c)� The�system�for�the�safe�introduction�of�new�interventions�and�treatments�is�evaluated�and�improved�as�required.
a)� The�system(s)�for�credentialling�and�defining�the�scope�of�clinical�practice�of�clinicians�is�compared�externally�and�improvements�are�made�to�ensure�better�practice.
and/or
b)� Research�on�credentialling�and�clinical�practices�is�used�by�the�organisation�to�inform�improvements.
and/or
c)� The�system�for�the�safe�introduction�of�new�interventions�is�compared�with�external�systems�and�improvements�are�made�to�ensure�better�practice.
(a)� The�organisation�demonstrates�that�it�is�a�leader�in�systems�for�credentialling�and�defining�the�scope�of�clinical�practice.
October 2010 395
Criterion LA – Awareness sA – implementationLA plus the following
MA – evaluationSA plus the following
eA – excellenceMA plus the following
oA – LeadershipEA plus the following
Criterion 3.1.3
Processesforcredentiallinganddefiningthescopeofclinicalpracticesupportsafe,qualityhealthcare.
this is a mandatory criterion
a)� The�governing�body�is�aware�of�its�responsibilities�for�ensuring�services�are�provided�by�competent�clinicians.
b)� There�is�an�organisational�policy�for�credentialling�clinicians�within�the�organisation.
c)� There�is�an�organisational�policy�for�defining�the�scope�of�clinical�practice�of�all�clinicians�within�the�organisation.
d)� Policy�exists�for�the�safe�introduction�of�new�interventions�and�treatments.
a)� There�is�a�credentialling�system�to�confirm�the�formal�qualifications,�training,�experience�and�clinical�competence�of�clinicians.
b)� The�process�for�assessing�the�credentials�of�applicants�is�consistent�with�national�standards�and�guidelines,�and�with�organisation�policy.
c)� Ongoing�monitoring�and�review�of�clinicians’�performance�is�linked�to�the�credentialling�system.
d)� The�process�for�recommending�the�scope�of�clinical�practice�is�consistent�with�national�standards�and�guidelines�and�organisation�policy.
e)� The�process�of�defining�the�scope�of�clinical�practice�is�organisation�or�facility�specific�and�relates�to�the�role�and�capabilities�of�the�organisation.
f)� A�process�for�reviewing�the�scope�of�clinical�practice�is�in�place�and�is�defined�as�part�of�the�appointment�process.
g)� Ongoing�monitoring�and�review�of�clinicians’�performance�is�linked�to�the�system�for�defining�the�scope�of�clinical�practice.
h)� A�system�exists�for�the�safe�introduction�of�new�interventions�and�treatments.
i)� The�clinician’s�credentials�are�reviewed�prior�to�the�introduction�of�new�services,�procedures�or�other�interventions.
a)� The�system�for�credentialling�clinicians�is�reviewed,�evaluated�and�improved�as�required.
b)� The�system�for�defining�the�scope�of�clinical�practice�for�clinicians�is�reviewed,�evaluated�and�improved�as�required.
c)� The�system�for�the�safe�introduction�of�new�interventions�and�treatments�is�evaluated�and�improved�as�required.
a)� The�system(s)�for�credentialling�and�defining�the�scope�of�clinical�practice�of�clinicians�is�compared�externally�and�improvements�are�made�to�ensure�better�practice.
and/or
b)� Research�on�credentialling�and�clinical�practices�is�used�by�the�organisation�to�inform�improvements.
and/or
c)� The�system�for�the�safe�introduction�of�new�interventions�is�compared�with�external�systems�and�improvements�are�made�to�ensure�better�practice.
(a)� The�organisation�demonstrates�that�it�is�a�leader�in�systems�for�credentialling�and�defining�the�scope�of�clinical�practice.
seCtion 5Standards, criteria, elements and guidelinesstandard 3.1:�The�governing�body�leads�the�organisation’s�strategic�direction�to�ensure�the�provision�of�quality,�safe�services
396 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 3.1.3
Processesforcredentiallinganddefiningthescopeofclinicalpracticesupportsafe,qualityhealthcare.(continued)
IntentThis�criterion�aims�to�ensure�that�the�organisation’s�processes�will�reflect�a�growing�understanding�of�the�role�of�credentialling�in�sound�clinical�governance�and�will�support�safe,�quality�health�care.�It�draws�upon�the�StandardforCredentiallingandDefiningtheScopeofClinicalPractice,�released�by�the�former�Australian�Council�for�Safety�and�Quality�in�Health�Care,�and�relevant�jurisdictional�policies.�
The�intent�of�this�criterion�is�to�ensure�that�the�skills�and�competence�of�all�clinicians�are�correctly�aligned�with�the�competence�of�a�healthcare�organisation,�so�that�the�right�clinicians�are�providing�the�right�care�and�services�in�the�right�healthcare�organisations.�
Relationships of 3.1.3 with other criteriaThe�organisation’s�processes�for�credentialling�and�defining�the�scope�of�clinical�practice�are�a�major�component�of�its�commitment�to�improving�performance�(Criterion�2.1.1)�and�ensuring�the�effective�management�of�corporate�and�clinical�risks�(Criterion�2.1.2).�These�processes�lie�within�the�purview�of�the�organisation’s�workforce�planning�(Criterion�2.2.1),�its�recruitment,�selection�and�appointment�system�(Criterion�2.2.2)�and�its�continuing�employment�and�development�system,�by�which�it�ensures�the�competence�of�staff�(Criterion�2.2.3).
Organisational responsibility and policyIn�a�healthcare�organisation,�members�of�the�governing�body�have�a�responsibility�for�the�quality�of�care�delivered�by�the�organisation,�and�this�accountability�is�shared�with�the�clinicians�providing�this�care.1
The�purpose�of�credentialling�and�defining�the�scope�of�clinical�practice�is�to�ensure�safe,�high�quality�health�care.�It�is�an�essential�component�of�any�consumer�/�patient�safety�or�clinical�governance�framework.
Credentialling�refers�to�the�formal�process�used�to�verify�the�qualifications,�experience,�professional�standing�and�other�relevant�professional�attributes�of�clinicians�for�the�purpose�of�forming�a�view�about�their�competence,�performance�and�professional�suitability�to�provide�safe,�high�quality�health�care�services�within�specific�organisational�environments.2�Competency�refers�to�specific�capabilities�and�is�made�up�of�knowledge,�skills�and�attitudes;�while�competence�refers�to�an�individual’s�overall�ability.3�It�is�important�to�acknowledge�that�competence�(the�ability�to�demonstrate�knowledge�or�a�skill)�is�not�always�translated�into�practice.�Performance�requires�competence�but�is�also�affected�by�system�and�individual�factors.4
Defining�the�scope�of�clinical�practice�follows�on�from�the�credentialling�of�medical�practitioners�and�other�clinicians,�and�involves�delineating�the�extent�of,�and�the�limits�to,�an�individual’s�clinical�practice�within�a�particular�organisation�based�on�that�individual’s�credentials,�competence,�performance�and�professional�suitability,�and�the�needs�and�the�capability�of�the�organisation�to�support�the�individual’s�scope�of�clinical�practice.2,�5
There�are�two�main�components�of�the�process�for�defining�the�scope�of�practice�of�a�clinician.�They�are6:
1.� Credentialling,�which�is�the�verification�of�the�clinician’s�credentials,�skills,�experience�and�competencies
2.� The�matching�of�these�with�the�role,�needs�and�capabilities�of�the�healthcare�organisation’s�level�of�service�provision,�staffing,�facilities�and�equipment,�and�support�systems�available.
The�governing�body�of�the�organisation�is�responsible�for�developing�and�implementing�a�policy�or�by-laws�on�credentialling�and�defining�the�scope�of�clinical�practice�for�all�clinicians.2�The�policy�or�by-laws�should:
• comply�with�all�relevant�legal�requirements
• allocate�responsibility�to�a�defined�organisational�committee�to�ensure�effective�processes�for�credentialling�and�for�continually�monitoring�the�clinical�practice
• identify�the�maximum�elapsed�time�following�which�the�processes�of�credentialling�and�defining�the�scope�of�clinical�practice�will�be�repeated
• specify�that�clinicians�who�are�required�to�be�registered�are�granted�rights�to�practise�within�the�organisation�contingent�at�all�times�upon�the�clinician�maintaining�appropriate�professional�registration
October 2010 397
• specify�the�extent�to�which,�and�to�whom,�the�organisation�will�disseminate�information�about�each�medical�practitioner’s�authorised�scope�of�clinical�practice
• specify�that�a�clinician’s�right�to�practise�within�the�organisation�will�be�concluded,�terminated�or�suspended�on�conclusion,�termination�or�suspension�of�the�clinician’s�appointment�to�the�organisation
• identify�the�circumstances�under�which�an�unplanned�review�of�a�clinician’s�credentials�and/or�scope�of�clinical�practice�may�be�initiated,�the�authorised�persons�and�bodies�within�or�outside�the�organisation�from�whom�a�request�for�an�unplanned�review�will�be�accepted,�and�how�the�results�of�such�a�review�will�be�implemented
• incorporate�an�appeals�committee�and�the�appeals�process;�if�responsibility�for�credentialling�/�scope�of�practice�decisions�lies�outside�the�organisation,�support�a�process�and�the�dissemination�of�information�so�that�staff�are�aware�of�the�mechanism�through�which�an�appeal�may�be�made�
• include�the�conditions,�if�any,�under�which�clinicians�may�administer�necessary�treatment�outside�their�authorised�scope�of�clinical�practice�in�emergency�situations�where�a�consumer�/�patient�may�be�at�risk�of�serious�harm�if�treatment�is�not�provided,�and�no�health�professional�or�medical�practitioner�with�an�appropriate�authorised�scope�of�clinical�practice�is�available
• include�provision�for�the�processes�of�credentialling�and�defining�the�scope�of�clinical�practice�to�be�undertaken�in�emergency�situations�where�clinical�expertise�is�required�on�a�temporary�basis,�and�clearly�identify�who�has�delegated�authority�to�undertake�these�processes.
Prompt points
¼ What statutory requirements and guidelines did the organisation consult in developing its policy / by-laws governing credentialling and defining the scope of practice?
¼ Under the terms of the organisation’s policy / by-laws, how often is credentialling carried out, and a clinician’s scope of practice redefined?
Credentialling and competency of cliniciansFor�the�purposes�of�credentialling�and�defining�the�scope�of�clinical�practice,�there�should�be�a�clear�definition�of�who�is�recognised�as�a�‘clinician’�within�the�organisation.�The�term�‘clinician’�used�in�the�context�of�this�guideline�applies�irrespective�of�legislated�requirements�for�registration,�and�encompasses�not�only�medical�practitioners,�but�all�trained�healthcare�providers�including�nurses,�dentists,�paramedics�and�all�allied�health�professionals,�except�for�those�required�to�work�under�supervision�(i.e.�junior�medical�officers�and�others�in�training).2�Credentials�are�the�formal�qualifications�attained�and�possessed�by�a�clinician,�and�may�be�demonstrated�in�the�first�instance�by�any�or�all�of:
• university�degrees
• fellowships�/�memberships�of�professional�colleges�or�associations
• registration�by�professional�bodies
• certificates�of�service
• certificates�of�completion�of�specific�courses
• verifiable�formal�instruction�or�supervised�training
• validated�competence
• confidential�professional�referee�reports.
The�process�for�assessing�the�credentials�of�an�applicant�is�outlined�by�theStandardforCredentiallingandDefiningtheScopeofClinicalPractice.2�Credentials�reflect�the�factors�that�may�contribute�to�a�clinician’s�performance,�but�provide�no�measure�of�actual�performance;�while�credentialling�involves�the�forming�of�an�opinion�about�a�clinician’s�performance�by�a�peer-level�committee�qualified�to�assess�that�performance.
An�important�aspect�of�credentialling�is�determining�the�competence�of�the�clinician,�which�has�been�defined�as�the�combination�of�skills,�knowledge,�values�and�abilities�that�underpin�effective�and/or�superior�professional�performance.7�The�clinician�will�be�expected�to�attain�certain�professional�competencies,�which�will�contribute�to�his�or�her�overall�competence.3�However,�competence�also�encompasses�“not�only�observable�behaviour�which�can�be�measured,�but�also�unobservable�attributes�including�attitudes,�values,�judgement�ability�and�personal�dispositions:�that�is�–�not�only�performance�but�capability”��(Worth-Butler�etal.,�quoted�in�2009�discussion�paper�on�health�workforce�principles3).�
seCtion 5Standards, criteria, elements and guidelinesstandard 3.1:�The�governing�body�leads�the�organisation’s�strategic�direction�to�ensure�the�provision�of�quality,�safe�services
398 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 3.1.3
Processesforcredentiallinganddefiningthescopeofclinicalpracticesupportsafe,qualityhealthcare.(continued)
Registration�is�a�regulatory�process�that�formalises�the�right�of�certain�clinicians�to�practise�health�care.�The�Australian�Health�Practitioner�Regulation�Agency�(AHPRA)8,�established�in�July�2010,�undertakes�the�professional�registration�and�accreditation�of�the�clinicians�within�its�ten�member�healthcare�professional�groups:�chiropractors,�dental�practitioners�and�specialists,�medical�practitioners�and�specialists,�nurses�and�midwives,�optometrists,�osteopaths,�pharmacists,�physiotherapists,�podiatrists�and�podiatric�specialists,�and�clinical�psychologists.�
Organisations�should�ensure�that�there�is�a�robust�system�in�place�to�investigate�the�credentials�of�overseas-trained�clinicians.�To�be�registered�to�practise�in�Australia�(in�professions�covered�by�AHPRA),�overseas-trained�clinicians�must�meet�requirements�for�English�language�proficiency,�qualifications�and/or�competence�as�described�by�the�relevant�professional�board.9�As�for�any�pre-employment�review,�care�should�be�made�to�check�claimed�work�experience,�additional�training,�references�and�employment�history�before�issuing�a�contract�or�commencing�immigration�processes.�The�review�of�previous�employment�is�not�necessarily�part�of�the�review�process�for�registration�of�overseas-trained�clinicians,�so�responsibility�for�the�integrity�of�this�process�may�rest�solely�with�the�organisation.�Where�verification�of�clinical�skills�is�difficult�or�uncertain,�an�extended�probationary�period�is�recommended.�The�findings�of�the�reviewer(s)�should�be�supported�by�all�appropriate�documentation.
Organisations�that�employ�junior�medical�officers�and�other�trainee�clinicians�should�have�policy�for�managing�their�supervision�and/or�for�ascertaining�skill�development�before�permitting�independent,�unsupervised�practice.�
Prompt points
¼ What credentials must a clinician present to the credentialling committee when being considered for appointment? How does the committee confirm those credentials?
¼ How does the credentialling committee determine the competence of clinicians?
¼ Does the committee’s process for investigating the qualifications of overseas-trained clinicians differ from that used for Australian-trained clinicians? If so, how?
¼ Does the organisation credential its junior medical officers? If not, how does the organisation ensure that its junior medical officers are appropriately supervised?
Defining the scope of clinical practiceDefining�the�scope�of�clinical�practice�is�the�outcome�of�matching�a�clinician’s�qualifications,�skills,�experience�and�competence�with�the�required�services�and�the�role�and�capabilities�of�the�organisation.�The�scope�of�practice�of�each�clinician�should�be�defined�in�the�context�of�the�organisation’s�facilities�and�clinical�and�non-clinical�support�services�to�be�provided�by�the�organisation,�to�enable�the�clinician�to�provide�safe,�high�quality�healthcare�services�in�the�specific�organisational�setting.�Defining�the�scope�of�clinical�practice�is�context-specific,�and�the�exact�process�may�therefore�be�unique�to�the�organisation�or�facility.�However,�the�process�must�be�transparent�and�details�made�available�to�all�staff.�The�scope�of�practice�for�all�clinicians�must�be�outlined�in�position�descriptions�and/or�employment�contracts�/�letters�of�appointment.�The�frequency�/�timing�of�reviews�of�scope�of�practice�should�also�be�included.
For�some�specific�staff�members,�it�may�be�appropriate�to�expand�their�scope�of�practice�in�line�with�their�professional�endorsements.�Endorsement�types�and�sub-types�vary�between�professions,�with�more�information�available�from�the�specific�AHPRA�boards.�As�an�example,�the�Board�of�Psychology�endorses�eight�different�types�of�practice,�including�clinical�psychology,�counselling�psychology,�and�education�and�developmental�psychology.
October 2010 399
Scope�of�practice�limitations�will�apply�due�to�the�level�of�training�and�experience�of�the�practitioner�and/or�the�defined�role�or�capability�of�the�site�and�extent�of�support�staff�expertise�and�technology�available.�For�clinicians�building�specialist�skills,�for�instance�in�surgery5,�anaesthesia10�or�obstetrics11,�there�must�be�clear�and�current�inclusion�and�exclusion�criteria�describing�those�procedures�that�can�be�performed�independently,�procedures�that�require�supervision�by�a�qualified�specialist,�and�procedures�that�must�be�performed�by�a�qualified�specialist.�The�inclusion�and�exclusion�criteria�for�each�clinician�must�be�readily�available�to�all�relevant�personnel.�However,�the�organisation�must�also�manage�the�dissemination�of�this�information�in�such�a�way�that�there�is�no�breach�of�legislation�relating�to�privacy,�trade�practices�or�defamation.
Prompt points
¼ Prior to writing a position description and inviting applicants, how is organisational need determined?
¼ How does the organisation ensure that scope of practice information is disseminated on a ‘need to know’ basis only?
Monitoring, redefining the scope of clinical practice and re-credentiallingThe�organisation�must�have�a�system�for�monitoring�the�ongoing�performance�of�clinicians,�and�this�will�factor�into�the�redefining�of�the�scope�of�practice.�The�system�should�include�a�means�for�ensuring�that�clinicians�work�within�their�defined�scope�of�practice.�In�many�cases,�the�system�will�be�outlined�by�the�organisational�policy,�which�will�provide�guidance�on�the�monitoring�of�performance�and�adherence�to�scope�of�practice.�The�organisation�should�work�with�clinicians�on�an�ongoing�basis�to�review�clinical�outcomes,�adverse�events,�and/or�complaints,�a�process�which�may�form�part�of�clinical�/�peer�review�meetings.�Close�attention�should�be�paid�to�any�indications�of�underperformance�such�as�persistence�with�outdated�practices,�clinical�disinterest�or�poor�procedural�outcomes.
As�well�as�demonstrating�that�all�relevant�registrations�and�memberships�have�been�maintained,�the�clinician�must�provide�details�of�any�further�endorsements�/�accreditations�achieved,�any�further�education�/�training�undertaken,�and�all�healthcare-related�activities�since�the�previous�credentialling.
The�process�for�re-credentialling�and�redefining�the�scope�of�practice�should�be�as�stringent�as�that�followed�for�the�initial�credentialling;�no�assumptions�should�be�made�about�a�clinician’s�qualifications�or�performance.�However,�the�process�should�also�be�non-punitive.�In�cases�where�there�are�any�areas�of�concern�about�competence�that�might�lead�to�restrictions�on�the�scope�of�practice,�these�should�be�addressed�as�soon�as�feasible�via�education�and�retraining.�
Apart�from�the�mandatory�period�review,�the�credentialling�committee�may�also�convene�if�there�is�substantive�change�in�the�work�environment�or�there�is�concern�about�the�performance�of�a�clinician.�A�clinician�has�the�right�to�appeal�a�decision�relating�to�his�or�her�credentialling�and/or�scope�of�practice.�The�organisation�must�establish�a�credentialling�and�scope�of�clinical�practice�appeals�committee�that�is�independent�of�the�original�credentialling�committee�whose�decision�is�being�appealed,�to�adjudicate�on�any�appealed�decision(s).�This�committee�should�be�peer-level,�and�its�members�should�have�a�demonstrated�understanding�of�the�processes�of�credentialling�and�defining�the�scope�of�practice,�and�have�the�necessary�skills�and�experience�to�provide�informed,�independent,�high�quality�advice.
All�decisions�and�actions�by�both�the�credentialling�committee�and�the�appeals�committee�should�be�comprehensively�documented.�Where�‘confidential’�referee�reports�are�involved,�there�is�a�possibility�that�the�applicant�may�see�the�report.�There�may�be�variations�between�jurisdictions�regarding�the�overriding�rights�in�these�instances,�so�committee�members�should�be�aware�of�any�legal�protections�for�their�decisions�and�documents.�Referees�should�be�forewarned�if�there�is�a�possibility�that�applicants�may�see�their�reports.�The�documents�should�be�securely�stored�and�copies�provided�to�the�clinician.
Prompt points
¼ What processes does the organisation use to monitor the ongoing competence of clinicians? What steps are taken in the event of an identified performance issue?
¼ What systems and processes would be followed if a decision of a credentialling and/or scope of clinical practice review was appealed?
seCtion 5Standards, criteria, elements and guidelinesstandard 3.1:�The�governing�body�leads�the�organisation’s�strategic�direction�to�ensure�the�provision�of�quality,�safe�services
400 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 3.1.3
Processesforcredentiallinganddefiningthescopeofclinicalpracticesupportsafe,qualityhealthcare.(continued)
New interventions and treatmentsThe�introduction�of�new�interventions�and�treatments�will�assist�organisations�to�provide�quality,�contemporary�care�and�services.�However,�the�safety�of�new�clinical�services,�procedures�or�other�interventions,�and�their�potential�to�improve�consumer�/�patient�outcomes,�are�the�overriding�considerations.2
Organisations�should�have�in�place�policy�for�the�introduction�of�new�interventions�and�treatments�that�operates�within�jurisdictional�legislation�and�is�linked�to�the�credentialling�and�scope�of�practice�policy.�
Policy�should:
• incorporate�a�definition�of�‘new�interventions�and�treatments’
• define�who�may�request�assessments�of�new�interventions�or�treatments,�and�the�process�by�which�they�may�submit�requests�for�those�assessments
• define�the�organisation’s�requirements�for�assessment�of�the�cost,�risks,�efficacy�and�cost-benefit�of�the�proposed�new�interventions�or�treatments,�including�whether�external�benchmarking�data�should�be�considered
• define�the�organisation’s�requirements�for�consideration�of�the�broader�healthcare�context�within�which�the�new�interventions�or�treatments�are�proposed�to�be�introduced
• define�the�individuals�or�committees�that�are�authorised�to�initiate�an�assessment�of�proposed�new�interventions�and�treatments
• define�the�individuals�or�committees�that�are�responsible�for�overseeing�the�assessment�of�proposed�new�interventions�and�treatments
• define�the�organisation’s�requirement�if�a�new�intervention�/�treatment,�which�had�not�yet�been�approved�and�therefore�remains�experimental,�was�referred�for�consideration�by�a�Human�Research�Ethics�Committee�or�a�Clinical�Ethics�Committee�(as�appropriate)
• formalise�the�monitoring�of�the�new�intervention�and�its�outcomes�against�predetermined�goals�for�a�specified�period�of�time�following�its�introduction.�
The�organisation�must�ensure�that�there�are�suitable�facilities�and�support�staff�for�the�safe�provision�of�the�new�service.�In�the�interest�of�consumers�/�patients,�clinicians�and�the�organisation,�the�adoption�of�new�interventions�and�treatments�must�be�carefully�managed�via�formal�approval�processes�that�are�effectively�applied.12
The�roll-out�of�a�new�service�should�be�documented�and�monitored.�Examination�of�the�challenges,�outcomes�and�any�adverse�events,�consumer�/�patient�feedback�and�costs�will�allow�decisions�regarding�the�continuation�or�refining�of�the�new�intervention�or�treatment�to�be�made�in�a�timely�and�informed�manner.�However,�the�review�process�should�not�be�used�to�limit�appropriate�professional�initiatives�or�to�inappropriately�restrict�measures�available�in�an�emergency�situation.�
Prompt points
¼ What role do clinicians play in the safe introduction of new interventions and treatments?
¼ How does the organisation assess applications for new interventions or treatments when new technology is involved?
¼ What evidence is there of consumer / patient involvement in the introduction and assessment of new interventions and treatments?
Evidence commonly presented
Consider whether the following will help to address criterion 3.1.3
¼ Evidence of compliance with policies on credentialling processes, introduction of new interventions, etc.
¼ Data on annual registration checks, including authentication and expiry date of licences / registrations
¼ By-laws that include credentialling committees
¼ Minutes of medical advisory council (MAC) meetings
¼ Credentialling policy and procedures, including the credentialling application and the monitoring and review process that comply with relevant State / Territory policies
October 2010 401
¼ Staff lists listing the skills of clinicians against the capabilities of the organisation
¼ Policy and procedures for the introduction of new interventions and treatments that comply with relevant State / Territory policies
¼ Reports of data (outcomes, adverse events, incidents of non-compliance, feedback) used for monitoring the credentialling system and actions taken
¼ Reports of reviews of the introduction of new interventions and treatments including data on outcomes, adverse events, feedback, costs, etc.
Performance measurementThis�criterion�states�that:�“Processes�for�credentialling�and�defining�the�scope�of�clinical�practice�support�safe,�quality�health�care”.�The�organisation�should�be�able�to�demonstrate�that�it�has�in�place�effective�processes�for�credentialling�clinicians�and�defining�the�scope�of�their�clinical�practice,�and�for�managing�the�safe�introduction�of�new�interventions�and�treatments.
Some�common�suggested�performance�measures�are�as�follows:
Number�of�clinicians�who�have�their�scope�of�practice�reviewed�within�the�policy-documented�timeframe
Total number of staff defined within policy as ‘clinicians’
Number�of�scope�of�practice�reviews�that�incorporate�individual�clinicians’�performance�reviews
Total number of scope of practice reviews
Number�of�clinicians�with�current�registration�/�indemnity�cover�noted�in�their�personnel�files
Total number of clinicians
Number�of�new�interventions�/�treatments�introduced�after�assessment�according�to�organisational�policy�and�procedures
Total number of new interventions / treatments introduced
Number�of�clinicians�appointed�according�to�defined�and�documented�organisational�need
Total number of clinicians appointed
seCtion 5Standards, criteria, elements and guidelinesstandard 3.1:�The�governing�body�leads�the�organisation’s�strategic�direction�to�ensure�the�provision�of�quality,�safe�services
402 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 3.1.3
Processesforcredentiallinganddefiningthescopeofclinicalpracticesupportsafe,qualityhealthcare.(continued)
References1.� NSW�Health.�QualityofhealthservicesinNewSouthWales
–aframeworkformanaging–issued1999.Sydney;�NSW�Health;�2005.
2.� Australian�Council�for�Safety�and�Quality�in�Health�Care.�Standardforcredentiallinganddefiningscopeofclinicalpractice.�Canberra�ACT;�Australian�Council�for�Safety�and�Quality�in�Health�Care;�2004.
3.� Department�of�Human�Services.�Healthworkforcecompetencyprinciples:AVictoriandiscussionpaper.Melbourne;�Victorian�Government;�2009.
4.� Rethans�J,�Norcini�J,�Baron-Maldonado�M�etal.�The�relationship�between�competence�and�performance:�implications�for�assessing�practice�performance.�MedEduc2002;�36(30):�901-909.
5.� Royal�Australasian�College�of�Surgeons�(RACS).Positionpaper:Appointmentsandcredentialingcommitteesthatdefinescopeofpractice.Melbourne�VIC;�RACS;�2009.
6.� NSW�Health.�Delineationofclinicalprivilegesforvisitingpractitionersandstaffspecialists:Policyforimplementation.Sydney;�NSW�Health;�2005.
7.� ACT�Nursing�and�Midwifery�Board.�RequirementsformaintainingcompetenceandcontinuingprofessionaldevelopmentauditnursesandmidwivesregisteredintheACT.Canberra;�ACT�Nursing�and�Midwifery�Board;�2008.
8.� Australian�Health�Practitioner�Regulation�Agency�(AHPRA).�AboutAHPRA.�Canberra�ACT;�AHPRA.�Accessed�from�http://www.ahpra.gov.au/About-AHPRA.aspx�on�31�August�2010.
9.� Australian�Health�Practitioner�Regulation�Agency�(AHPRA).�Overseaspractitioners.�Canberra�ACT;�AHPRA.�Accessed�from�http://www.ahpra.gov.au/Registration/Registration-Process/Overseas-Practitioners.aspx�on�16�July�2010.
10.� Australian�&�New�Zealand�College�of�Anaesthetists�(ANZCA).�PS2Statementoncredentiallinganddefiningthescopeofclinicalpracticeinanaesthesia.�Sydney�NSW;�ANZCA;�2006.
11.� Royal�Australian�and�New�Zealand�College�of�Obstetricians�&�Gynaecologists�(RANZCOG).�StatementsoftheRANZCOG:Workforceandpracticeissues.Sydney�NSW;�RANZCOG.�Accessed�from�http://www.ranzcog.edu.au/gpdiploma/collegestatements.shtml�on�26�July�2010.
12.� Australian�Safety�&�Efficacy�Register�of�New�Interventional�Procedures�–�Surgical�(ASERNIP–S)�and�Royal�Australasian�College�of�Surgeons.�Areviewofpoliciesandprocessesfortheintroductionofnewinterventionalprocedures.�ASERNIP–S�Report�No�58.�Adelaide�SA;�Australian�Department�of�Health�and�Ageing;�2007.
Standards and guidelinesAustralian�Council�for�Safety�and�Quality�in�Health�Care.�Nationalguidelinesforcredentialsandclinicalprivileges.Melbourne�VIC;�Australian�Council�for�Safety�and�Quality�in�Health�Care;�2002.
Office�of�Safety�and�Quality�in�Healthcare.�Thepolicyforcredentiallinganddefiningthescopeofclinicalpracticeformedicalpractitioners�2nd�edn.�Perth�WA;�Department�of�Health�WA;�2009.
Queensland�Health.�CredentialinganddefiningthescopeofclinicalpracticeformedicalpractitionersinQueensland:Apolicyandresourcehandbook.�Brisbane;�Queensland�Government;�2009.
Quality�&�Safety�Branch�DHS.�CredentiallinganddefiningthescopeofclinicalpracticeformedicalpractitionersinVictorianhealthservices–apolicyhandbook.�Melbourne;�Vic�Dept�Human�Services;�2007.
Frommer�M,�Heinke�M�and�Barton�M.�ThecredentiallingofcancercliniciansinAustralia:Report.�Sydney�NSW;�Cancer�Council�Australia�and�Australian�Cancer�Network;�2005.
Holmboe�ES�and�Hawkins�RE�(eds).�Practicalguidetotheevaluationofclinicalcompetence.�Philadelphia�USA;�Mosby�Elsevier;�2008.
NSW�Health.�Theclinician’stoolkitforimprovingpatientcare.Sydney;�NSW�Health;�2001.
Department�of�Human�Services.CredentiallinganddefiningthescopeofclinicalpracticeformedicalpractitionersinVictorianhealthservices–apolicyhandbook.�Melbourne;�Victorian�Government;�2009.
October 2010 403
Further readingChiarella�M.�AnoverviewofthecompetencymovementinAustraliannursingandmidwifery.�Sydney�NSW;�Nursing�and�Midwifery�Office,�NSW�Health;�2006.
Community�Services�and�Health�Industry�Training�Board�(CS&H�ITB).�CompetencystandardsforhealthandalliedhealthprofessionalsinAustralia.Melbourne�VIC;�CS&H�ITB;�2005.
Brand�CA,�Ibrahim�JE,�Cameron�PA�and�Scott�IA.�Standards�for�health�care:�a�necessary�but�unknown�quantity.�MedJAust2008;�189(5):�257-260.
Epstein�Ronald�M�and�Hundert�Edward�M.�Defining�and�assessing�professional�competence.�JAMA�2002;�287(2):�226-235.
Wass�Val,�van�der�Vleuten�Cees,�Shatzer�John�and�Jones�Roger.�Assessment�of�clinical�competence.�Lancet�2001;�357(9260):�945-949.
seCtion 5Standards, criteria, elements and guidelinesstandard 3.1:�The�governing�body�leads�the�organisation’s�strategic�direction�to�ensure�the�provision�of�quality,�safe�services
404 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
IntentThe�intent�of�this�criterion�is�to�ensure�that�external�service�providers�are�managed�effectively,�so�that�they�provide�care�and�services�that�are�safe�and�of�the�highest�achievable�quality.
Relationships of 3.1.4 with other criteriaThe�organisation�may�arrange�for�certain�areas�of�operation�to�be�supplied�or�managed�by�external�service�providers.�Outsourcing�of�services�is�an�aspect�of�the�organisation’s�workforce�planning�(Criterion�2.2.1).�
It�is�likely�that�many�of�the�functions�performed�by�external�service�providers�will�fall�within�the�scope�of�other�criteria�–�for�example,�laundry�services�(Criterion�1.5.2),�food�preparation�and�delivery�(Criterion�1.5.7),�equipment�installation�and�maintenance�(Criterion�3.2.2),�waste�management�(Criterion�3.2.3)�and�
security�(Criterion�3.2.5).�It�is�the�responsibility�of�the�organisation�to�ensure�both�the�standard�of�the�services�provided,�and�that�any�contracted�personnel�are�given�all�necessary�orientation�and�safety�training�(Criterion�3.2.4).�The�use�of�external�service�providers�is�a�risk�that�must�be�managed�(Criterion�2.1.2)�in�order�to�avoid�incidents�(Criterion�2.1.3)�and�complaints�(Criterion�2.1.4).
PoliciesExternal�service�providers�may�supply�regular,�periodic�or�one-off�services�to�both�clinical�and�non-clinical�areas�of�the�healthcare�organisation.�Outsourced�services,�including�contracted�services,�may�be�governed�by�decisions�and�policy�from�a�higher�level,�such�as�a�head�office,�area�health�service�or�network.
Criterion LA – Awareness sA – implementationLA plus the following
MA – evaluationSA plus the following
eA – excellenceMA plus the following
oA – LeadershipEA plus the following
Criterion 3.1.4
External�service�providers�are�managed�to�maximise�quality,�safe�health�care�and�service�delivery.
a)� Policy�exists�for�the�management�of�external�service�providers.
a)� External�service�providers�can�demonstrate�compliance�with�relevant�regulatory�requirements.
b)� Services�provided�externally�are�consistent�with�specified�standards.
c)� There�are�documented�agreements�with�all�external�service�providers�that�include�performance�measures.
d)� External�service�providers�supply�evidence�of�internal�evaluation�for�the�services�that�they�are�providing�to�the�organisation.�
e)� Dispute�resolution�mechanisms�are�identified�and�communicated�to�the�external�provider.
a)� Agreements�with�external�service�providers�are�reviewed�and�improved�as�required.
b)� The�organisation�evaluates�the�performance�of�external�service�providers�through�agreed�performance�measures�including�clinical�outcomes�and�financial�performance�where�appropriate,�and�improvements�are�made�as�required.
a)� Agreements�with�external�service�providers�and�systems�for�monitoring�performance�are�compared�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.
a)� The�organisation�demonstrates�it�is�a�leader�in�managing�external�service�providers.
October 2010 405
To�ensure�standards�of�quality�and�integrity,�senior�managers�must�guarantee�that�probity�requirements�are�met�and�understand�the�structures�that�support�decision�making�in�relation�to�service�provision�to�facilitate�compliance.�For�example,�in�most�public�and�private�sector�organisations�there�will�be�an�identified�expenditure�above�which�services�will�be�tendered.
Many�States�/�Territories�have�prepared�public�sector�procurement�policies�and�guidelines�on�the�management�of�external�service�providers.1–3�In�addition,�organisations�should�have�a�delegation�manual�that�nominates�staff�with�the�delegated�authority�to�select�suppliers�of�specific�services.4�
Increasingly,�tendered�services�are�commissioned�using�online�processes;�policies�need�to�be�updated�to�reflect�this.�In�the�private�sector,�policies�should�reflect�jurisdictional�legislation�and�any�belief�systems,�structural�frameworks,�financial�drivers�or�other�goals�that�will�guide�service�provision�for�the�business.
Prompt points
¼ Is there policy / by-laws covering the appointment and management of external service providers?
¼ How does the organisation manage local service suppliers appointed through centralised tendering processes?
¼ Does the organisation maintain a register of external service providers? How is this cross-referenced with contracts or service agreements?
¼ What process determines KPIs for contracts? How are they monitored by the governing body?
Criterion LA – Awareness sA – implementationLA plus the following
MA – evaluationSA plus the following
eA – excellenceMA plus the following
oA – LeadershipEA plus the following
Criterion 3.1.4
External�service�providers�are�managed�to�maximise�quality,�safe�health�care�and�service�delivery.
a)� Policy�exists�for�the�management�of�external�service�providers.
a)� External�service�providers�can�demonstrate�compliance�with�relevant�regulatory�requirements.
b)� Services�provided�externally�are�consistent�with�specified�standards.
c)� There�are�documented�agreements�with�all�external�service�providers�that�include�performance�measures.
d)� External�service�providers�supply�evidence�of�internal�evaluation�for�the�services�that�they�are�providing�to�the�organisation.�
e)� Dispute�resolution�mechanisms�are�identified�and�communicated�to�the�external�provider.
a)� Agreements�with�external�service�providers�are�reviewed�and�improved�as�required.
b)� The�organisation�evaluates�the�performance�of�external�service�providers�through�agreed�performance�measures�including�clinical�outcomes�and�financial�performance�where�appropriate,�and�improvements�are�made�as�required.
a)� Agreements�with�external�service�providers�and�systems�for�monitoring�performance�are�compared�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.
a)� The�organisation�demonstrates�it�is�a�leader�in�managing�external�service�providers.
seCtion 5Standards, criteria, elements and guidelinesstandard 3.1:�The�governing�body�leads�the�organisation’s�strategic�direction�to�ensure�the�provision�of�quality,�safe�services
406 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 3.1.4
External�service�providers�are�managed�to�maximise�quality,�safe�health�care�and�service�delivery.�(continued)
Documented agreements Contracts�and�agreements�need�to�abide�by�jurisdictional�legislation.�A�process�to�determine�which�contracts�need�legal�oversight�during�their�preparation�must�be�agreed�upon�and�documented�by�the�governing�body.�Agreements�with�high�value�or�risk�should�have�legal�oversight.�Many�government�departments�provide�templates�for�service�agreements,�and�these�will�vary�depending�upon�the�business�structures�entering�into�the�agreement.
Organisations�may�also�maintain�lists�of�preferred�suppliers�for�specific�projects.�This�is�most�common�for�tradesmen�who�may�be�needed,�but�not�always�available,�at�short�notice.�There�should�be�a�documented�process�for�the�selection�of�preferred�suppliers�and�a�process�to�review�the�outcome�of�the�service�provided.5�Care�must�be�taken�when�appointing�external�contractors,�particularly�where�a�conflict�of�interest�could�be�construed.
A�contract�or�service�agreement�is�important�for�both�the�healthcare�organisation�and�the�service�provider�to�ensure�quality�maintenance�of�the�service.�The�fundamental�responsibility�for�quality�rests�with�the�contracting�healthcare�organisation�and�its�governing�body.�In�establishing�the�legal�arrangement,�the�organisation�needs�to�include�the�level�of�service�expected�and�the�evidence�of�compliance�with�that�service’s�regulatory�or�industry�standards�required.�
Contracts�and�service�agreements�must�include�measures�and�timelines�against�expectations�of�service�provision.�Performance�indicators�and�their�measures�may�be�simple�or�complex,�but�must�be�specific,�achievable�and�relevant.�Examples�include�turnaround�times,�feedback,�survey�information�and�counts�of�services�provided.
Prompt points
¼ Is there a system to track agreements with external service providers, including those negotiated by head or regional offices or by networks? Does the system alert the organisation to agreements / contracts that have reached term or time for review?
¼ How is performance of external service suppliers managed?
¼ What dispute resolution mechanisms are in place for the organisation? Has the process and names of contact persons been communicated to service suppliers in the terms of the agreement or in other correspondence?
¼ Is performance against agreed performance measures reviewed before contracts for service provision are renewed or at predetermined times in long-term agreements? How is this information communicated to the governing body? What action is taken when performance fails to meet performance measures?
Standards and regulatory legislation complianceA�number�of�legislated�requirements�regulate�the�provision�of�certain�services�to�protect�public�health�and�safety.�When�commissioning�service�providers,�organisations�must�ensure�that�they�are�approved�to�provide�the�commissioned�service.�
Food�service�providers�should�follow�the�FoodStandardsAustraliaNewZealand(FSANZ)�standards�for�food�safety.6
Pathology�services�must�be�accredited�by�an�approved�body.7�There�are�also�standards�for�collection�stations�from�which�pathology�services�source�samples.8,�9
Tradesmen�must�be�appropriately�certified�to�perform�the�projects�assigned,�and�must�abide�by�legislated�requirements.�In�most�States�/�Territories,�the�Department�of�Consumer�Affairs�is�responsible�for�handling�queries�in�relation�to�licensing�of�tradesmen.�
Linen�services�should�meet�regulatory�requirements�for�infection�control,�as�outlined�in�AS�4146:2000�Laundrypractice.
October 2010 407
Service�providers�may�provide�services�that�involve�many�different�staff�operating�on�the�organisation’s�premises.�Examples�include�security�guards,�cleaners�and�agency�nurses.�In�these�cases,�the�contract�will�require�clearly�delineated�responsibilities�regarding�access�to�organisational�facilities�and�the�provision�of�work-related�equipment.�In�addition,�it�is�important�that�contracts�clarify�the�role�of�the�contractor,�such�as�for�security�guards,�who�may�be�asked�to�restrain�aggressive�or�mentally�unstable�patients.10
The�organisation�should�retain�details�of�evidence�that�their�suppliers�fulfil�licensing�and�quality�standards�in�the�jurisdiction(s)�in�which�the�organisation�operates,�such�as�‘Working�with�Children’�and�police�checks.11�In�the�case�of�long-term�contracts,�this�evidence�should�be�rechecked�according�to�a�predetermined�timeframe.�
Prompt points
¼ In what areas is compliance with standards or retention of accreditation a condition for appointment or a performance measure on service providers’ contracts?
Evaluation of service providedEvaluation�and�monitoring�of�supplier�performance�may�relate�to�price,�service�and/or�quality,�and�the�measures�for�evaluation�should�be�decided�in�advance�and�recorded�in�the�contracted�agreement.�Monitoring�may�be�as�simple�as�sending�an�appropriately�qualified�person�to�check�the�satisfactory�completion�of�a�trades�job,�to�regular�audits�for�quality�and�accuracy�of�services�or�timeliness,�as�may�be�more�appropriate�for�ongoing�suppliers�of�food,�laundry�or�pathology�services.�Some�contracted�services�may�be�expected�to�provide�details�of�their�tasks�and�workloads,�particularly�where�fees�vary�with�the�volume�of�work.�For�example,�waste�disposal�services�may�report�on�volumes�of�different�classes�of�waste�and�any�aberrant�separation�of�classes�of�waste.�Pathology�services�might�list�services�by�type,�with�cost�and�volume.
Irrespective�of�whether�the�organisation�/�department�was�included�in�the�selection�of�its�service�providers,�it�should�monitor�the�service�received�and�have�channels�by�which�staff�can�feed�back�any�concerns.�Records�of�feedback�from�staff,�consumers�/�patients�and�visitors�regarding�service�provision�should�be�addressed�individually�as�appropriate,�and�retained�for�cumulative�review�against�the�agreed�standards�for�supply�of�the�service.
Examples�of�performance�measures�include:
• turnaround�times�for�recruitment�advertising,�haematology�samples�or�imaging
• feedback�forms�for�education�services�or�employment�assistance�schemes
• staff�survey�and/or�complaints�for�security�performance
• timeliness�and�numbers�moved�for�transport�services
• according�to�a�specific�standard�for�infection�control
• consumer�/�patient�surveys�and�complaints�for�food�and�food�service.�
Prompt points
¼ How is compliance with external standards and any other performance measures stated on contracts checked and maintained?
¼ How are a supplier’s reported service levels and costings cross-checked / audited?
¼ How does the organisation use education, incentives and/or hold providers to account, to improve the quality / value of service received from external suppliers?
¼ How is performance measured and reported to the senior management team?
seCtion 5Standards, criteria, elements and guidelinesstandard 3.1:�The�governing�body�leads�the�organisation’s�strategic�direction�to�ensure�the�provision�of�quality,�safe�services
408 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Performance measurementThis�criterion�states�that:�“External�service�providers�are�managed�to�maximise�quality,�safe�health�care�and�service�delivery”.�The�organisation�should�be�able�to�demonstrate�that�its�management�of�its�use�of�external�service�providers�ensures�that�all�services�provided�meet�the�necessary�and�contractually�agreed�standard.
Some�common�suggested�performance�measures�are�as�follows:
Number�of�external�service�providers�with�a�current�contract
Total number of external service providers
Number�of�contracts�with�external�service�providers�that�contain�performances�measures�/�indicators
Total number of external service provider contracts
Number�of�external�service�providers�that�supply�workers�compensation�and�insurance�information��to�the�organisation
Total number of external service providers
Criterion 3.1.4
External�service�providers�are�managed�to�maximise�quality,�safe�health�care�and�service�delivery.�(continued)
Evidence commonly presented
Consider whether the following will help to address criterion 3.1.4
¼ Policies relating to external service providers, including organisational information on service provision by service providers contracted through centralised processes
¼ Contracts with external service providers that include detailed task information and performance measures
¼ Administrative systems (or spreadsheets / databases) for coordinating the management of external service providers and staff who manage these systems
¼ Tender documents and advertising of tender
¼ Review meetings with subcontracted services – meeting records or correspondence
¼ Relevant questions on consumer / patient feedback survey forms and outcomes of surveys
¼ Audits of cleaning, or other specified performance markers such as infection control
¼ Documents demonstrating the handling of complaints about subcontracted services
October 2010 409
Number�of�contracted�external�service�providers�reviewed�against�their�performance�measures�/�indicators
Number of contracted external service providers
Number�of�staff�and�consumers�/�patients�satisfied�with�services�provided�by�external�service�providers
Total number of staff and consumers / patients surveyed
References1.� NSW�Department�of�Commerce.NSWGovernment
procurementguidelines:Serviceproviderperformancemanagement.�Sydney;�NSW�Government�and�NSW�Treasury;�2007.
2.� Victorian�Auditor�General’s�Office�(VAGO).�Publicsectorprocurement:turningprinciplesintopractice.�Melbourne�VIC;�VAGO;�2007.
3.� Australian�Department�of�Finance.�AustralianGovernmentprocurementstatement.�Canberra�ACT;�Australian�Government;�2009.
4.� NSW�Health.�Delegationsmanual–Combined(Administrativefinancialstaff).�Sydney;�NSW�Health.�Accessed�from�http://www.health.nsw.gov.au/resources/policies/manuals/comb_delegations.asp�on�7�December�2009.
5.� Ombudsman�Victoria.�Probitycontrolsinpublichospitalsfortheprocurementofnon-clinicalgoodsandservices.Melbourne�VIC;�Ombudsman�Victoria;�2008.
6.� Food�Standards�Australia�New�Zealand�(FSANZ).�AustraliaNewZealandfoodstandardscode.Canberra�ACT;�FSANZ.�Accessed�from�http://www.foodstandards.gov.au/thecode/foodstandardscode/�on�25�January�2010.
7.� National�Pathology�Accreditation�Advisory�Council�(NPAAC).�Standardsforpathologylaboratoryparticipationinexternalproficiencytestingprograms.Canberra�ACT;�Australian�Dept�of�Health�and�Ageing.�Accessed�from��http://www.health.gov.au/internet/main/publishing.nsf/Content/npaac-stand-ext-test-toc�on�3�December.
8.� Department�of�Health�and�Ageing�(DoHA).�Guidelineforapprovedpathologycollectioncentres.Canberra�ACT;�DoHA;�2006.
9.� National�Pathology�Accreditation�Advisory�Council�(NPAAC).�Requirementsforapprovedcollectioncentres(NPAACTier3standard)(draftforsecondedn).Canberra�ACT;�NPAAC;�2009.
10.� Kemp�M.�Hospital�guards�defy�law�to�restrain�patients.�AdelaideNow�(6�May�2009).�Accessed�from�http://www.news.com.au/adelaidenow/story/0,27574,25441237-2682,00.html�on�4�December�2009.
11.� Australian�Institute�of�Family�Studies.�Pre-employment�screening:�Working�with�children�checks�and�police�checks.�Resourcesheet�2010;�13.�Accessed�from�http://www.aifs.gov.au/nch/resources/police/policechecks.html�on�1�September�2010.
seCtion 5Standards, criteria, elements and guidelinesstandard 3.1:�The�governing�body�leads�the�organisation’s�strategic�direction�to�ensure�the�provision�of�quality,�safe�services
410 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion LA – Awareness sA – implementationLA plus the following
MA – evaluationSA plus the following
eA – excellenceMA plus the following
oA – LeadershipEA plus the following
Criterion 3.1.5
Documentedcorporateandclinicalpoliciesandproceduresassisttheorganisationtoprovidequality,safehealthcare.
this is a mandatory criterion
a)� The�organisation�is�aware�of�relevant:
� (i)� legislation
� (ii)� professional�guidelines
� (iii)� codes�of�practice�
� (iv)� Australian�standards
� (v)� codes�of�ethics.�
b)� Documented�corporate�and�clinical�policies�and�procedures�refer�to�by-laws,�operating�and�management�requirements.�
a)� A�framework�for�corporate�and�clinical�policy�and�procedure�development�and�review�is�in�place.
b)� Policies�and�procedures�reference:
� (i)� current�issues
� (ii)� Australian�standards
� (iii)� legislation
� (iv)� professional�guidelines
� (v)� codes�of�practice
� (vi)� codes�of�ethics
� (vii)�evidence.
c)� A�system�exists�that:�
� (i)� �audits�compliance�with�relevant�legislation
� (ii)� �informs�relevant�staff�of�new�or�amended�legislation
� (iii)� �educates�staff�on�relevant�legislation�applicable�to�their�area�of�responsibility.
d)� Stakeholders�including�staff�are�involved�in�the�development�of�local�policy�and�procedures.
e)� Changes�to�practice�and�service�in�clinical�and�non-clinical�areas�are�reflected�in�updated�policies�and�procedures.�
f)� A�system�for�document�control�is�implemented.
g)� A�process�for�the�distribution�and�implementation�of�new�and�reviewed�policies�and�procedures�is�in�place.
h)� There�is�adherence�to�by-laws,�operating�requirements�and�management�requirements.
i)� A�system�for�monitoring�compliance�with�policies�and�procedures�is�implemented.
a)� The�framework�for�policy�development�and�review�is�evaluated�and�improved�as�required.
b)� Policies�and�procedures�are�regularly�reviewed,�updated�and�improved�as�required.
c)� The�system�for�ensuring�implementation�of,�and�compliance�with,�key�or�amended�legislative�requirements�is�evaluated�and�improved,�as�required.�
a)� The�framework�for�corporate�and�clinical�policy�and�procedure�development�and�management�is�compared�with�internal�and�external�systems,�and�improvements�are�made�to�ensure�better�practice.
and/or
b)� Other�organisations�review�and�use�the�organisation’s�policies�and�procedures�as�a�framework�for�their�policy�implementation.�
a)� The�organisation�demonstrates�it�is�a�leader�in�corporate�and�clinical�policies�and�procedures.
October 2010 411
Criterion LA – Awareness sA – implementationLA plus the following
MA – evaluationSA plus the following
eA – excellenceMA plus the following
oA – LeadershipEA plus the following
Criterion 3.1.5
Documentedcorporateandclinicalpoliciesandproceduresassisttheorganisationtoprovidequality,safehealthcare.
this is a mandatory criterion
a)� The�organisation�is�aware�of�relevant:
� (i)� legislation
� (ii)� professional�guidelines
� (iii)� codes�of�practice�
� (iv)� Australian�standards
� (v)� codes�of�ethics.�
b)� Documented�corporate�and�clinical�policies�and�procedures�refer�to�by-laws,�operating�and�management�requirements.�
a)� A�framework�for�corporate�and�clinical�policy�and�procedure�development�and�review�is�in�place.
b)� Policies�and�procedures�reference:
� (i)� current�issues
� (ii)� Australian�standards
� (iii)� legislation
� (iv)� professional�guidelines
� (v)� codes�of�practice
� (vi)� codes�of�ethics
� (vii)�evidence.
c)� A�system�exists�that:�
� (i)� �audits�compliance�with�relevant�legislation
� (ii)� �informs�relevant�staff�of�new�or�amended�legislation
� (iii)� �educates�staff�on�relevant�legislation�applicable�to�their�area�of�responsibility.
d)� Stakeholders�including�staff�are�involved�in�the�development�of�local�policy�and�procedures.
e)� Changes�to�practice�and�service�in�clinical�and�non-clinical�areas�are�reflected�in�updated�policies�and�procedures.�
f)� A�system�for�document�control�is�implemented.
g)� A�process�for�the�distribution�and�implementation�of�new�and�reviewed�policies�and�procedures�is�in�place.
h)� There�is�adherence�to�by-laws,�operating�requirements�and�management�requirements.
i)� A�system�for�monitoring�compliance�with�policies�and�procedures�is�implemented.
a)� The�framework�for�policy�development�and�review�is�evaluated�and�improved�as�required.
b)� Policies�and�procedures�are�regularly�reviewed,�updated�and�improved�as�required.
c)� The�system�for�ensuring�implementation�of,�and�compliance�with,�key�or�amended�legislative�requirements�is�evaluated�and�improved,�as�required.�
a)� The�framework�for�corporate�and�clinical�policy�and�procedure�development�and�management�is�compared�with�internal�and�external�systems,�and�improvements�are�made�to�ensure�better�practice.
and/or
b)� Other�organisations�review�and�use�the�organisation’s�policies�and�procedures�as�a�framework�for�their�policy�implementation.�
a)� The�organisation�demonstrates�it�is�a�leader�in�corporate�and�clinical�policies�and�procedures.
seCtion 5Standards, criteria, elements and guidelinesstandard 3.1:�The�governing�body�leads�the�organisation’s�strategic�direction�to�ensure�the�provision�of�quality,�safe�services
412 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 3.1.5
Documentedcorporateandclinicalpoliciesandproceduresassisttheorganisationtoprovidequality,safehealthcare.(continued)
IntentPolicy,�by-laws,�guidelines�and�procedures�represent�the�translation�of�legislation,�Australian�standards,�and�codes�of�practice�and�ethics�into�a�framework�that�allows�the�organisation�to�meet�its�obligations�to�the�community�it�serves.�The�intent�of�this�criterion�is�to�ensure�that�the�organisation�is�guided�by�well-constructed�and�effective�policy;�that�managers,�staff,�volunteers,�consumers�/�patients�and�other�stakeholders�are�informed�of�policy,�by-laws�and�guidelines�relevant�to�their�roles�within�the�organisation;�and�that�the�practical�implementation�of�policy�in�the�form�of�appropriate,�best�evidence-based�procedures�will�result�in�safe,�high�quality�health�care.
Relationships of 3.1.5 with other criteriaCorporate�and�clinical�policies�and�procedures�form�the�infrastructure�within�which�the�organisation�meets�its�obligation�to�provide�quality�care.�Consequently,�this�guideline�should�be�read�in�conjunction�with�all�other�criteria.
Organisational policyWithin�the�healthcare�system,�all�organisations�will�have�policies�to�which�they�adhere,�and�which�guide�operation�at�both�the�corporate�and�the�clinical�level.�Policies�usually�arise�from�overriding�legal�obligations,�and�outline�general�courses�of�action�designed�to�achieve�a�set�of�stated�outcomes.�They�will�include�specific�references�to�their�authority�and�a�statement�as�to�who�is�bound�by�them,�and�cover�a�significant�aspect�of�the�organisation’s�operation.
Corporate�policies�may�include:
• appointment�of�senior�staff
• delegation
• credentialling�/�scope�of�practice
• introduction�of�new�interventions
• committee�structures
• reporting�and�outcomes
• disciplinary�action
• recruitment�and�retention
• advertising
• secondary�employment
• information�management
• privacy�and�confidentiality
• conflict�of�interest
• declaration�of�private�interests
• acceptance�of�gifts�and�benefits
• Code�of�Conduct
• Occupational�Health�&�Safety
• security.
Clinical�policies�may�include:
• admissions�
• discharge�of�consumers�/�patients
• clinical�handover
• infection�control
• prevention�and�management�of�iatrogenic�wounds
• prevention�and�management�of�falls
• blood�and�blood�component�management
• management�of�specific�diseases
• medication�management
• correct�consumer�/�patient,�correct�procedure,�correct�site
• consent
• end-of-life�decision�making
• mortality�management.
While�State�/�Territory�health�departments�will�issue�policies,�the�size�and�nature�of�the�organisation�will�dictate�the�manner�in�which�the�requirements�of�these�policies�are�integrated�into�the�framework�of�operation.�Public�facilities�will�be�governed�by�area�or�regional�policies�based�upon�those�of�the�relevant�authority,�while�private�hospitals�and�other�independent�organisations�will�draft�their�own�policies�directly�from�State�/�Territory�directives�and�according�to�the�requirements�of�their�by-laws,�operating�requirements�and/or�management�requirements.�While�the�implementation�of�policy�is�not�discretionary,�the�translation�of�jurisdictional�policy�to�organisational�policy�does�allow�for�the�exercise�of�local�discretion�in�how�stated�outcomes�are�to�be�achieved.
Australian�standards,�professional�codes�of�practice,�codes�of�ethics�and�other�guidelines�are�rarely�legislated.�However,�there�is�an�expectation�that�the�organisation�will�reference�these�documents�in�its�policies,�and�that�compliance�will�be�demonstrated�through�evaluation�processes.�Policy�will�also�be�shaped�by�evidence�of�best�practice,�and�will�respond�to�issues�as�they�occur.
October 2010 413
Prompt points
¼ For what aspects of the organisation’s operation do corporate policies exist? – clinical policies?
¼ What non-legislative documents are referenced within the organisation’s policies?
¼ Which of the organisation’s policies make reference to evidence-based practice?
Development and review of policies and proceduresA�framework�for�developing�policies�will�ensure�that�those�policies�are�consistent�across�the�organisation�and�that�all�of�the�essential�elements�are�included:�the�aim,�the�expected�outcome(s),�the�references�and�evidence�used�to�develop�the�policy,�how�and�when�the�outcomes�are�to�be�monitored,�reviewed�and�updated.
Policies�and�procedures�should�be�reviewed�at�least�once�within�the�EQuIP�cycle.�This�process�should�also�incorporate�a�review�of�the�framework�via�which�policies�are�developed�and�implemented,�and�improvements�made�to�the�systems,�the�delegation�of�responsibility�and/or�the�management�of�policy�development�as�required.�The�organisation�should�be�able�to�demonstrate�the�system(s)�by�which�it�obtains�the�most�current�information�about�legislation,�standards�and�evidence;�how�it�responds�to�this�information;�and�how�this�response�is�documented.�All�active�policies�and�procedures�should�reflect�current�legislation,�standards�and�evidence;�and�all�changes�that�are�made�to�existing�policies�and�procedures�and�the�reasons�for�them�should�be�thoroughly�documented.
Prompt points
¼ How does the organisation ensure that its policies and procedures are based upon the most current information?
¼ How does the organisation involve staff in the development of policies and procedures? What other stakeholders are involved?
¼ How often does the organisation review its policies and procedures?
Dissemination, implementation and complianceIt�is�essential�that�staff�at�all�levels�understand�their�responsibilities�with�respect�to�implementation�of,�and�compliance�with,�policies�and�procedures.�An�explanation�of�the�framework�under�which�policies�and�procedures�are�developed�and�reviewed�should�be�included�in�orientation�for�new�staff,�and�should�make�part�of�regular�education�‘refresher’�sessions�for�all�staff.�The�implementation�of�procedures�can�also�be�made�the�subject�of�sessions�targeted�at�particular�staff,�to�facilitate�understanding�of�the�relevant�legislation�and�compliance�on�the�part�of�those�individuals�operating�within�their�scope.�Staff�feedback�should�be�sought�to�assess�the�usefulness�of�these�sessions,�and�changes�made�to�the�content�or�approach�if�required.�Quality�care�cannot�be�provided�unless�there�is�a�system�that�ensures�that�the�organisation’s�policies�are�read�by�relevant�staff�and�that�a�sufficient�level�of�understanding�is�attained,�so�that�the�reasoning�behind�the�development�of�procedures�is�clear�and�correct�implementation�thus�facilitated.
Systems�to�disseminate�information�when�new�legislation�is�enacted�or�amendments�made�to�existing�legislation�/�standards�/�codes�/�guidelines�are�required�to�make�certain�that�staff�are�aware�of�their�legal�responsibilities,�that�all�active�procedures�are�in�accordance�with�the�most�current�information,�and�that�all�changes�made�to�procedures�are�reflected�in�the�altered�conduct�of�staff.�Along�with�the�policies�and�procedures�themselves,�the�organisation�should�review�the�means�by�which�material�is�disseminated,�to�ensure�that�all�necessary�information�reaches�all�relevant�staff�in�a�timely�manner,�and�make�changes�when�required.
Organisations�must�have�audit�systems�in�place�to�monitor�compliance�with�policies�and�procedures.�Organisations�may�wish�to�treat�instances�of��non-compliance�as�reportable�incidents,�particularly�in�the�case�of�high-risk�areas�such�as�mandatory�‘timeouts’�prior�to�surgery.�However,�incident�reporting�alone�is�not�a�sufficient�means�of�auditing�compliance.�Where�departures�from�policies�or�procedures�are�identified�via�spot-checks,�ongoing�monitoring,�reviews�of�incidents�and/or�staff�discussion�or�feedback,�analysis�of�the�reasons�for�the�non-compliance�will�allow�the�need�for�a�new�or�amended�policy�or�procedure�to�be�determined,�or�staff�behaviour�to�be�amended.�The�means�by�which�compliance�is�audited�should�also�be�subjected�to�regular�review,�to�make�certain�that�the�most�effective�processes�for�monitoring�and,�where�required,�improvement�are�in�place.
seCtion 5Standards, criteria, elements and guidelinesstandard 3.1:�The�governing�body�leads�the�organisation’s�strategic�direction�to�ensure�the�provision�of�quality,�safe�services
414 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 3.1.5
Documentedcorporateandclinicalpoliciesandproceduresassisttheorganisationtoprovidequality,safehealthcare.(continued)
Prompt points
¼ How does the organisation ensure that its staff are aware of their legal responsibilities with respect to policies and procedures?
¼ How are procedures implemented? How does the organisation monitor compliance with procedures? How does the organisation deal with identified instances of non-compliance?
Document controlThe�organisation’s�policies�and�procedures�must�be�managed�via�a�system�of�document�control�–�including�policy�and�procedures�for�the�preparation,�dissemination,�implementation�and�rescinding�of�policy�and�procedures.�There�are�various�ways�in�which�this�may�be�done,�and�the�form�and�the�scope�of�the�process�will�vary�according�to�the�size�and�complexity�of�the�facility.�It�is�imperative�that�the�most�current�documentation�is�circulated�and�implemented,�and�that�all�superseded�versions�are�withdrawn�and�archived.�Large�organisations�may�wish�to�employ�designated�document�controllers.�Decisions�must�be�made,�and�procedures�instigated,�to�manage�the�naming�and/or�numbering,�formatting�(hard�copy�and/or�electronic)�and�storage�of�documents.�Commercial�software�programs�are�available�to�assist�with�the�management�of�organisational�documentation,�which�may�be�extended�from�policies�and�procedures�to�include�other�relevant�documents�such�as�annual�reports,�standard�operating�procedures,�forms,�contracts,�etc.�Jurisdictional�legislation�and�policy�will�dictate�the�length�of�time�over�which�various�records�must�be�stored.�The�document�control�system�will�govern�and�facilitate�this�process.
Prompt points
¼ What system of document control does the organisation employ? Who is in charge of it?
¼ How does it ensure that the most current policies and procedures are available?
¼ What is the process for withdrawing earlier versions of documents?
¼ In what format(s) are earlier versions of policies and procedures stored?
Evidence commonly presented
Consider whether the following will help to address criterion 3.1.5
¼ Framework for the development of policies
¼ Corporate and clinical policies
¼ Schedule for review of policies and procedures
¼ Systems for identification and dissemination of information on new or amended legislation, Australian standards, codes of practice, guidelines, etc.
¼ Processes for incorporating legislation, Australian standards, codes of practice, guidelines, etc., into policies
¼ An example of the revision of existing policies / procedures due to new information
¼ Evaluation of compliance with policies and procedures
¼ Systems for retrieving superseded policies / procedures
October 2010 415
GuidelinesAS/NZS�ISO�31000:2010�Riskmanagement—Principlesandguidelines.
AS�3806:2006Complianceprograms.Second�edn.
AS�ISO�10013:2003�Guidelinesforqualitymanagementsystemdocumentation.
Performance managementThis�criterion�states�that:�“Documented�corporate�and�clinical�policies�and�procedures�assist�the�organisation�to�provide�quality,�safe�health�care”.�The�organisation�should�be�able�to�demonstrate�that�its�development�of�policies�and�procedures�incorporates�the�most�current�information�on�legislation,�Australian�standards,�codes�of�practice�and�ethics,�guidelines�and�evidence�of�best�practice,�and�that�it�monitors�compliance�with�its�policies�and�procedures,�so�that�it�may�meet�its�obligations�to�the�community�it�serves�in�terms�of�the�provision�of�safe,�high�quality,�contemporary�health�care.
Some�common�suggested�performance�measures�are�as�follows:
Number�of�staff�attending�education�sessions�about�policies�and�procedures�per�calendar�year
Total number of staff
Number�of�policies�and�procedures�that�have�a�stated�review�date
Total number of policies and procedures
Number�of�policies�and�procedures�reviewed�within�the�required�timeframe
Total number of policies and procedures
Number�of�clinical�policies�reviewed�and�updated�to�reflect�current�clinical�practice
Total number of clinical policies
Number�of�staff�educated�on�legislation�related�to�their�area�of�responsibility
Total number of staff in that area of responsibility
Number�of�staff�in�compliance�with�a�specific�policy�or�procedure
Total number of staff working within the area to which that specific policy or procedure applies
416 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
October 2010 417
3.2�Safe�Practice�and�Environment�Standard
The�standard�is:�The organisation maintains a safe environment for employees, consumers / patients and visitors.
The�intent�of�the�Safe�Practice�and�Environment�standard�is�to�ensure�that�the�healthcare�environment�is�safe�and�healthcare�providers�work�in�a�safe�manner.�Safe�Practice�and�Environment�criteria�all�require�the�systematic�application�of�risk�management�principles�to�determine�priorities�and�eliminate�risks�or�implement�controls.�
There�are�five�criteria�in�this�standard.�They�are:
3.2.1 Safety management systems ensuresafetyandwellbeingofconsumers/patients,staff,visitorsandcontractors.
3.2.2� �Buildings, signage, plant, medical devices, equipment, supplies, utilities and consumables�are�managed�safely�and�used�efficiently�and�effectively.
3.2.3� Waste and environmental management supports�safe�practice�and�a�safe�and�sustainable�environment.
3.2.4 Emergency and disaster management supportssafepracticeandasafeenvironment.
3.2.5� Security management supports�safe�practice�and�a�safe�environment.
seCtion 5Standards, criteria, elements and guidelines
seCtion 5Standards, criteria, elements and guidelinesstandard 3.2:�The�organisation�maintains�a�safe�environment�for�employees,�consumers�/�patients�and�visitors
418 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion LA – Awareness sA – implementationLA plus the following
MA – evaluationSA plus the following
eA – excellenceMA plus the following
oA – LeadershipEA plus the following
Criterion 3.2.1
Safetymanagementsystemsensuresafetyandwellbeingofconsumers/patients,staff,visitorsandcontractors.
this is a mandatory criterion
a)� Documented�policies�for�safety�management�systems�are�in�accordance�with�relevant�jurisdictional�legislation�and�include:
� (i)� �workplace�health�and�safety
� (ii)� �workers�compensation
� (iii)� manual�handling
� (iv)� radiation�safety
� (v)� �management�of�dangerous�goods�and�hazardous�substances.
b)� Health�and�safety�risks�that�may�cause�harm�are�identified.
c)� Staff�are�educated�about�and�provided�with�information�on�workplace�health�and�safety�and�their�responsibilities.
d)� External�service�providers�are�supplied�with�relevant�information�and�comply�with�the�organisation’s�health�and�safety�requirements.
e)� Occupational�Health�&�Safety�(OH&S)�requirements�are�communicated�to�carers�and�visitors�as�required.
f)� There�are�documented�policies�and�procedures�on�the�procurement,�management�and�disposal�of�dangerous�goods�and�hazardous�substances,�and�a�register�of�hazardous�substances�is�maintained.
g)� A�register�is�kept�for�all�radioactive�substances,�safe�disposal�of�all�radioactive�waste�and�radiation�equipment.
h)� A�personal�radiation�monitoring�system�is�in�place,�together�with�any�relevant�area�monitoring.
a)� Safety�management�systems�are�managed�with�reference�to�any�relevant:
� (i)� Australian�standards
� (ii)� legislation
� (iii)� codes�of�practice
� (iv)� industry�guidelines.
b)� There�is�an�organisation-wide�system�to�assess�health�and�safety�risks,�determine�priorities�and�eliminate�the�risks�or�implement�controls.
c)� Service�planning�includes�health�and�safety�together�with�injury�prevention�strategies.
d)� Staff�are�involved�in�decisions�that�affect�workplace�health�and�safety�and�wellbeing.
e)� There�are�documented�safe�work�practices�/�safety�rules�for�all�relevant�procedures�and�tasks.
f)� A�hazards�identification�system�identifies�risks�and�implements�controls,�and�takes�corrective�action.
g)� Manual�handling�risks�in�both�clinical�and�non-clinical�areas�are�assessed�and�appropriate�controls�are�implemented.
h)� There�is�an�injury�management�program�that�reflects�legislation.
i)� Staff�with�formal�OH&S�responsibilities�are�appropriately�trained.
j)� There�is�a�radiation�safety�management�plan�which�is�coordinated�with�external�authorities.
k)� Consumer�/�patient�radiation�is�kept�to�a�minimum�whilst�maintaining�good�diagnostic�quality.
l)� Staff�exposure�to�radiation�is�kept�low�as�reasonably�achievable�(ALARA).
m)� A�radiation�safety�report�is�provided�to�the�ethics�committee�on�any�research�proposal�involving�irradiation�of�human�subjects.�
a)� The�safety�management�and�injury�management�systems�are�evaluated�and�improvements�are�made�to�support�safe�practice�and�a�safe�environment.
b)� The�design�and�layout�of�the�organisation’s�current�or�planned�physical�environment�are�evaluated.�
a)� Performance�indicators�for�safety�management�and�injury�management�systems�are�measured�and�compared�internally�and�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.
a)� The�organisation�demonstrates�it�is�a�leader�in�safety�management�systems.
October 2010 419
Criterion LA – Awareness sA – implementationLA plus the following
MA – evaluationSA plus the following
eA – excellenceMA plus the following
oA – LeadershipEA plus the following
Criterion 3.2.1
Safetymanagementsystemsensuresafetyandwellbeingofconsumers/patients,staff,visitorsandcontractors.
this is a mandatory criterion
a)� Documented�policies�for�safety�management�systems�are�in�accordance�with�relevant�jurisdictional�legislation�and�include:
� (i)� �workplace�health�and�safety
� (ii)� �workers�compensation
� (iii)� manual�handling
� (iv)� radiation�safety
� (v)� �management�of�dangerous�goods�and�hazardous�substances.
b)� Health�and�safety�risks�that�may�cause�harm�are�identified.
c)� Staff�are�educated�about�and�provided�with�information�on�workplace�health�and�safety�and�their�responsibilities.
d)� External�service�providers�are�supplied�with�relevant�information�and�comply�with�the�organisation’s�health�and�safety�requirements.
e)� Occupational�Health�&�Safety�(OH&S)�requirements�are�communicated�to�carers�and�visitors�as�required.
f)� There�are�documented�policies�and�procedures�on�the�procurement,�management�and�disposal�of�dangerous�goods�and�hazardous�substances,�and�a�register�of�hazardous�substances�is�maintained.
g)� A�register�is�kept�for�all�radioactive�substances,�safe�disposal�of�all�radioactive�waste�and�radiation�equipment.
h)� A�personal�radiation�monitoring�system�is�in�place,�together�with�any�relevant�area�monitoring.
a)� Safety�management�systems�are�managed�with�reference�to�any�relevant:
� (i)� Australian�standards
� (ii)� legislation
� (iii)� codes�of�practice
� (iv)� industry�guidelines.
b)� There�is�an�organisation-wide�system�to�assess�health�and�safety�risks,�determine�priorities�and�eliminate�the�risks�or�implement�controls.
c)� Service�planning�includes�health�and�safety�together�with�injury�prevention�strategies.
d)� Staff�are�involved�in�decisions�that�affect�workplace�health�and�safety�and�wellbeing.
e)� There�are�documented�safe�work�practices�/�safety�rules�for�all�relevant�procedures�and�tasks.
f)� A�hazards�identification�system�identifies�risks�and�implements�controls,�and�takes�corrective�action.
g)� Manual�handling�risks�in�both�clinical�and�non-clinical�areas�are�assessed�and�appropriate�controls�are�implemented.
h)� There�is�an�injury�management�program�that�reflects�legislation.
i)� Staff�with�formal�OH&S�responsibilities�are�appropriately�trained.
j)� There�is�a�radiation�safety�management�plan�which�is�coordinated�with�external�authorities.
k)� Consumer�/�patient�radiation�is�kept�to�a�minimum�whilst�maintaining�good�diagnostic�quality.
l)� Staff�exposure�to�radiation�is�kept�low�as�reasonably�achievable�(ALARA).
m)� A�radiation�safety�report�is�provided�to�the�ethics�committee�on�any�research�proposal�involving�irradiation�of�human�subjects.�
a)� The�safety�management�and�injury�management�systems�are�evaluated�and�improvements�are�made�to�support�safe�practice�and�a�safe�environment.
b)� The�design�and�layout�of�the�organisation’s�current�or�planned�physical�environment�are�evaluated.�
a)� Performance�indicators�for�safety�management�and�injury�management�systems�are�measured�and�compared�internally�and�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.
a)� The�organisation�demonstrates�it�is�a�leader�in�safety�management�systems.
seCtion 5Standards, criteria, elements and guidelinesstandard 3.2:�The�organisation�maintains�a�safe�environment�for�employees,�consumers�/�patients�and�visitors
420 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 3.2.1
Safetymanagementsystemsensuresafetyandwellbeingofconsumers/patients,staff,visitorsandcontractors.(continued)
IntentThe�intent�of�this�criterion�is�to�ensure�that�healthcare�organisations�take�responsibility�for�the�health�and�safety�of�employees,�contractors,�management,�consumers�/�patients�and�visitors�via�a�comprehensive�and�integrated�safety�management�system.
Relationships of 3.2.1 with other criteriaThis�criterion�addresses�safety�management�systems�in�the�workplace�environment.�To�ensure�safe�management�systems,�staff�levels�need�to�be�commensurate�with�the�workload�(Criterion�2.2.1).�Organisational�systems�and�personal�responsibilities�for�workplace�safety�should�be�addressed�during�staff�orientation�(Criterion�2.2.2)�and�training�(Criterion�2.2.4).�The�design�of�the�facility�(Criterion�3.2.2)�will�impact�upon�specific�safety�issues,�such�as�falls�risk�(Criterion�1.5.4).�Safety�management�systems�will�operate�within�the�organisation’s�integrated�risk�management�framework�(Criterion�2.1.2).�Failure�to�implement�a�comprehensive�system�of�safety�management�may�lead�to�incidents�(Criterion�2.1.3)�and�complaints�(Criterion�2.1.4).
Safety management systemsA�safety�management�system�is�a�comprehensive�and�integrated�system�that�ensures�that�all�work�at�the�organisation�is�conducted�safely.�It�should�be�fully�documented,�accessible�and�comprehensible�to�those�that�need�to�use�it.�The�safety�management�system�recognises�the�potential�for�errors�and�establishes�control�measures�that�are�fully�implemented,�to�ensure�that�errors�do�not�result�in�incidents�or�near�misses.1�It�comprises�a�set�of�work�practices�and�procedures�for�monitoring�and�improving�the�safety�of�all�aspects�of�the�operation.
The�safety�management�system�includes:
• policy:�effective�health�and�safety�policies�set�a�clear�direction�for�the�organisation�to�follow
• planning:�an�effective�management�structure�and�arrangements�are�in�place�for�delivering�the�policy.�There�is�a�planned�and�systematic�approach�to�implementing�the�health�and�safety�policy.�Individual�responsibilities�should�be�clearly�outlined�and�may�be�stated�in�position�descriptions�or�similar�and�policies�and�procedures
• implementation:�the�policies,�procedures�and�resources�are�put�in�place�to�manage�all�aspects�of�the�control�measures�that�ensure�safe�operation�of�the�facility
• assessment:�performance�and�compliance�are�measured�against�agreed�standards�to�reveal�when�and�where�improvement�is�needed
• management�review:�the�organisation�learns�from�all�relevant�experience�and�applies�the�lessons.
The�organisation’s�implementation�of�its�safety�management�systems�will�be�carried�out�in�conjunction�with�its�design�and�layout�of�its�physical�environment.�While�the�physical�environment�is�in�part�an�outcome�of�the�organisation’s�planning�and�management�of�its�buildings�and�plant�(as�addressed�within�criterion�3.2.2),�the�concept�of�‘physical�environment’�also�encompasses�the�safe�and�effective�use�of�space�–�that�is,�it�addresses�issues�such�as�what�equipment�is�available�and�where�it�is�used,�the�design�and�placement�of�workstations,�how�workflow�is�organised�so�as�to�maintain�efficiency�and�meet�the�requirements�of�infection�control�procedures,�the�reduction�/�elimination�of�falls�risks,�and�so�forth.�The�design�and�layout�of�the�physical�environment�is�a�critical�aspect�of�the�organisation’s�management�of�Occupational�Health�&�Safety,�and�in�particular�of�manual�handling�/�task�(see�below).�The�organisation�should�not�only�regularly�evaluate�its�existing�systems,�making�improvements�as�required,�but�plan�ahead�for�any�anticipated�changes�in�service�delivery�and/or�the�size�and�composition�of�its�workforce.
October 2010 421
Prompt points
¼ Do the safety policies and procedures address all the high-risk activities undertaken by the organisation? Wherever appropriate, do they separately consider the safety of staff, consumers / patients, carers, visitors and contractors?
¼ Are policies appropriately referenced to demonstrate awareness of regulatory obligations? Are they regularly reviewed and updated to reflect changes in regulations?
¼ What changes to the safety management system have been made in response to monitoring of reported incidents or other feedback? How was the implementation of the change managed? Are these processes, and any resulting changes, linked to risk management procedures, and the monitoring of risks (such as through the risk register)?
¼ How often does the organisation evaluate its current physical environment? What changes to design and layout have been made in response to anticipated changes in the organisation’s operation?
Occupational Health & Safety Depending�upon�their�size,�organisations�should�have�a�health�and�safety�officer�and/or�an�Occupational�Health�&�Safety�(OH&S)�committee�on�which�all�staff�groups�or�departments�are�represented,�as�required�by�legislation.�There�must�be�employee�representation�in�the�process,�not�only�representation�by�management.�Staff�who�accept�formal�OH&S�responsibilities�within�the�organisation�are�usually�required�to�undergo�accredited�training,�and�organisations�should�provide�access�to�such�training�and�allow�all�time�necessary�for�it�to�be�completed.�
Smaller�organisations�with�few�employees�may�seek�to�fulfil�their�staff�consultation�requirements�through�regular�team�meetings�where�OH&S�is�a�standing�agenda�item�and�staff�are�required�to�provide�input.�There�should�be�documented�evidence�of�the�consultative�process,�such�as�minutes.�Similarly,�there�should�be�documented�processes�that�ensure�that�issues�arising�within�the�Committee�are�notified�to�the�appropriate�executive�manager�or�board�/�executive�team.�Any�issues�raised�by�the�OH&S�Committee�that�require�a�response�should�be�documented�within�the�minutes�under�‘Business�Arising’�and�followed�through�for�a�decision.
There�should�be�a�process�to�ensure�that�all�staff�have�read�and�understood�health�and�safety�policies�and�procedures�and�this�should�be�part�of�the�induction�process.�Written�policies�for�health�and�safety�may�include:
• manual�handling�/�task
• radiation�safety
• slips�/�trips�/�falls
• electrical�safety
• noise�control
• hazardous�substances�and�dangerous�goods
• smoking
• ergonomics�–�assessments�of�all�working�environments�including�workstations�
• violence�and�aggression�
• management�of�incidents�and�near�misses
• staff�immunisation�–�a�risk-based�program�in�accordance�with�the�AustralianImmunisationHandbook2
• off-site�attendance�to�consumers�/�patients
• needlestick�injury�and�bodily�fluid�exposure�prevention
• provision�of�protective�clothing�and�equipment.
Prompt points
¼ Is there an OH&S system in place? Do policies, procedures, resources, communication processes and data link in a way that results in a ‘system’, rather than exist as stand-alone entities?
¼ Do staff understand their responsibilities in OH&S? Are there competency checks in key areas? What OH&S training is provided for staff? Is additional training available for OH&S representatives? Is attendance at training documented and non-attendance followed up?
¼ Are there records of meetings by the OH&S Committee (or any body with equivalent responsibilities)?
¼ How are major health and safety risks identified? How are incidents reported and managed? Are data collected and if so, how is it used? Is there a register of safe work method statements? Are these methods adopted by the staff?
¼ How are external service contractors made aware of policy and monitored for compliance with it?
seCtion 5Standards, criteria, elements and guidelinesstandard 3.2:�The�organisation�maintains�a�safe�environment�for�employees,�consumers�/�patients�and�visitors
422 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 3.2.1
Safetymanagementsystemsensuresafetyandwellbeingofconsumers/patients,staff,visitorsandcontractors.(continued)
Manual handling / taskThere�are�three�steps�to�reducing�manual�handling�/�task�incidents.�They�are:
1.� Identification
2.� Assessment�
3.� Control.
Identification: Manual�handling�tasks�should�be�identified�and�documented,�with�particular�attention�to�the�tasks�with�the�greatest�risk.�To�identify�these�tasks,�two�types�of�information�should�be�collected:�past�experiences�such�as�injury�statistics,�and�information�on�current�activities�gathered�by�staff�consultation�or�observation,�such�as�task�analysis.
Assessment: The�severity�of�the�risk�should�then�be�assessed.�For�example,�consumer�/�patient�lifting�in�a�surgical�or�orthopaedic�ward�would�pose�a�greater�risk�than�in�a�paediatric�ward.�While�both�require�manual�lifting�of�a�consumer�/�patient,�the�latter�would�normally�require�the�lifting�of�a�smaller�load�and�would�present�a�lower�risk.�Factors�to�consider�in�a�manual�handling�/�task�assessment�may�include�frequency�and/or�duration�of�task,�postural�factors,�weight�of�the�load,�load�characteristics,�environmental�factors�and�the�experience�of�the�staff�member.
The�risk�of�consumers�/�patients�having�a�fall�and�requiring�assistance�post-fall�applies�in�every�healthcare�organisation,�including�day�procedure�centres�and�community�health�centres.�The�use�of�anaesthesia�and�some�other�medications�increases�the�risk�of�a�fall�occurring�and�appropriate�risk�management�strategies�should�be�employed�to�minimise�identified�risk.�This�is�addressed�in�further�detail�within�criterion�1.5.4.
Control: The�National�Occupational�Health�and�Safety�Commission�(Australia)�Regulation�and�Codes3�and�some�additional�jurisdictional�requirements�call�for�risk�factors�to�be�controlled�by�redesigning�the�task�and�providing�general�training.�It�is�important�to�involve�the�staff,�the�OH&S�representative�/�committee�and�workplace�manager�in�any�redesigning�of�manual�handling�/�task�procedures.�The�use�of�consumer�/�patient�lifters�is�one�way�to�demonstrate�that�redesign�has�occurred.�
If�redesign�is�not�reasonably�practicable,�or�as�a�short-term�/�temporary�measure,�the�organisation�could�employ�team�lifting�or�provide�mechanical�aids�such�as�slide�sheets,�PAT�slides�and�trolleys,�and�training�and�supervision�in�the�use�of�these.�Often�the�best�solution�may�be�a�combination�of�one�or�more�of�these�controls.�Ergonomic�principles�should�be�considered�prior�to�the�purchase�of�any�equipment,�design�of�a�task�or�any�work�modifications.�There�should�be�procedures�for�the�use�and�trial�of�equipment�prior�to�use,�including�training�for�staff�using�the�equipment.�Records�of�these�equipment�trials�and�associated�training�should�be�retained�to�support�these�actions.
Policy�and�procedures�should�be�available�on�handling�bariatric�consumers�/�patients�to�avoid�injury�to�staff.�When�specialised�equipment�is�purchased,�training�in�the�use�of�that�equipment�should�be�performed�prior�to�its�implementation�and�should�also�become�a�part�of�orientation.
Injury and return-to-work managementThe�organisation�must�have�an�injury�management�policy�and�a�return-to-work�program�that�reflects�the�requirements�of�the�appropriate�State�/�Territory�legislation.�Correct�injury�management�ensures�the�prompt,�safe�and�durable�return-to-work�of�an�injured�worker.4�The�organisation’s�return-to-work�program�should�outline�the�policy�and�procedures�implemented�to�assist�injured�workers�with�their�return�to�the�workplace,�as�well�as�providing�all�other�relevant�information,�such�as�the�means�by�which�treatment�or�rehabilitation�may�be�accessed.�Staff�must�be�made�aware�of�the�return-to-work�program�(via�posters,�newsletters,�etc.),�and�all�related�information�must�be�freely�accessible.
October 2010 423
Prompt points
¼ Is there a manual handling / task policy? When was it last reviewed?
¼ How are external service contractors made aware of the policy? How does the organisation monitor compliance by their external service contractors?
¼ Is there regular mandatory training in manual handling / task that meets specific staff / task needs? Is there a ‘no-lift’ policy?
¼ Does service planning include injury prevention strategies? Is there appropriate representation at strategic planning meetings?
¼ How do staff access the organisation’s injury management and return-to-work policies?
Sources of radiation and radiation safety systemsSources�of�radiation�are�essential�to�modern�health�care.�Radiation�is�a�vital�diagnostic�tool,�such�as�in�imaging�departments,�and�radiotherapy�may�be�used�to�the�treat�some�malignancies.5�Potential�exposure�needs�to�be�managed�and�according�to�the�relevant�code(s)�of�practice;�the�development�of�policy�and�procedures�to�support�this�management�will�be�a�requirement�for�a�large�group�of�organisations.
There�are�three�main�concepts�in�protecting�staff�from�radiation.�They�are:
• Time: The�amount�of�radiation�exposure�received�is�proportional�to�the�time�exposed.�Minimise�the�time�spent�handling�radioactive�substances�or�with�radiation�producing�equipment.�
• Distance: The�intensity�of�radiation�drops�rapidly�the�further�away�from�the�source.�Maximise�distance�from�sources�of�radiation�at�all�times.�This�includes,�for�example,�using�tongs�instead�of�hands�to�handle�radioactive�samples.�
• Shielding: Increasing�shielding�around�a�radiation�source�will�reduce�exposure.�
These�three�concepts�use�the�ALARA�(As�Low�As�Reasonably�Achievable)�principle�for�limiting�exposure�to�radiation�and�this�principle�should�be�considered�at�all�times�where�there�is�risk�of�exposure.
All�organisations�should�be�familiar�with�the�radiation�protection�standards�and�guidelines.�These�generally�pertain�to�exposure�and�dosage�and�can�be�found�on�the�Australian�Radiation�Protection�and�Nuclear�Safety�Agency�(ARPANSA)�website6,�where�guidelines,�codes�of�practice�and�other�relevant�information�are�available.�Control�of�radiation�exposure�is�governed�by�legislation�at�both�a�Federal�and�State�/�Territory�level.
In�organisations�where�lasers�are�used,�policies�and�procedures�should�reference�AS/NZS�4173:2004�Guidetothesafeuseoflasersinhealthcare.7�All�licences�and�safety�arrangements�should�be�in�place.
Depending�on�their�size,�organisations�should�have�a�radiation�safety�officer�and/or�a�radiation�safety�committee,�as�required�by�legislation.�A�radiation�management�plan�for�the�organisation�that�complies�with�the�ARPANSA�CodeofPracticeforRadiationProtectionintheMedicalApplicationsofIonizingRadiation8�should�be�implemented.
The�radiation�management�plan�should�note�those�persons�responsible�for�handling�and�purchase�of�any�radioactive�substances,�licences�and�compliance�with�any�standards�or�legislation.�There�should�be�a�register�of�radioactive�substances�and�relevant�equipment�on�site�at�any�time�that�is�regularly�updated.�
A�radiation�safety�report�should�be�provided�to�the�organisation’s�ethics�committee�(or�equivalent)�where�any�research�proposal�involves�irradiation�of�human�subjects,�in�accordance�with�the�ARPANSA�CodeofPracticefortheExposureofHumanstoIonizingRadiationforResearchPurposes.9�Where�required�by�the�State�/�Territory�regulatory�authority,�approval�for�the�research�is�also�sought�from�the�Radiation�Advisory�Council.�Staff�radiation�exposure�should�be�reviewed�by�the�radiation�safety�committee�or�the�alternative�relevant�authority�in�each�organisation.
seCtion 5Standards, criteria, elements and guidelinesstandard 3.2:�The�organisation�maintains�a�safe�environment�for�employees,�consumers�/�patients�and�visitors
424 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 3.2.1
Safetymanagementsystemsensuresafetyandwellbeingofconsumers/patients,staff,visitorsandcontractors.(continued)
Prompt points
¼ Are there risk identification and management reports, including for radiation? incident reports?
¼ Is there a radiation management program? Does the organisation have a Radiation Safety Officer and/or a Radiation Safety Committee? Do management / executives have a copy of the organisation’s Radiation Safety Plan?
¼ How does the organisation handle and dispose of radioactive waste?
¼ How often are the results of employee radiation exposure testing reviewed? How is this documented?
¼ How often is the radiation shielding (physical barriers and aprons) checked?
¼ Are Occupational Health and Safety reports, audits and/or meeting minutes available?
¼ Are results of external audits, numerical profiles, etc. trended, and implementation of recommendations made?
Hazardous substancesHazardous�substances�and�dangerous�goods�are�those�substances�that:
• are�referenced�in�the�National�Occupational�Health�and�Safety�Commission�ListofDesignatedHazardousSubstancesortheApprovedCriteriaforClassifyingHazardousSubstances�http://www.safeworkaustralia.gov.au/swa/HealthSafety/HazardousSubstances/FAQ/
• are�listed�in�the�Australian�Dangerous�Goods�(ADG)�Code�for�the�TransportofDangerousGoodsbyRoadandRail�http://www.infrastructure.gov.au/transport/australia/dangerous/�publications.aspx�
• meet�the�classification�criteria�of�the�ADG�Code.
The�application�of�risk�management�principles�and�compliance�with�each�State�/�Territory�hazardous�substances�code�of�practice�is�essential�in�ensuring�the�safety�and�wellbeing�of�consumers�/�patients,�staff�and�visitors�to�the�organisation.�Where�no�individual�policies�for�the�management�of�hazardous�materials�exist,�the�risk�management�policy�should�cover�areas�such�as:
• storage�/�security�/�isolation
• signage�/�information�/�labelling�/�identification�(including�information�from�provider)
• handling�/�use�
• spillage�(including�emergency�procedures)
• exposure�control,�monitoring�and�health�surveillance�(records�of�any�monitoring�or�health�surveillance�should�be�kept�for�30�years)
• personal�protective�equipment
• records
• transport
• disposal
• induction�and�training
• licensing
• maintenance�/�inspection�–�review�of�controls
• workplace�legislation�–�hazardous�substances,�dangerous�goods
• biological�hazards.
Material�Safety�Data�Sheets�(MSDSs)�should�be�available�for�staff�at�point�of�use�and�for�applicable�emergency�agencies�such�as�the�fire�brigade.�Hazardous�substances�are�to�be�properly�labelled�and�maintained�on�a�register�of�all�hazardous�substances�in�the�workplace.�Labels�should�never�be�altered�and�substances�should�be�stored�in�their�original�containers.
Chemicals�and�cleaning�solutions�bought�in�domestic�quantities�from�a�supermarket�or�other�supplier�should�be�handled�according�to�the�manufacturer’s�instructions.�Since�these�products�have�not�been�developed�specifically�for�healthcare�settings,�they�should�be�used�sparingly�within�the�organisation.�In�any�healthcare�organisation,�higher�standards�apply�than�in�the�home,�and�products�are�tested�accordingly.
October 2010 425
Prompt points
¼ Are completed checklists and action plans to address identified deficiencies for each health industry hazard in line with State / Territory bodies available?
¼ Are there Occupational Health & Safety reports, audits and/or meeting minutes?
¼ Are Material Safety Data Sheets and a master index available to all staff?
¼ Are risk identification and management reports, including for radiation, available?
Evidence commonly presented
Consider whether the following will help to address criterion 3.2.1
¼ Completed checklist and action plan to address identified deficiencies for each health industry hazard, in line with State / Territory bodies
¼ Occupational Health and Safety reports, audits and/or meeting minutes
¼ Incident reports
¼ Availability of Material Safety Data Sheets and a master index
¼ Policies and procedures on safety management systems
¼ Risk identification and management reports
¼ Evidence of staff involvement in workplace health and safety
¼ Evidence of staff training and competency checks in workplace health and safety
¼ Register of safe work method statements
seCtion 5Standards, criteria, elements and guidelinesstandard 3.2:�The�organisation�maintains�a�safe�environment�for�employees,�consumers�/�patients�and�visitors
426 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 3.2.1
Safetymanagementsystemsensuresafetyandwellbeingofconsumers/patients,staff,visitorsandcontractors.(continued)
Performance measurementThis�criterion�states�that:�“Safety�management�systems�ensure�safety�and�wellbeing�of�consumers�/�patients,�staff,�visitors�and�contractors”.�The�organisation�should�be�able�to�demonstrate:�that�it�takes�responsibility�for�all�aspects�of�health�and�safety�via�the�implementation�of�appropriate�policies�and�procedures,�including�those�covering�injury�management�and�return-to-work;�its�proactive�attitude�to�risk�management;�its�response�to�the�occurrence�of�injuries�and�incidents,�including�near�misses;�and�an�ongoing�program�of�staff�education�that�includes�regular�competency�checks.
Some�common�performance�measures�are�as�follows:
Number�of�incidents�reported�that�relate�to�hazardous�substances�/�radiation�/�equipment�/��manual�handling�/�task
Total number of incidents
Comment:counttheincidentsforeachseparatecategory
Number�of�workers�compensation�claims�arising�from�a�manual�handling�/�task�incident
Total number of workers compensation claims
Number�of�staff�currently�on�workers�compensation
Total number of staff
Number�of�staff�working�hours�lost�to�workplace�injury
Total number of staff working hours
Number�of�staff�satisfied�with�the�organisation’s�return-to-work�program
Total number of staff who used the return-to-work program
Number�of�staff�who�completed�competencies�in�areas�such�as�dangerous�goods�/�hazardous�substances�/�radiation�/�manual�handling�/�task
Total number of staff undertaking competencies
October 2010 427
Number�of�chemicals�that�have�a�current�Material�Safety�Data�Sheet
Total number of chemicals
Number�of�staff�satisfied�with�the�organisation’s�safety�strategies
Total number of staff surveyed
References1.� Government�of�South�Australia.�OccupationalHealth,
SafetyandWelfareRegulations1995.�In:�South�Australian�Consolidated�Regulations.�Adelaide;�Government�of�SA.�Accessed�from�www.austlii.edu.au�on�20�November�2008.
2.� Australian�Technical�Advisory�Group�on�Immunisation�(ATAGI)�and�National�Health�and�Medical�Research�Council�(NHMRC).�AustralianImmunisationHandbook.Canberra�ACT;�Australian�Dept�of�Health�and�Ageing.�Accessed�from�http://www.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook-home�on�8�March�2010.
3.� Australian�Government.�NationalOccupationalHealthandSafetyCommissionRegulations.Canberra�ACT;�Attorney-General’s�Department;�2003.
4.� WorkCover�NSW.�Injurymanagementandreturn-to-workprograms:Factsheet2.�Sydney;�NSW�Government;�2008.
5.� Australian�Radiation�Protection�and�Nuclear�Safety�Agency�(ARPANSA).�Nationalstandardforlimitingoccupationalexposuretoionizingradiation.Radiation�Protection�Series�No.�1,�Republished�2002.�Canberra�ACT;�National�Occupation�Health�and�Safety�Commission;�1995.
6.� Australian�Radiation�Protection�and�Nuclear�Safety�Agency�(ARPANSA).�RadiationProtectionSeries.Melbourne�VIC;�Australian�Government.�Accessed�from�http://www.arpansa.gov.au/Publications/codes/rps.cfm�on�29�June�2010.
7.� AS/NZS�4173:2004�Guidetothesafeuseoflasersinhealthcare.
8.� Australian�Radiation�Protection�and�Nuclear�Safety�Agency�(ARPANSA).�Codeofpractice:Radiationprotectioninthemedicalapplicationsofionizingradiation.Radiation�Protection�Series�No.�14.�Canberra�ACT;�Australian�Government;�2008.
9.� Australian�Radiation�Protection�and�Nuclear�Safety�Agency�(ARPANSA).Codeofpractice:Exposureofhumanstoionizingradiationforresearchpurposes.Radiation�Protection�Series�No.�8.�Canberra�ACT;�Australian�Government;�2005.
seCtion 5Standards, criteria, elements and guidelinesstandard 3.2:�The�organisation�maintains�a�safe�environment�for�employees,�consumers�/�patients�and�visitors
428 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion LA – Awareness sA – implementationLA plus the following
MA – evaluationSA plus the following
eA – excellenceMA plus the following
oA – LeadershipEA plus the following
Criterion 3.2.2
Buildings,�signage,�plant,�medical�devices,�equipment,�supplies,�utilities�and�consumables�are�managed�safely�and�used�efficiently�and�effectively.
a)� Documented�policy�/�procedures�for:
� (i)� buildings�/�workplaces
� (ii)� plant
� (iii)� �medical�devices�and�equipment
� (iv)� other�equipment
� (v)� supplies
� (vi)� utilities
� (vii)� consumables
� (viii)�workplace�design�
� address�health,�safety�and�service�requirements.
b)� Medical�devices�are:
� (i)� selected
� (ii)� installed�
� (iii)� operated�
� (iv)� maintained�
� (v)� repaired�
� (vi)� calibrated�where�necessary
� by�competent,�qualified�people.
c)� Plant�and�other�equipment�are�installed�and�operated�in�accordance�with�manufacturer�specifications.
d)� Plant�logs�exist�and�are�in�accordance�with�manufacturer�requirements.
e)� There�is�a�cleaning�schedule�for�all�areas�of�the�buildings�and�for�equipment.
f)� Purchase�and�supply�procedures�ensure�that�products�are�available�or�that�appropriate�alternatives�are�supplied.
g)� There�is�clear�external�signage�at�appropriate�locations.
h)� The�organisation�has�identified�disability�and�cultural�signage�needs.
i)� Disability�access�and�facilities�meet�legislative�requirements�where�they�exist,�and/or�are�based�on�recognised�guidelines.
j)� The�organisation�has�procedures�that�ensure�the�efficient�and�sustainable�use�of�energy�and�water.
a)� There�is�a�system�to�plan,�manage�and�operate:
� (i)� buildings�/�workplaces
� (ii)� plant
� (iii)� �medical�equipment�/�devices
� (iv)� other�equipment
� (v)� supplies
� (vi)� utilities
� (vii)� consumables.
b)� Buildings,�plant,�medical�devices�and�equipment,�utilities,�consumables�and�supplies�are�managed�with�reference�to�any�relevant:
� (i)� Australian�standards
� (ii)� legislation
� (iii)� codes�of�practice
� (iv)� industry�guidelines.
c)� Relevant�staff�are�trained�in�the�safe�and�appropriate�use�of�medical�devices�and�equipment.
d)� There�is�a�documented,�planned�and�coordinated�preventative�maintenance�system.
e)� The�organisation�provides�resources�that�support�cleaning�requirements.
f)� Services�/�departments�are�sign�posted�appropriate�to�the�needs�of�the�community�and�the�organisation.
g)� Sign�posting�reflects�the�use�of�multilingual�/�international�symbols�appropriate�to�the�community’s�needs.
a)� The�safety�and�accessibility�of�the�buildings�/�workplace,�and�the�safe�and�consistent�operation�of�plant�and�equipment,�is�evaluated,�and�improvements�are�made�to�reduce�risk.
b)� The�acquisition,�use,�maintenance�and�storage�of�medical�devices�/�medical�equipment�is�monitored�and�evaluated.
c)� Maintenance�and�replacement�of�buildings,�plant,�medical�and�other�equipment�is�planned,�prioritised�and�budgeted�for.
d)� Incidents�and�hazards�associated�with�building,�plant,�medical�devices,�equipment,�utilities,�consumables�and�supplies�are�documented,�evaluated,�and�action�is�taken�to�reduce�risk.
e)� The�quality�of�cleaning�practices�is�evaluated�and�improved�as�required.
f)� The�organisation�regularly�evaluates�whether�the�signage�meets�community�needs�and�makes�necessary�improvements.
g)� Energy�and�water�use�is�evaluated�annually�and�improvements�are�made�to�enhance�efficiency.
a)� Management�systems�related�to�buildings,�plant,�equipment,�medical�devices,�consumables�and�supplies�are�measured�and�compared�internally�and�externally,�and�improvements�are�made�to�ensure�better�practice.
and/or
b)� Signage�and�physical�access�are�compared�with�available�published�standards�and�external�data,�and�improvements�are�made�to�ensure�better�practice.�
and/or
c)� Utilities�are�monitored�over�time,�and�efforts�made�to�ensure�efficient,�effective�and�sustainable�use�of�energy�and�water�resources.
a)� The�organisation�demonstrates�it�is�a�leader�in�the�management�of�buildings,�signage,�plant,�medical�devices,�equipment,�supplies,�utilities�and�consumables.
October 2010 429
Criterion LA – Awareness sA – implementationLA plus the following
MA – evaluationSA plus the following
eA – excellenceMA plus the following
oA – LeadershipEA plus the following
Criterion 3.2.2
Buildings,�signage,�plant,�medical�devices,�equipment,�supplies,�utilities�and�consumables�are�managed�safely�and�used�efficiently�and�effectively.
a)� Documented�policy�/�procedures�for:
� (i)� buildings�/�workplaces
� (ii)� plant
� (iii)� �medical�devices�and�equipment
� (iv)� other�equipment
� (v)� supplies
� (vi)� utilities
� (vii)� consumables
� (viii)�workplace�design�
� address�health,�safety�and�service�requirements.
b)� Medical�devices�are:
� (i)� selected
� (ii)� installed�
� (iii)� operated�
� (iv)� maintained�
� (v)� repaired�
� (vi)� calibrated�where�necessary
� by�competent,�qualified�people.
c)� Plant�and�other�equipment�are�installed�and�operated�in�accordance�with�manufacturer�specifications.
d)� Plant�logs�exist�and�are�in�accordance�with�manufacturer�requirements.
e)� There�is�a�cleaning�schedule�for�all�areas�of�the�buildings�and�for�equipment.
f)� Purchase�and�supply�procedures�ensure�that�products�are�available�or�that�appropriate�alternatives�are�supplied.
g)� There�is�clear�external�signage�at�appropriate�locations.
h)� The�organisation�has�identified�disability�and�cultural�signage�needs.
i)� Disability�access�and�facilities�meet�legislative�requirements�where�they�exist,�and/or�are�based�on�recognised�guidelines.
j)� The�organisation�has�procedures�that�ensure�the�efficient�and�sustainable�use�of�energy�and�water.
a)� There�is�a�system�to�plan,�manage�and�operate:
� (i)� buildings�/�workplaces
� (ii)� plant
� (iii)� �medical�equipment�/�devices
� (iv)� other�equipment
� (v)� supplies
� (vi)� utilities
� (vii)� consumables.
b)� Buildings,�plant,�medical�devices�and�equipment,�utilities,�consumables�and�supplies�are�managed�with�reference�to�any�relevant:
� (i)� Australian�standards
� (ii)� legislation
� (iii)� codes�of�practice
� (iv)� industry�guidelines.
c)� Relevant�staff�are�trained�in�the�safe�and�appropriate�use�of�medical�devices�and�equipment.
d)� There�is�a�documented,�planned�and�coordinated�preventative�maintenance�system.
e)� The�organisation�provides�resources�that�support�cleaning�requirements.
f)� Services�/�departments�are�sign�posted�appropriate�to�the�needs�of�the�community�and�the�organisation.
g)� Sign�posting�reflects�the�use�of�multilingual�/�international�symbols�appropriate�to�the�community’s�needs.
a)� The�safety�and�accessibility�of�the�buildings�/�workplace,�and�the�safe�and�consistent�operation�of�plant�and�equipment,�is�evaluated,�and�improvements�are�made�to�reduce�risk.
b)� The�acquisition,�use,�maintenance�and�storage�of�medical�devices�/�medical�equipment�is�monitored�and�evaluated.
c)� Maintenance�and�replacement�of�buildings,�plant,�medical�and�other�equipment�is�planned,�prioritised�and�budgeted�for.
d)� Incidents�and�hazards�associated�with�building,�plant,�medical�devices,�equipment,�utilities,�consumables�and�supplies�are�documented,�evaluated,�and�action�is�taken�to�reduce�risk.
e)� The�quality�of�cleaning�practices�is�evaluated�and�improved�as�required.
f)� The�organisation�regularly�evaluates�whether�the�signage�meets�community�needs�and�makes�necessary�improvements.
g)� Energy�and�water�use�is�evaluated�annually�and�improvements�are�made�to�enhance�efficiency.
a)� Management�systems�related�to�buildings,�plant,�equipment,�medical�devices,�consumables�and�supplies�are�measured�and�compared�internally�and�externally,�and�improvements�are�made�to�ensure�better�practice.
and/or
b)� Signage�and�physical�access�are�compared�with�available�published�standards�and�external�data,�and�improvements�are�made�to�ensure�better�practice.�
and/or
c)� Utilities�are�monitored�over�time,�and�efforts�made�to�ensure�efficient,�effective�and�sustainable�use�of�energy�and�water�resources.
a)� The�organisation�demonstrates�it�is�a�leader�in�the�management�of�buildings,�signage,�plant,�medical�devices,�equipment,�supplies,�utilities�and�consumables.
seCtion 5Standards, criteria, elements and guidelinesstandard 3.2:�The�organisation�maintains�a�safe�environment�for�employees,�consumers�/�patients�and�visitors
430 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 3.2.2
Buildings,�signage,�plant,�medical�devices,�equipment,�supplies,�utilities�and�consumables�are�managed�safely�and�used�efficiently�and�effectively.�(continued)
IntentThe�intent�of�this�criterion�is�to�ensure�that�all�buildings,�signage,�plant,�medical�devices,�equipment,�supplies,�utilities�and�consumables�owned�or�used�by�the�organisation�are�managed�in�a�way�that�will�support�the�creation�and�maintenance�of�a�safe�healthcare�environment.
Relationships of 3.2.2 with other criteriaThe�organisation’s�management�of�its�buildings,�signage,�plant,�medical�devices,�equipment,�utilities,�supplies�and�consumables�is�an�aspect�of�its�responsibility�to�ensure�the�safety�of�consumers�/�patients,�staff,�visitors�and�contractors�(Criterion�3.2.1)�and�to�manage�risk�(Criterion�2.1.2).�It�must�reflect�the�organisation’s�commitment�to�safe�practice�and�a�safe�environment,�as�per�its�emergency�and�disaster�management�policies�(Criterion�3.2.4),�while�also�providing�for�those�consumers�/�patients�and�carers�with�diverse�needs�and�from�diverse�backgrounds�(Criterion�1.6.3).�The�implementation�of�efficient�cleaning�practices,�as�well�as�water�usage�and�the�choice�of�electrical�goods,�will�fall�under�the�organisation’s�responsibility�for�providing�a�safe�and�sustainable�environment�(Criterion�3.2.3)�and�may�be�influenced�by�its�management�of�infection�control�(Criterion�1.5.2).�A�failure�in�the�efficiency�and/or�effectiveness�of�management�of�its�buildings,�signage,�plant,�medical�devices,�equipment,�supplies,�utilities�and�consumables�may�lead�to�incidents�and�complaints�(Criteria�2.1.3�and�2.1.4).
Planning and developmentThe�organisation’s�management�of�its�buildings,�plant�and�equipment�requires�the�development�of�policy�and�procedures�drawn�from�relevant�legislation,�codes�of�practice�and�Australian�standards,�and�which�address�how�the�organisation�will�maximise�the�safety�and�comfort,�and�supply�the�needs,�of�the�community�it�serves.�The�Australasian�Health�Infrastructure�Alliance�(formerly�the�Health�Capital�Asset�Managers’�Consortium�of�Australia�and�New�Zealand)�has�developed�the�Australasian�Health�Facilities�Guideline�(AusHFG)1,�a�comprehensive�guide�to�the�planning,�design,�building�and�refurbishment�of�healthcare�facilities.�It�also�covers�the�planning,�selection�and�installation�of�plant�and�equipment,�aspects�of�sustainability,�access�features�for�those�with�special�needs,�and�workplace�design�and�ergonomics.�The�AusHFG�is�intended�to�promote�a�best-practice�approach�to�health�facility�planning,�and�is�subjected�to�a�continuous�review�process�to�ensure�that�the�content�reflects�contemporary�models�of�care�and�health�planning�practice.�It�also�lists�all�appropriate�jurisdictional�legislation,�including�Occupational�Health�&�Safety�legislation,�and�relevant�Australian�standards.�
In�November�2007,�the�AusHFG�was�officially�endorsed�for�use�by�Australian�States�/�Territories�and�by�the�Ministry�of�Health,�New�Zealand.�Using�this�document�as�its�guide,�organisations�should�develop�policy�and�procedures�that�will�provide�an�effective�managerial�framework.
In�existing�facilities,�or�where�an�area�is�designated�for�a�new�purpose,�it�can�be�difficult�to�redesign�workspaces�without�major�renovation.�If�the�organisation�intends�to�adapt�an�existing�space�for�a�new�purpose,�it�should�plan�the�changes�and�manage�the�area�so�as�to�ensure�compliance�with�relevant�Occupational�Health�&�Safety�legislation.
The�organisation’s�planning�and�development�should�also�strive�for�continual�improvements�to�the�environment�and�for�a�reduction�in�risk,�by�evaluating�the�workplace�and�making�changes�as�necessary.�As�part�of�its�system�of�planning,�organisations�should�recognise�that�over�time,�buildings,�plant,�medical�devices�and�other�equipment�may�require�maintenance�and/or�repair,�or�to�be�replaced.�Events�such�as�these�should�be�expected,�prioritised�and�budgeted�for,�in�order�to�ensure�that�safety�of�the�environment�is�not�compromised.�Success�or�the�need�for�improvement�in�the�area�of�workplace�planning�/�design�may�be�gauged�by�surveying�consumers�/�patients,�visitors�and�staff.
October 2010 431
Prompt points
¼ Was the workplace purpose-built, or was an existing facility adapted? If an existing facility was adapted, what measures were taken to ensure that the environment was appropriate to the work?
¼ What legislation / guidelines were consulted when planning for disabled access to the facility?
¼ If dangerous goods and/or hazardous substances are stored onsite, what legislation / codes of practice were consulted in planning for their storage?
¼ How did considerations of ergonomics influence the design and layout of the workplace?
¼ Highlight some improvements made to the workplace after it was re-evaluated?
¼ How does the organisation prioritise maintenance, repairs and/or replacement of buildings, plant, medical devices and other equipment?
Plant, equipment, vehicles, supplies and consumablesPlant,�equipment,�vehicles,�supplies�and�consumables�purchased�by�the�organisation�should�support�the�provision�of�care�and�services,�and�protect�the�health�and�safety�of�consumers�/�patients,�staff�and�others�within�the�organisation.�Effective�planning�and�assessment�of�equipment�may�include�reviewing�the�community’s�needs,�involving�staff�who�use�the�equipment,�and�seeking�opinions�of�those�consumers�/�patients�who�use�the�equipment.�The�process�for�assessment�of�new�plant,�equipment,�supplies�and�vehicles�should�include:
• compliance�with�relevant�legislative�requirements,�codes�of�practice,�Australian�standards�and�guidelines
• intended�use�and�user�and�consumer�/�patient�needs
• cost�benefits
• safety,�including�manual�handling�/�task�issues
• infection�control,�including�waste�management�issues
• energy�efficiency�and�environmental�sustainability
• training�needs
• storage�and�distribution.
Installation�of�plant�and�equipment�should�be�in�accordance�with�the�manufacturers’�specifications,�with�the�plant�/�equipment�appropriately�tested�and�commissioned�and�all�necessary�licences�obtained.�Current�information�and�scientific�data�from�manufacturers�relating�to�their�products’�requirements�should�be�available�for�reference�and�guidance�for�both�the�operation�and�maintenance�of�plant�and�equipment.
Plant�logs�and�maintenance�processes�should�ensure�that�plant�/�equipment�is�maintained�and�serviced�by�people�trained�in�maintenance�of�that�equipment�and�in�accordance�with�manufacturer�specifications�and�relevant�standards,�including�maintenance�on�high-risk�plant�such�as�cooling�towers�and�pressure�vessels.�Documented�processes�for�procurement,�upgrading�and�replacing�equipment�and�supplies�should�be�in�place.�The�organisation�may�address�issues�of�planning,�purchasing�and�provision�through�a�comprehensive�asset�management�system.�A�program�to�address�breakdown�or�any�planned,�deferred�and/or�outstanding�maintenance�requirements�should�be�developed.
The�safe�operation�of�electrically�operated�equipment�used�in�health�care�should�be�monitored�in�regard�to�electrical�shock,�thermal,�radiant�and�mechanical�hazards.�Organisations�should�refer�to�State�/�Territory�legislation,�Australian�standards,�and�any�other�relevant�guidelines.�Specialised�equipment�should�only�be�operated�by�trained�staff�to�minimise�the�likelihood�of�injury�and�to�obtain�the�best�results.
Vehicles,�according�to�their�use�and/or�location,�may�be�considered�as�either�a�workplace�or�as�plant.�It�is�the�responsibility�of�the�organisation�to�maintain�all�owned,�operated�and�leased�vehicles.�
Efficient�management�of�supplies�and�consumables�requires�that�systems�of�ordering,�storage,�distribution,�and�control�of�inventory�be�implemented�by�the�organisation.�Items�designed�for�single�use�should�not�be�reused�unless�the�organisation�has�specific�policies�and�guidelines�for�safe�reuse�incorporating�relevant�statutory�requirements,�codes�of�practice�and�Australian�standards.�There�should�also�be�a�system�to�manage�the�recall�of�any�supply�or�consumable,�as�per�bulletins�from�the�Therapeutic�Goods�Administration.
seCtion 5Standards, criteria, elements and guidelinesstandard 3.2:�The�organisation�maintains�a�safe�environment�for�employees,�consumers�/�patients�and�visitors
432 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 3.2.2
Buildings,�signage,�plant,�medical�devices,�equipment,�supplies,�utilities�and�consumables�are�managed�safely�and�used�efficiently�and�effectively.�(continued)
Prompt points
¼ For what plant / equipment / vehicles are logs kept? Who updates the logs?
¼ How did considerations of efficiency and environmental sustainability influence the purchase of plant / equipment / vehicles?
¼ What plant / equipment / vehicles within the organisation require the operator(s) to be licensed? How is correct licensing of operators, including drivers of vehicles, monitored?
¼ Who carries out maintenance on the organisation’s plant / equipment / vehicles? How often is it carried out? What records are kept?
¼ In the event of the recall of a consumable by the Therapeutic Goods Administration, what is the organisation’s procedure?
Medical devicesA�medical�device�is�“any�instrument,�apparatus�or�appliance,�including�software,�whether�used�alone�or�in�combination,�together�with�any�accessories�necessary�for�correct�operation,�which�makes�physical�or�electrical�contact�with�the�patient,�or�transfers�energy�to�or�from�the�patient,�or�detects�such�energy�transfer�to�or�from�the�patient,�or�is�intended�to�diagnose,�treat�or�monitor�a�patient”.2
The�term�‘medical�device’�applies�to�all�equipment�used�in�treatment,�diagnostic�activities,�monitoring,�and�direct�consumer�/�patient�care.�This�includes,�but�is�not�limited�to,�devices�used�for:
• life�support:�anaesthesia�machines,�ventilators,�heart-lung�machines,�etc.
• monitoring:�bedside�monitors,�telemetry�monitors,�etc.
• treatment:�lasers,�electrosurgery,�diathermy,�etc.
• diagnostics:�pathology�laboratory�analysers,�radiology�equipment,�endoscopes,�etc.
• patient�support:�hospital�beds,�specialty�beds,�etc.
An�organisation�should�have�documented�management�strategies�for�all�medical�devices�used�within�its�facilities�including:
• medical�devices�owned,�leased�or�rented�by�the�organisation
• medical�devices�on�short,�medium�or�long-term�loan�to�the�organisation
• medical�devices�being�trialled�by�the�organisation
• medical�devices�prescribed�by�the�organisation’s�staff�to�consumers�/�patients.�
The�planning�for�and�procurement�of�medical�devices�should�support�the�provision�of�clinical�services�and�quality�care,�reflect�the�organisation’s�commitment�to�the�health,�wellbeing�and�safety�of�consumers�/�patients,�and�meet�the�community’s�expectations.�The�process�for�assessment�of�new�medical�devices�should�include�consideration�of�their�clinical�efficacy�and�effectiveness,�human�factors,�Occupational�Health�&�Safety,�infection�control,�cost�of�ownership�and�clinical�life,�and�should�be�undertaken�in�consultation�with�all�relevant�staff.�
Many�medical�devices�require�specific�training�and�some�require�licensing�of�the�individuals�who�will�operate�the�device.�The�organisation�must�ensure�that�all�those�involved�in�the�operation�of�medical�devices�have�undergone�all�necessary�training,�are�competent,�and�that�where�required,�all�correct�licences�have�been�obtained.
Increasingly,�medical�devices�are�utilising�elements�of�information�and�communications�technology�(I&CT).�A�growing�number�of�medical�devices�are�in�essence�a�desktop�computer,�notebook�or�network�server�running�dedicated�medical�software,�or�a�system�incorporating�a�desktop(s),�notebook(s)�or�server(s).�However,�the�organisation�should�manage�all�such�devices�as�medical�devices,�not�as�I&CT.�
Installation,�calibration,�maintenance�and,�finally,�decommissioning�and�disposal�of�medical�devices�should�be�carried�out�by�registered�and/or�appropriately�qualified,�trained�and�competent�individuals.�Records�should�be�kept�of�all�medical�device�maintenance.
Responsibility�should�also�be�assigned�for�the�cleaning,�sterilisation�and/or�recommissioning�of�each�individual�device,�as�this�is�a�specialised�task�that�does�not�fall�within�the�province�of�the�organisation’s�general�cleaning�staff.3
October 2010 433
Prompt points
¼ What processes exist within the organisation to ensure broad consultation during medical device procurement?
¼ In managing medical devices within the organisation, how does the biomedical engineering department ensure appropriate engagement on I&CT issues?
¼ What processes and approval mechanisms can the organisation demonstrate with respect to the management of medical devices, including record keeping, risk evaluation, scope of routine testing programs, contract management and resource availability?
¼ In the event of a recall of a medical device by the Therapeutic Goods Administration, what is the organisation’s procedure?
Signage and special needsClear�signage�is�an�important�aspect�of�any�healthcare�organisation.�In�an�emergency,�an�individual’s�ability�to�determine�quickly�the�location�of�the�organisation�and/or�how�to�access�the�required�department�can�be�critical,�while�at�any�time�clear�signage�will�ensure�that�the�consumer�/�patient�and�the�visitor�alike�can�find�their�way�around�easily,�and�that�a�visit�to�the�organisation�is�not�attended�by�confusion,�stress�or�unnecessary�loss�of�time.�Installation�of�signage�upon�the�roads�surrounding�the�healthcare�organisation�will�need�to�be�organised�in�consultation�with�local�councils�and�the�appropriate�roads�authority.
The�organisation’s�external�signage�should�provide�the�following�information:
• appropriate�routes�of�access
• hours�of�access
• after-hours�access�(where�applicable)
• telephone�numbers
• details�of�other�healthcare�organisations�in�the�area,�particularly�the�nearest�accident�/�emergency�facility.
External�signage�may�also�relate�to�such�management�issues�as�designated�parking�/�non-parking�zones,�ambulance�bays,�and�the�enforcement�of�a�non-smoking�policy.
Internal�signage�must�provide�clear�directions�to�specific�areas�of�the�organisation,�as�well�as�providing�health�and�safety�information�including�non-smoking�areas,�restricted�mobile�phone�usage�and�the�presence�of�any�hazards.�All�exits�must�be�clearly�marked.
Clear,�effective,�well-positioned�signage�is�an�important�aspect�of�the�efficient�operation�of�any�healthcare�organisation,�and�one�that�should�be�monitored�and�reassessed�according�to�changes�in�the�community�being�serviced�and�the�level�of�satisfaction�expressed�by�consumers�/�patients�and�visitors.�Surveys�may�be�used�to�assess�satisfaction�levels.
Prompt points
¼ Is the organisation’s signage language-based or symbol-based? What factors influenced this choice?
¼ Does the organisation provide signage in languages other than English? How were the other languages chosen?
¼ What special needs signage is found within this organisation?
¼ How often are the organisation’s signage arrangements reassessed? On what basis are changes to the signage made?
UtilitiesUtilities�are�the�basic�services�that�the�organisation�uses�to�function,�including�water,�power,�ventilation,�medical�gases�and�suction�systems,�and�communications�systems.�Supplies�and�consumables�are�generally�commodities�with�a�shorter�life�while�in�use�than�items�that�would�remain�in�inventory�after�distribution�or�assignment�for�use,�such�as�dressings,�syringes,�disposable�gloves,�catheters,�etc.
Policies�governing�the�use�of�utilities�should�cover�emergency�and�disaster�management.�The�organisation�should�also�have�procedures�to�ensure�that�the�use�of�energy�and�water�is�efficient�and�sustainable.�These�should�address�considerations�such�as�purchasing�electrical�equipment�with�a�high�energy�rating,�and�programs�to�conserve�energy�and�water�(switching�off�equipment,�good�plumbing�maintenance,�etc.).�The�organisation’s�energy�and�water�use�should�be�assessed�annually,�and�efforts�made�to�improve�efficiency.
seCtion 5Standards, criteria, elements and guidelinesstandard 3.2:�The�organisation�maintains�a�safe�environment�for�employees,�consumers�/�patients�and�visitors
434 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 3.2.2
Buildings,�signage,�plant,�medical�devices,�equipment,�supplies,�utilities�and�consumables�are�managed�safely�and�used�efficiently�and�effectively.�(continued)
Prompt points
¼ How has the organisation improved the efficiency of its energy and water usage?
Cleaning, maintenance and hazard managementIn�order�to�be�efficient�and�effective,�the�organisation’s�management�of�its�buildings,�signage,�plant,�equipment,�utilities,�supplies�and�consumables�should�be�supported�by�a�well-planned�and�well-resourced�system�of�cleaning,�maintenance�and�hazard�control.
In�order�to�ensure�thorough�cleaning,�there�should�be�a�schedule�that�clearly�describes�all�areas�to�be�cleaned,�as�well�as�the�specific�surfaces�/�objects�to�be�cleaned�(e.g.�floors,�toilets,�desk�tops,�computer�screens).�This�schedule�should�also�specify�which�surfaces�/�objects�are�not�to�be�touched�(e.g.�medical�devices).�Cleaning�is�not�only�crucial�in�its�own�right�but�a�vital�component�of�the�organisation’s�infection�control�and�waste�management�systems.�It�is�the�organisation’s�responsibility�to�ensure�that�cleaning�is�sufficiently�staffed�and�resourced,�and�that�cleaning�products�are�stored�and�used�as�per�manufacturer’s�instructions�and�relevant�OH&S�policies.�The�frequency�of�cleaning�of�specific�areas�should�be�related�to�a�risk�assessment.
Maintenance�is�also�an�essential�aspect�of�the�organisation’s�management�of�its�buildings,�plant,�equipment�and�vehicles.�However,�maintenance�should�not�merely�be�reactive:�the�organisation�should�implement�a�planned�and�coordinated�system�of�preventive�maintenance,�in�order�to�retain�all�assets�in�good�working�order,�to�extend�the�working�life�of�critical�and�expensive�equipment,�and�to�reduce�the�risk�associated�with�poorly�operating�equipment.�All�stages�of�preventive�maintenance,�from�planning�to�completion,�should�be�documented.�Any�instance�of�deferred�maintenance,�that�is,�maintenance�that�should�be�performed,�but�is�not,�for�reasons�ranging�from�budgetary�constraints�to�staffing�limitations,�should�also�be�recorded�and�an�explanation�provided.
Well-implemented�systems�of�cleaning,�preventive�maintenance�and�hazard�reduction�are�fundamental�to�the�organisation’s�efficient�and�effective�management�of�its�buildings,�signage,�plant,�equipment,�utilities,�supplies�and�consumables,�and�the�quality�and�efficacy�of�the�systems�should�be�regularly�evaluated,�and�improvements�made�as�required.
Prompt points
¼ How does the organisation ensure that its cleaning requirements are sufficiently resourced?
¼ How and by whom is the organisation’s program of preventive maintenance planned?
¼ How does the organisation encourage the reporting of near misses within its management of its buildings, signage, plant, equipment, utilities, supplies and consumables?
¼ What improvements have been made to the organisation’s cleaning, maintenance and hazard reduction systems, and why were they made?
Evidence commonly presented
Consider whether the following will help to address criterion 3.2.2
¼ Risk ratings / assessments
¼ Preventive maintenance plan, including deferred maintenance records
¼ Preventive maintenance plan review
¼ Systems for handling recalled goods or devices
¼ Incident reports, including near misses
¼ Evidence of disability and cultural needs identification
¼ Policies on:
– purchase and supply – buildings, signage, plant, equipment,
utilities, supplies and consumables – workplace design
¼ Asset register
¼ Contracts, including biomedical and IT contracts
¼ Results of mandatory plant / equipment testing
October 2010 435
Performance measurementThis�criterion�states�that:�“Buildings,�signage,�plant,�medical�devices,�equipment,�supplies,�utilities�and�consumables�are�managed�safely�and�used�efficiently�and�effectively”.�The�organisation�should�be�able�to�demonstrate�that�it�has�policies�and�procedures�for�the�safe�and�efficient�use�of�its�assets,�that�it�proactively�maintains�them,�and�replaces�them�as�needed;�and�that�it�meets�all�standard�and�jurisdictional�requirements�for�the�procurement,�operation�and�maintenance�of�its�medical�devices.
Some�common�suggested�performance�measures�are�as�follows:
Number�of�incidents�resulting�in�loss�of�critical�services
Total number of incidents
Number�of�injuries�sustained�by�staff�relating�to�the�use�of�equipment�or�medical�devices
Total number of injuries sustained by staff
Number�of�incidents,�including�complaints,�relating�to�building�defects��(trip�hazards,�lighting�problems,�insufficient�or�incorrect�signage,�etc.)
Total number of incidents and complaints
Number�of�scheduled�preventative�maintenance�services�completed�on�time
Total number of scheduled preventative maintenance services
Number�of�vehicle�accidents�/�breakdowns
Total number of vehicles
Number�of�Root�Cause�Analysis�recommendations�implemented
Total number of Root Cause analysis recommendations
Number�of�consumers�/�patients�satisfied�with�the�organisation’s�signage
Total number of consumers / patients surveyed
Number�of�staff�and�consumers�/�patients�who�are�satisfied�with�the�design�/�layout�of�the�organisation
Total number of staff and consumers / patients surveyed
seCtion 5Standards, criteria, elements and guidelinesstandard 3.2:�The�organisation�maintains�a�safe�environment�for�employees,�consumers�/�patients�and�visitors
436 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 3.2.2
Buildings,�signage,�plant,�medical�devices,�equipment,�supplies,�utilities�and�consumables�are�managed�safely�and�used�efficiently�and�effectively.�(continued)
References1.� Australasian�Health�Infrastructure�Alliance.�Australasian
healthfacilityguidelines(AusHFG).�Sydney�NSW;�Centre�for�Health�Assets�Australasia,�UNSW;�2009.
2.� AS/NZS�3551:2004�Technicalmanagementprogramsformedicaldevices.
3.� AS/NZS�4187:2003�Cleaning,disinfectingandsterilizingreusablemedicalandsurgicalinstrumentsandequipment,andmaintenanceofassociatedenvironmentsinhealthcarefacilities.
StandardsAustralian�Building�Codes�Board�(ABCB).BuildingCodeofAustralia.�Canberra�ACT;�ABCB.�Accessed�from�http://www.abcb.gov.au�on�2�June�2010.�� �Volume�One�(Class�2�to�Class�9�Buildings)�
Volume�One�Appendices�(Variations�&�Additions)��Volume�Two�(Class�1�&�Class�10�Buildings).
ISO�7001:2007�Graphicalsymbols–Publicinformationsymbols.
AS�2342:1992�Development,testingandimplementationofinformationandsafetysymbolsandsymbolicsigns.
AS/NZS�2500:2004�Guidetothesafeuseofelectricityinpatientcare.
October 2010 437
seCtion 5Standards, criteria, elements and guidelinesstandard 3.2:�The�organisation�maintains�a�safe�environment�for�employees,�consumers�/�patients�and�visitors
438 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
IntentHealthcare�organisations�are�accountable�for�their�waste�from�the�point�of�its�generation�to�its�final�disposal.�The�intent�of�this�criterion�is�to�ensure�that�organisations�demonstrate�both�a�safe�practice�and�a�responsible�environmental�approach�to�waste�management.
Relationships of 3.2.3 with other criteriaGeneration�of�waste�is�an�unavoidable�consequence�of�the�delivery�of�health�care,�and�one�that�must�be�carefully�managed.�Due�to�the�nature�of�the�waste�produced�within�healthcare�organisations,�all�waste�management�policies�must�be�shaped�with�reference�to�considerations�of�infection�control�(Criterion�1.5.2).�The�risks�associated�with�each�of�the�various�categories�of�waste�generated�must�be�managed�(Criterion�2.1.2),�and�failure�to�do�so�may�result�in�incidents�and�complaints�(Criteria�2.1.3�and�2.1.4).�The�collection�and�disposal�of�waste�may�be�outsourced�to�external�service�providers�(Criterion�3.1.4),�and�this�process�must�be�managed�by�the�organisation.
Criterion LA – Awareness sA – implementationLA plus the following
MA – evaluationSA plus the following
eA – excellenceMA plus the following
oA – LeadershipEA plus the following
Criterion 3.2.3
Waste�and�environmental�management�supports�safe�practice�and�a�safe�and�sustainable�environment.
a)� There�is�an�organisation-wide�waste�and�environmental�management�policy.
b)� Waste�management�streams�are�identified�and�signage�is�displayed.
c)� Staff�are�instructed�in,�and�provided�with,�information�on�their�responsibilities�in�waste�and�environmental�management.
d)� External�service�providers�comply�with�any�requirements�for�the�handling,�transport�and�disposal�of�waste.
e)� There�is�a�policy�to�reduce�carbon�emissions�and�improve�environmental�sustainability.
a)� Waste�is�managed�with�reference�to�any�relevant:
� (i)� Australian�standards
� (ii)� legislation
� (iii)� codes�of�practice
� (iv)� industry�guidelines.
b)� Controls�are�implemented�covering�identification,�handling,�separation�and�segregation�of�clinical,�radioactive�and�hazardous�waste,�and�non-clinical�waste.
c)� There�is�a�system�to�assess,�separate,�handle,�transport�and�dispose�of�all�waste�streams.
d)� Waste�management�systems�are�coordinated�with�external�authorities.
e)� Recycling,�reducing�and�reusing�processes�support�resource�conservation�and�waste�and�environmental�management.�
f)� The�system�to�reduce�carbon�emissions�and�improve�environmental�sustainability�is�implemented.
a)� The�waste�and�environmental�management�system�is�evaluated,�and�improved�as�required.
b)� The�system�to�reduce�carbon�emissions�and�improve�environmental�sustainability�is�monitored�over�time,�and�improvements�are�implemented�as�required.
a)� Performance�indicators�for�the�management�of�waste�are�measured�and�compared�internally�and�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.
and/or
b)� There�are�processes�in�place�to�advocate�/�promote�awareness�of�environmental�sustainability.
a)� The�organisation�demonstrates�it�is�a�leader�in�waste�and�environmental�management,�supporting�safe�practice�and�a�safe�and�sustainable�environment.
October 2010 439
Waste management policiesWithin�a�healthcare�organisation,�waste�management�requires�not�only�the�collection�and�disposal�of�waste,�but�also�control�of�all�associated�risks,�including�that�of�infection.�A�variety�of�different�forms�of�waste�will�be�generated�by�any�organisation�within�the�healthcare�system.�Segregation,�or�the�division�of�waste�into�various�categories�according�to�its�nature,�source�and�hazard�level,�allows�simultaneously�for�the�control�of�risk,�and�for�financial�gain�through�both�the�recovery�of�reusable�and�recyclable�materials�and�the�avoidance�of�unnecessary�handling�/�destruction�of�non-hazardous�material.�At�both�Federal�and�State�/�Territory�levels,�policies�of�sustainability�have�been�embraced�in�Australia;�these�are�shaped�around�strategies�aimed�at�environmental,�social�and�financial�gain�through�greater�responsibility�in�the�use�of�resources.1�The�expression�‘greenhouse�
gas’�in�fact�refers�to�a�combination�of�six�gases,�of�which�carbon�dioxide�(CO
2)�is�a�major�one;�the�term�
‘carbon�emission’�usually�refers�to�the�generation�of�all�gases�that�contribute�to�global�warming�and�climate�change.2�Apart�from�producing�solid�waste,�healthcare�organisations�also�contribute�to�carbon�emissions�through�such�actions�as�the�combustion�of�fossil�fuels,�the�use�of�transportation,�the�consumption�of�electricity�and�paper,�and�the�production�of�refrigerants.�Organisations�should�have�a�policy�in�place�to�reduce�carbon�emissions�based�upon�the�principles�of�avoidance,�modification,�and�reduction�of�usage.3�Electronic,�or�‘e-waste’,�refers�to�the�disposal�of�superseded�computers,�mobile�phones,�televisions,�and�other�electronic�and�battery-operated�devices4,�which�at�the�present�time�are�considered�another�form�of�hazardous�waste.5
Criterion LA – Awareness sA – implementationLA plus the following
MA – evaluationSA plus the following
eA – excellenceMA plus the following
oA – LeadershipEA plus the following
Criterion 3.2.3
Waste�and�environmental�management�supports�safe�practice�and�a�safe�and�sustainable�environment.
a)� There�is�an�organisation-wide�waste�and�environmental�management�policy.
b)� Waste�management�streams�are�identified�and�signage�is�displayed.
c)� Staff�are�instructed�in,�and�provided�with,�information�on�their�responsibilities�in�waste�and�environmental�management.
d)� External�service�providers�comply�with�any�requirements�for�the�handling,�transport�and�disposal�of�waste.
e)� There�is�a�policy�to�reduce�carbon�emissions�and�improve�environmental�sustainability.
a)� Waste�is�managed�with�reference�to�any�relevant:
� (i)� Australian�standards
� (ii)� legislation
� (iii)� codes�of�practice
� (iv)� industry�guidelines.
b)� Controls�are�implemented�covering�identification,�handling,�separation�and�segregation�of�clinical,�radioactive�and�hazardous�waste,�and�non-clinical�waste.
c)� There�is�a�system�to�assess,�separate,�handle,�transport�and�dispose�of�all�waste�streams.
d)� Waste�management�systems�are�coordinated�with�external�authorities.
e)� Recycling,�reducing�and�reusing�processes�support�resource�conservation�and�waste�and�environmental�management.�
f)� The�system�to�reduce�carbon�emissions�and�improve�environmental�sustainability�is�implemented.
a)� The�waste�and�environmental�management�system�is�evaluated,�and�improved�as�required.
b)� The�system�to�reduce�carbon�emissions�and�improve�environmental�sustainability�is�monitored�over�time,�and�improvements�are�implemented�as�required.
a)� Performance�indicators�for�the�management�of�waste�are�measured�and�compared�internally�and�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.
and/or
b)� There�are�processes�in�place�to�advocate�/�promote�awareness�of�environmental�sustainability.
a)� The�organisation�demonstrates�it�is�a�leader�in�waste�and�environmental�management,�supporting�safe�practice�and�a�safe�and�sustainable�environment.
seCtion 5Standards, criteria, elements and guidelinesstandard 3.2:�The�organisation�maintains�a�safe�environment�for�employees,�consumers�/�patients�and�visitors
440 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 3.2.3
Waste�and�environmental�management�supports�safe�practice�and�a�safe�and�sustainable�environment.�(continued)
Healthcare�organisations�generate�both�clinical�and�non-clinical�(general)�waste.�Furthermore,�changes�in�the�approach�to�infection�control�have�resulted�in�a�significant�increase�in�the�volume�of�waste�generated,�due�to�the�shift�towards�single-use,�disposable�clinical�products.�Health�care,�like�other�industries,�must�now�also�deal�with�the�problem�of�e-waste.�Strict�policies�and�procedures�in�waste�management�are�necessary�in�order�to:
• protect�the�health�and�safety�of�the�public
• provide�a�safe�work�environment
• reduce�waste�handling�and�disposal�volumes�/�costs�without�compromising�health�care
• minimise�the�environmental�impact,�including�as�a�result�of�carbon�emissions,�of�waste�generation,�treatment�and�disposal.
Prompt points
¼ What legislation / polices / standards were referenced in the shaping of the organisation’s waste management policy?
¼ How does the organisation act to reduce its environmental impact?
Classification, segregation and minimisation of wasteThe�healthcare�industry�produces�a�wide�variety�of�waste,�some�of�which�poses�a�hazard�to�staff,�consumers�/�patients,�the�public�and�those�employed�to�transport�and�dispose�of�the�waste.�
Hazardous�waste�can�be�generated�in�any�healthcare�setting�and�must�be�appropriately�managed.�Waste�management�streams�should�be�identified�and�indicated�via�suitable�signage.�The�segregation�and�disposal�of�clinical�waste�must�be�managed�with�accordance�with�State�/�Territory�requirements,�and�must�conform�to:
• relevant�statutory�requirements
• codes�of�practice
• Australian�standards
• Occupational�Health�&�Safety�guidelines
• the�requirements�of�the�relevant�environmental�protection�agencies�and�health�departments
• any�requirements�of�local�government.
Wherever�appropriate�collection�/�processing�facilities�are�available,�a�recycling�program�should�be�a�major�aspect�of�the�organisation’s�waste�minimisation�strategy.�At�both�a�Federal�and�State�/�Territory�level,�guidelines�for�sustainability�require�that�organisations�pursue�a�policy�of�reduce,reuse,recycle.6�
However,�in�implementing�such�a�policy,�the�duty�of�care�must�always�take�precedence;�and�the�organisation�should�therefore�shape�its�strategy�around�its�obligations�in�the�management�of�hazardous�waste�and�infection�control,�and�its�guidelines�for�the�safe�use�of�equipment,�which�should�include�a�process�for�reporting�faults.�Furthermore,�the�use�of�reusable�items�should�be�considered�only�where�it�does�not�compromise�consumer�/�patient�safety,�and�is�suitable�for�the�size�and�location�of�the�organisation.
Prompt points
¼ What different forms of waste are produced by the organisation?
¼ What is the organisation doing to minimise its waste production?
¼ What proportion of the waste is recycled rather than discarded to landfill?
October 2010 441
Management, training and educationWithin�the�organisation,�all�staff�will�generate�waste,�and�all�staff�must�take�responsibility�for�the�correct�identification,�segregation�and�disposal�of�waste.�The�organisation�should�not�assume�that�staff�will�be�able�to�correctly�classify�any�given�form�of�waste,�nor�rely�entirely�upon�its�signage,�but�should�provide�instruction�as�to�the�correct�procedures.�The�content�of�this�instruction�should�be�refined�over�time�to�ensure�that�all�necessary�information�is�being�provided.
The�collection,�storage�and�disposal�of�certain�kinds�of�waste,�such�as�radioactive,�cytotoxic�or�pharmaceutical�waste,�may�require�specific�training�and�even�licensing�of�the�individuals�concerned�in�its�handling.�It�is�the�organisation’s�responsibility�to�ensure�that�staff�are�made�aware�of�their�obligations�in�this�respect,�to�provide�access�to�the�appropriate�training�/�licensing,�and�to�supply�all�appropriate�personal�protective�equipment.�The�organisation�must�also�ensure�that�untrained�and/or�unlicensed�individuals�are�not�permitted�to�handle�the�waste�in�question.
All�staff�must�be�made�aware�of�their�responsibilities�with�regard�to�sustainability�and�the�reduction�of�carbon�emissions.�The�organisation�must�work�continually�towards�improving�its�environmental�management,�and�may�wish�to�encourage�staff�to�suggest�and/or�implement�their�own�changes�and�improvements�to�existing�workplace�systems.
As�a�means�of�calculating�an�organisation’s�energy�and�emissions�data,�and�measuring�the�success�of�its�environmental�management�policies,�the�Federal�Government’s�Department�of�Climate�Change�offers�an�Online�System�for�Comprehensive�Activity�Reporting�(OSCAR)�(http://www.climatechange.gov.au/government/initiatives/oscar.aspx).
Prompt points
¼ How does the organisation instruct staff as to their responsibilities in waste management?
¼ How does the organisation ensure that its waste management policies and procedures are being implemented?
¼ Does the organisation generate waste that requires those handling it to be licensed? How is the licensing achieved?
¼ How are staff encouraged to assist in the organisation’s environmental management?
¼ Does the organisation develop and use an annual waste management plan?
External service providers and transport of wasteThe�organisation’s�waste�management�system�will�typically�include�the�use�of�external�service�providers,�or�contractors,�who�will�collect,�transport�and�dispose�of�accumulated�waste�of�all�kinds.�It�is�the�responsibility�of�the�organisation�to�ensure�that�all�waste�is�correctly�segregated,�packaged�and�identified�prior�to�off-site�transportation;�and�also�to�ensure�that�all�those�involved�in�the�management�of�waste�are�correctly�licensed�and�operating�according�to�all�relevant�legislation�and�codes�of�practice.�One�option�available�to�management�is�an�audit.�The�company’s�premises�may�be�audited,�as�may�the�collected�waste,�to�ensure�the�correct�provision�of�services.
The�transportation�of�waste�is�governed�by�legislation,�codes�of�practice�and�guidelines,�which�should�be�consulted�where�applicable,�including�the�Australian�Code�for�the�Transport�of�Dangerous�Goods�by�Road�and�Rail.7�A�list�of�the�relevant�competent�authorities�may�be�found�at�the�website�of�the�Department�of�Infrastructure,�Transport,�Regional�Development�and�Local�Government,�which�“works�with�the�States�and�Territories,�and�the�National�Transport�Commission,�to�promote�best�practice�and�internationally�harmonised�legislation�for�the�land�transport�of�dangerous�goods�in�Australia”.8
Prompt points
¼ Does the organisation use an external service provider for the collection, transport and/or disposal of clinical and related waste? How was the provider chosen?
¼ How does the organisation ensure that the external service provider is compliant with the requirements of the relevant authorities?
seCtion 5Standards, criteria, elements and guidelinesstandard 3.2:�The�organisation�maintains�a�safe�environment�for�employees,�consumers�/�patients�and�visitors
442 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 3.2.3
Waste�and�environmental�management�supports�safe�practice�and�a�safe�and�sustainable�environment.�(continued)
Evidence commonly presented
Consider whether the following will help to address criterion 3.2.3
¼ Policies and procedures on waste and environmental management
¼ Waste identification strategies and evidence of their effectiveness
¼ Waste reduction strategies
¼ Waste minimisation promotion strategies
¼ Results of waste audits
¼ Evidence of staff education
¼ Contracts with external service providers such as waste removal contracts
¼ Waste management performance indicator reports
October 2010 443
Performance measurementThis�criterion�states�that:�“Waste�and�environmental�management�supports�safe�practice�and�a�safe�and�sustainable�environment”.�Various�aims�are�encompassed�within�this�criterion.�The�organisation�should�measure�its�performance�both�in�terms�of�its�duty�of�care,�and�with�respect�to�its�commitment�to�environmental�sustainability.�The�organisation�should�also�be�mindful�that�some�of�the�critical�aspects�of�waste�management,�in�particular�the�correct�segregation�of�waste,�may�only�be�demonstrated�via�official�auditing.
Some�common�suggested�performance�measures�are�as�follows:
Weight�or�volume�of�clinical�waste
Weight or volume of all waste
Weight�or�volume�of�general�waste
Weight or volume of all waste
Weight�or�volume�of�recycling�waste
Weight or volume of all waste
Number�of�bins�/�receptacles�overfilled�at�time�of�audit
Total number of bins / receptacles at time of audit
Number�of�bins�/�receptacles�containing�incorrectly�segregated�waste�at�time�of�audit
Total number of bins / receptacles at time of audit
Reams�of�paper�purchased�during�the�previous�year
Reams of paper purchased during the current year
Organisation’s�greenhouse�gas�emissions�during�the�previous�year
Organisations greenhouse gas emissions during current year
Number�of�staff�satisfied�with�the�organisation’s�waste�and�environmental�conservation�strategies
Total number of staff surveyed
seCtion 5Standards, criteria, elements and guidelinesstandard 3.2:�The�organisation�maintains�a�safe�environment�for�employees,�consumers�/�patients�and�visitors
444 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 3.2.3
Waste�and�environmental�management�supports�safe�practice�and�a�safe�and�sustainable�environment.�(continued)
References1.� Department�of�Environment,�Water,�Heritage�and�the�
Arts.�Nationalwastepolicy:lesswaste,moreresources.National�waste�policy�fact�sheet.�Canberra�ACT;�Australian�Government;�2009.
2.� Queensland�Department�of�Environment�and�Resource�Management.�It’sacarbonjungleoutthere:Asurvivalguideforbusiness.�ClimateSmart�Business.�Brisbane;�Queensland�Government;�2009.
3.� Victorian�Environment�Protection�Authority�(EPA).�Draftcarbonmanagementprinciples–EPAdiscussionpaper.Melbourne;�Victorian�Government;�2007.
4.� Hyder�Consulting.�WasteandrecyclinginAustralia.Canberra�ACT;�Australian�Department�of�Environment,�Water,�Heritage�and�the�Arts;�2008.
5.� Canberra�Environment�and�Sustainability�Resource�Centre.�Electronicwastemanagementandminimisationforlocalgovernments:Aneducationandtrainingprogram.�Canberra�ACT;�Australian�Department�of�Environment,�Water,�Heritage�and�the�Arts;�2009.
6.� Sustainability�Victoria.Recyclingandreusinginyourworkplace.ResourceSmart.�Melbourne;�Victorian�Government;�2008.
7.� National�Transport�Commission�(NTC)�Australia.�AustralianCodefortheTransportofDangerousGoodsbyRoadAndRail(ADGCode).�Vol.�1,�7th�edn.�Melbourne�VIC;�Australian�Government;�2007.
8.� Australian�Department�of�Infrastructure,�Transport,�Regional�Development�and�Local�Government.TransportinAustralia–Dangerousgoods.Canberra�ACT;�Australian�Government.�Accessed�from�http://www.infrastructure.gov.au/transport/australia/dangerous/index.aspx�on�5�May�2010.
Standards and guidelinesProductivity�Commission.Wastemanagement–Inquiryoverview.Melbourne�VIC;�Australian�Government;�2006.
Waste�Policy�Taskforce.�Anationalwastepolicy:Managingwasteto2020.�Canberra�ACT;�Australian�Department�of�the�Environment,�Water,�Heritage�and�the�Arts;�2009.
Australia�and�New�Zealand�Clinical�Waste�Management�Group.�Industrycodeofpracticeforthemanagementofclinicalandrelatedwaste.�5th�edn.�Sydney�NSW;�Waste�Management�Association�of�Australia;�2007.
NSW�Health.�Wastemanagementguidelinesforhealthcarefacilities.PD2005_132.�Sydney;�NSW�Health;�1998.
AS/NZS�3816:1998�Managementofclinicalandrelatedwastes.
AS�4031:1992/Amdt�1-1996�Non-reusablecontainersforthecollectionofsharpmedicalitemsusedinhealthcareareas.
AS/NZS�4261:1994/Amdt�1-1997�Reusablecontainersforthecollectionofsharpitemsusedinhumanandanimalmedicalapplications.
Advisory�Committee�on�the�Transport�of�Dangerous�Goods�Competent�Authorities�Sub-Committee.�GuidancenotesforthetransportofClass6.2(InfectiousSubstances)Dangerousgoods.Canberra�ACT;�Federal�Office�of�Road�Safety;�1997.
Further readingNSW�Dept�of�Environment�and�Climate�Change.�Wasteavoidanceandresourcerecoverystrategy,2007.Sydney;�NSW�Government;�2007.
Department�of�Environment,�Water,�Heritage�and�the�Arts.�Hazardoussubstancesandhazardouswaste.National�Waste�Policy�Fact�Sheet.�Canberra�ACT;�Australian�Government;�2009.
Waste�audits�as�a�management�tool�–�Robyn�Pearson�shows�us�how.�WME(WasteManagementandEnvironment),�2002;�October:�25-28.
Queensland�Department�of�Environment�and�Resource�Management.�Top10workplacetips.Acarboncutting,costsavingsurvivalguideforbusiness.�Brisbane,�QLD;�Queensland�Government;�2009.
October 2010 445
seCtion 5Standards, criteria, elements and guidelinesstandard 3.2:�The�organisation�maintains�a�safe�environment�for�employees,�consumers�/�patients�and�visitors
446 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion LA – Awareness sA – implementationLA plus the following
MA – evaluationSA plus the following
eA – excellenceMA plus the following
oA – LeadershipEA plus the following
Criterion 3.2.4
Emergencyanddisastermanagementsupportssafepracticeandasafeenvironment.
this is a mandatory criterion
a)� There�is�an�organisation-wide�policy�for�emergency�and�disaster�management�and�business�continuity.
b)� Likely�emergencies�are�identified�and�response�and�evacuation�plans�are�prominently�displayed.
c)� Staff�are�educated�and�trained�at�orientation�and�annually�in�response�to�emergencies�and�in�evacuation.
d)� Emergency�practice�/�drill�exercises�including�fire�and�evacuation�are�regularly�conducted.
e)� External�service�providers�comply�with�the�organisation’s�requirements�for�the�prevention�of�emergencies.
f)� There�is�documented�evidence�that�an�authorised�external�provider�undertakes�a�full�fire�report�on�the�premises�at�least�once�within�each�EQuIP�cycle�and�in�accordance�with�jurisdictional�legislation.�
a)� There�is�evidence�that�the�systems�to�manage�emergencies�operate�with�reference�to�any�relevant:
� (i)� Australian�standards
� (ii)� legislation
� (iii)� codes�of�practice
� (iv)� industry�guidelines.
b)� Business�continuity�plans�have�been�developed�to�cover�disasters�/�emergencies.
c)� There�are�systems�for�prevention,�preparedness,�response�and�recovery�in�emergencies,�including�triage�and�deployment�of�medical�teams�where�appropriate.
d)� Internal�and�external�emergency�and�disaster�management�plans�are�developed�and�reviewed�in�consultation�with�relevant�authorities.
e)� Communication�systems�are�in�place�to�manage�any�emergencies�or�disasters.
f)� Relevant�staff�have�access�to�first�aid�equipment�and�supplies�and�are�trained�in�their�use.
g)� There�is�an�appropriately�trained�fire�officer.
h)� There�is�a�documented�plan�to�implement�recommendations�from�the�fire�action�plan.
a)� Emergency�and�disaster�management�systems�are�evaluated,�and�improved�as�required.
b)� Staff�training�and�competence�in�managing�emergency�procedures,�including�evacuation,�is�evaluated�and�improvements�are�made�as�required.
a)� Performance�indicators�for�emergency�preparedness�and�disaster�management�are�measured�and�compared�internally�and�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.
and/or
b)� Innovative�processes�which�prepare�for�any�disasters�are�demonstrated�by�the�organisation.
and/or
c)� Major�incident�management�plans�integrate�with�those�of�other�services�within�the�community.
a)� The�organisation�demonstrates�it�is�a�leader�in�emergency�and�disaster�management.
October 2010 447
Criterion LA – Awareness sA – implementationLA plus the following
MA – evaluationSA plus the following
eA – excellenceMA plus the following
oA – LeadershipEA plus the following
Criterion 3.2.4
Emergencyanddisastermanagementsupportssafepracticeandasafeenvironment.
this is a mandatory criterion
a)� There�is�an�organisation-wide�policy�for�emergency�and�disaster�management�and�business�continuity.
b)� Likely�emergencies�are�identified�and�response�and�evacuation�plans�are�prominently�displayed.
c)� Staff�are�educated�and�trained�at�orientation�and�annually�in�response�to�emergencies�and�in�evacuation.
d)� Emergency�practice�/�drill�exercises�including�fire�and�evacuation�are�regularly�conducted.
e)� External�service�providers�comply�with�the�organisation’s�requirements�for�the�prevention�of�emergencies.
f)� There�is�documented�evidence�that�an�authorised�external�provider�undertakes�a�full�fire�report�on�the�premises�at�least�once�within�each�EQuIP�cycle�and�in�accordance�with�jurisdictional�legislation.�
a)� There�is�evidence�that�the�systems�to�manage�emergencies�operate�with�reference�to�any�relevant:
� (i)� Australian�standards
� (ii)� legislation
� (iii)� codes�of�practice
� (iv)� industry�guidelines.
b)� Business�continuity�plans�have�been�developed�to�cover�disasters�/�emergencies.
c)� There�are�systems�for�prevention,�preparedness,�response�and�recovery�in�emergencies,�including�triage�and�deployment�of�medical�teams�where�appropriate.
d)� Internal�and�external�emergency�and�disaster�management�plans�are�developed�and�reviewed�in�consultation�with�relevant�authorities.
e)� Communication�systems�are�in�place�to�manage�any�emergencies�or�disasters.
f)� Relevant�staff�have�access�to�first�aid�equipment�and�supplies�and�are�trained�in�their�use.
g)� There�is�an�appropriately�trained�fire�officer.
h)� There�is�a�documented�plan�to�implement�recommendations�from�the�fire�action�plan.
a)� Emergency�and�disaster�management�systems�are�evaluated,�and�improved�as�required.
b)� Staff�training�and�competence�in�managing�emergency�procedures,�including�evacuation,�is�evaluated�and�improvements�are�made�as�required.
a)� Performance�indicators�for�emergency�preparedness�and�disaster�management�are�measured�and�compared�internally�and�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.
and/or
b)� Innovative�processes�which�prepare�for�any�disasters�are�demonstrated�by�the�organisation.
and/or
c)� Major�incident�management�plans�integrate�with�those�of�other�services�within�the�community.
a)� The�organisation�demonstrates�it�is�a�leader�in�emergency�and�disaster�management.
seCtion 5Standards, criteria, elements and guidelinesstandard 3.2:�The�organisation�maintains�a�safe�environment�for�employees,�consumers�/�patients�and�visitors
448 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 3.2.4
Emergencyanddisastermanagementsupportssafepracticeandasafeenvironment.�(continued)
IntentThe�intent�of�this�criterion�is�to�ensure�that�healthcare�organisations�have�systems,�policies,�procedures�and�training�programs�in�place�that�identify�and�manage�potential�emergency�situations�that�may�arise�either�internally�or�externally,�in�terms�of�consequence,�exposure,�probability�and�preventative�actions.�Organisations�should�demonstrate�development�and�implementation�of�appropriate�emergency�response�systems�in�consultation�with�external�emergency�response�organisations�and�other�relevant�bodies.
Relationships of 3.2.4 with other criteriaSuccessful�emergency�and�disaster�management�requires�a�multifaceted,�organisation-wide�program�of�policies,�procedures,�education�and�training�in�which�a�range�of�critical�situations,�both�internal�and�external�to�the�organisation�itself,�are�anticipated�and�planned�for.�The�development,�implementation�and�regular�re-evaluation�of�such�a�program�is�a�part�of�the�organisation’s�overall�safety�management�system�(Criterion�3.2.1),�including�the�design�and�safe�management�of�its�buildings,�plant�and�equipment,�and�the�approach�to�signage�(Criterion�3.2.2).�This�criterion�also�falls�within�the�scope�of�the�integrated�risk�management�framework�(Criterion�2.1.2)�and�management�of�security�(Criterion�3.2.5).
Emergency and disaster management systems and plansAn�emergency�or�a�disaster�is�“a�serious�disruption�to�community�life�that�threatens�or�causes�death�or�injury�in�that�community,�and/or�damage�to�property,�which�is�beyond�the�day-to-day�capacity�of�the�prescribed�statutory�authorities,�and�which�requires�special�mobilisation�and�organisation�of�resources�other�than�those�normally�available�to�those�authorities”.1�The�difference�between�an�emergency�and�a�disaster�is�usually�considered�to�be�one�of�scale;�a�disaster�is�an�emergency�that�overwhelms�the�immediate�capabilities�of�the�authorities�and�services�that�must�respond�to�it.�The�seriousness�of�the�event�must�be�gauged�relative�to�where�it�occurs�and�the�capacity�of�the�organisation(s)�that�must�respond�to�it;�what�might�be�an�emergency�to�a�large�city�hospital�could�be�considered�a�disaster�by�a�small�rural�hospital.�
An�external�emergency�or�disaster�may�necessitate�preparation�for�the�reception�of�a�significant�number�of�victims�and/or�the�allocation�and�transport�of�personnel�and�resources�to�an�external�site.2�An�internal�emergency�or�disaster�can�be�caused�by�factors�that�may�be�internal�or�external�to�the�organisation,�may�adversely�affect�consumers�/�patients,�visitors�and�staff�and�require�an�immediate�response.2
Disaster�and�emergency�management�within�the�health�system�is�overseen�at�a�Federal�level,�although�the�immediate�response�is�primarily�the�responsibility�of�State�and�Territory�governments,�with�the�Commonwealth�lending�assistance.�The�Emergency�Management�Australia�Division�of�the�Attorney-General’s�Department3�is�responsible�for�crisis�coordination�and�management�undertaken�when�requests�for�assistance�are�received�from�the�States�and�Territories,�and�encourages�an�integrated�‘all�hazards,�all�agencies’�strategy�for�disaster�management.�This�comprehensive�approach�was�identified�as�essential�in�the�Council�of�Australian�Governments’�NaturalDisastersinAustralia:Reformingmitigation,reliefandrecoveryarrangementsreport4,�and�is�now�reflected�in�the�State�/�Territory�legislation�governing�emergency�and�disaster�response,�which�should�guide�organisations�in�their�own�emergency�planning.�
Evacuation�plans�should�be�developed�for�each�facility�within�the�organisation�and�prominently�displayed,�ideally�as�a�diagram(s)�showing�exit�paths.�Staff�must�be�made�aware�of�the�significance�of�the�various�alarms�used�by�their�organisation,�and�trained�in�the�correct�reactions�and�their�assembly�points.�Evacuation�drills�should�be�planned�and�carried�out�so�that�all�staff,�from�all�facilities�and�through�all�shifts,�are�familiar�with�the�proper�course�of�action.�
Emergency�planning�should�include�a�provision�for�regular�updating�and�posting�of�consumer�/�patient�lists,�senior�hospital�staff�and�staff�on�duty,�to�facilitate�a�rapid�response.
Fire�safety�is�a�key�aspect�of�the�organisation’s�emergency�and�disaster�planning,�and�must�be�managed�so�that�consumers�/�patients,�staff�and�others�are�not�placed�at�undue�risk.�Organisations�should�develop�an�appropriate�fire�management�plan�and�specific�policies�and�procedures�that�consider�all�people�and�all�areas�of�the�organisation.�Fire�plans�should�cover:
• identification�of�fire�and�explosion�risks
• fire�safety�and�preventative�strategies
• fire�and�explosion�emergency�procedures�for�preparedness,�response�and�recovery
October 2010 449
• raising�the�alarm
• effective�arrangements�for�a�fire�response�team
• an�emergency�communication�system,�including�methods�for�activating�external�services�such�as�fire-fighting�authorities,�ambulance,�etc.
• assignment�of�personnel�to�specific�tasks�and�responsibilities
• information�readily�available�for�staff�throughout�the�organisation
• emergency�services
• fire-fighting�response
• evacuation�from�all�parts�of�all�buildings
• staff�training�/�education,�and�regular�fire�and�evacuation�drills.
Preparedness�is�critical�to�responding�to�an�emergency�in�an�appropriate�and�timely�manner.�Emergency�and�disaster�management�systems�must�be�regularly�reviewed�and�updated�in�light�of�current�best-practice�evidence,�as�well�as�internal�factors�such�as�alterations�to�buildings�and�changes�in�staffing�or�services�provided.�
Should�the�organisation�experience�or�be�involved�in�an�emergency,�inevitably�there�will�be�lessons�to�be�learned�about�its�systems�and�procedures.�Every�aspect�of�the�review�that�follows�such�an�incident�should�be�thoroughly�documented,�to�demonstrate�the�resultant�changes�made�to�any�or�all�aspects�of�the�pre-existing�plan,�including�evacuation�plans,�staff�training�and�communication�systems.
Prompt points
¼ How is the ‘all hazards, all agencies’ approach to emergency and disaster management reflected in the organisation’s systems? Are any specific disasters or emergencies highlighted in its planning? Why?
¼ Under what legislation, codes of practice and/or Australian standards were the plan(s) developed? What civil authorities were consulted?
Developing plans in consultation with relevant authoritiesPlanning�should�be�carried�out�in�consultation�with�relevant�regional�and�local�authorities,�and�include�testing�of�major�emergency�plans.�Relevant�authorities�may�vary�between�jurisdictions�but�would�include�the�local�council,�the�police,�ambulance,�and�fire�and�emergency�services.�Where�appropriate,�community�partners�should�also�be�consulted;�communities�that�are�actively�engaged�in�the�process�of�emergency�planning�and�management�show�greater�resilience�and�better�recovery�in�the�event�of�an�actual�emergency.5–7
The�following�points�may�be�useful�in�developing�a�coordinated�plan�in�response�to�potential�emergencies:
• the�use�of�colour-coding�for�emergencies�in�line�with�acceptable�international�/�national�guidelines�or�standards
• identification�of�key�responsibilities�and�accountabilities
• specification�of�division�of�duties�in�an�emergency
• development�of�critical�operating�procedures
• development�of�a�communication�infrastructure
• development�of�a�crisis�response�infrastructure
• ensuring�the�availability�of�appropriate�drugs,�supplies�and�equipment�for�various�medical�emergencies�to�assist�a�rapid�and�effective�response
• planning�for�deployment�of�medical�teams,�where�appropriate
• development�of�an�evacuation�plan�and�procedures,�including�drills�and�debriefing�processes
• regular�training�and�exercises�for�a�range�of�potential�threats.
Specific�circumstances�may�warrant�the�development�of�plans�for�chemical,�biological�and/or�radiological�events.
seCtion 5Standards, criteria, elements and guidelinesstandard 3.2:�The�organisation�maintains�a�safe�environment�for�employees,�consumers�/�patients�and�visitors
450 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 3.2.4
Emergencyanddisastermanagementsupportssafepracticeandasafeenvironment.�(continued)
Prompt points
¼ If the organisation becomes aware of a disaster, who manages the allocation of duties? What policies / procedures allow the coordinator to reallocate staff to an alternative role? How would this be tracked?
¼ Has the organisation planned for the dispatch of a medical team? If so, what preparations have been made for the dispatch?
¼ Does the organisation have an assigned role in regional plans for emergencies? If it participates, what role does the organisation play in regional emergency / disaster planning?
Business continuityBusiness�continuity�is�defined�as�management�and�planning�for�the�continued�availability�of�essential�services�during�and�after�an�emergency,�including�all�the�functions�and�resources�associated�with�the�provision�of�these�services.8�Business�continuity�planning�should�focus�upon�the�analysis�of�risk,�and�then�address�those�threats�most�likely�to�interrupt�services.�Good�risk�management�will�increase�the�organisation’s�resilience,�and�minimise�potential�downtime.9
The�response�of�an�organisation�to�a�disaster�/�emergency�will�depend�upon�the�type�of�organisation,�the�severity�of�the�incident�and�the�number�of�staff�affected.�When�planning�for�continuity�of�business�during�a�state�of�emergency,�an�organisation�with�inpatients�should�consider�developing�separate�scenarios�for:
1.� continuing�business�as�usual,�while�managing�any�interruptions�to�staffing,�consumer�/�patient�flow�and/or�supplies
2.� ceasing�elective�admissions,�with�ongoing�management�of�admitted�consumers�/�patients�
3.� ceasing�elective�admissions,�and�transferring�admitted�consumers�/�patients�to�another�facility.
Prompt points
¼ In the event of drastic understaffing, due to natural disaster or epidemic, how does the organisation plan to ensure continuity of care?
¼ In the event of an emergency that impacts directly upon the organisation, how does its business continuity plan ensure ongoing access to medical gases?
¼ What steps has the organisation taken towards self-sufficiency in the event of an emergency?
¼ If a natural disaster or an epidemic left the organisation drastically understaffed, how would it assess whether it could maintain services for consumers / patients already admitted?
Policies, procedures, systems and processesIn�public�hospitals,�emergency�and�disaster�management�policies�may�be�developed�on�a�State�/�Territory-wide�or�regional�basis�and�will�integrate�with�centralised�responses�coordinated�through�groups�such�as�the�Emergency�Management�Australia�Division�of�the�Attorney-General’s�Department.3
In�response,�organisations�will�need�to�consider�how�those�policy�decisions�will�be�applied�and�actioned,�down�to�a�facility,�building�or�department�level.�It�is�of�primary�importance�that�procedures�are�updated�regularly�and�in�response�to�impacting�factors,�such�as:
• changes�to�the�overriding�policy
• personnel�changes,�particularly�first�aid�officers�and�fire�wardens
• departmental�relocations�or�reconfigurations�of�patient�care�areas
• access�to�the�proposed�evacuation�route�or�assembly�area.
October 2010 451
Organisations�in�areas�at�risk�of�bushfires�or�whose�community�includes�such�areas�should�consider�providing�guidance�to�staff�(policies�and�procedures)�on�appropriate�precautions�for�days�of�extreme�fire�risk.�For�instance,�on�these�days,�the�emergency�coordinating�staff�at�the�organisation�might�be�provided�with�a�copy�of�the�community�worker’s�schedule�and�kept�informed�of�their�progress�as�they�move�around�the�district�during�the�day,�so�they�can�be�contacted�and/or�traced�in�case�fire�risk�circumstances�change.
Prompt points
¼ What jurisdictional legislation, codes of practice and standards does the organisation’s emergency policies and procedures refer to?
Communication systemsState�/�Territory�plans�include�information�about�communication�and�coordination�of�action�in�the�event�of�a�disaster.�At�the�local�level,�the�organisation�will�decide�upon�the�most�suitable�emergency�communication�system�for�its�size�and�specific�needs;�it�should�ensure�there�are�effective�methods�for�activating�external�services�such�as�fire-fighting�authorities.�
An�organisational�communication�system�usually�comprises�an�Emergency�Warning�Intercommunications�System�(EWIS),�a�Fire�Indicator�Panel�(FIP)�and�a�Warden�Intercom�Phone�(WIP),�supplemented�by�appropriate�individual�alarms�and�mobile�phones.�However,�when�integrating�mobile�phones�into�the�emergency�system,�organisations�should�exercise�caution;�if�the�power�supply�were�disrupted,�it�might�not�be�possible�to�recharge�phones�when�needed.�Consideration�should�be�given�to�satellite�phones�and/or�battery�rechargers�where�appropriate.�Responsibility�for�portable�devices�employed�within�an�emergency�communication�system�and�the�conditions�of�their�use�should�be�clearly�defined�within�the�organisation’s�communications�plan.
Prompt points
¼ What are the components of the organisation’s emergency communication system?
¼ How would key communications be affected if the power supply were disrupted?
Fire report and fire action planWithin�the�scope�of�this�criterion,�the�expression�‘full�fire�report’�is�used�to�describe�an�inspection�that�includes�a�review�of�fire�safety�risks�associated�with�a�building.�The�terms�used�to�describe�building�fire�safety�certificates�and�reports�vary�between�jurisdictions.
A�‘full�fire�report’�is�required�at�least�once�within�the�EQuIP5�cycle,�or�according�to�notified�jurisdictional�variations;�for�example,�the�maximum�accepted�time�since�the�last�review�for�Victorian�healthcare�facilities�is�five�years,�though�in�other�States�/�Territories�it�is�four�years.�The�assessor�who�prepares�the�‘full�fire�report’�should�use�the�Building�Code�of�Australia�(BCA)�as�a�guide�for�their�review�of�fire�safety�risk�and�should�report�their�findings�in�relation�to�the�building’s�structure,�its�safety�installations�/�measures,�their�performance�and�maintenance.�
The�person�preparing�the�‘full�fire�report’�should:
• have�experience�and/or�a�qualification�that�includes�building�fire�safety�risk�mitigation
• be�familiar�with�the�BCA�
• be�external�to�the�organisation.�
In�some�jurisdictions,�assessors�may�be�aligned�to�the�jurisdictional�fire�authority.�A�listing�of�consultants�and�organisations�working�in�different�areas�of�fire�risk�protection�is�maintained�by�the�Fire�Protection�Association�of�Australia,�http://www.fpaa.com.au/providers/.�
Note:�the�external�fire�inspection�report�demonstrating�BCA�compliance�and�any�subsequent�action�plan�must�be�forwarded�to�the�ACHS�six�weeks�prior�to�the�onsite�survey.�Experience�indicates�that�it�may�take�several�months�for�organisations�to�obtain�all�the�necessary�documentation.�For�this�reason,�it�is�strongly�recommended�that�organisations�initiate�the�fire�inspection�cycle�12�months�prior�to�the�onsite�survey.
Prompt points
¼ When was the organisation’s last cycle of inspection and maintenance on essential safety measures undertaken?
¼ What actions were taken in response to the last full fire report? What actions are proposed in the future?
seCtion 5Standards, criteria, elements and guidelinesstandard 3.2:�The�organisation�maintains�a�safe�environment�for�employees,�consumers�/�patients�and�visitors
452 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 3.2.4
Emergencyanddisastermanagementsupportssafepracticeandasafeenvironment.�(continued)
External service providers in precautions and preventionIn�planning�for�emergencies,�organisations�must�ensure�that�external�service�providers�are�aware�of�their�responsibilities�and�act�in�compliance�with�the�organisation’s�policies�and�procedures.
External�service�providers,�such�as�contractors�and�agency�nurses,�should�undergo�a�site�orientation�to�ensure�they�are�aware�of�the�organisational�requirements.�Contract�staff�members�working�in�consumer�/�patient�care�areas�must�be�briefed�on�the�emergency�communication�system�and�evacuation�procedures�from�the�location�in�which�they�are�working.�
Night�shifts,�school�holiday�periods�and�during�the�‘flu�season�are�times�when�numbers�of�consumer�/�patient�care�staff�who�have�completed�full�fire�training�may�be�low.�The�organisation�must�ensure�that�at�all�times,�staff�on�duty�are�familiar�with�the�location�and�correct�operation�of�the�fire�walls�and�doors,�and�contingency�plans�for�protecting�consumers�/�patients�if�an�emergency�arises.
Prompt points
¼ What systems / processes are used to ensure that tradesmen do not inadvertently cause or contribute to an emergency situation?
¼ How does the organisation ensure that any external suppliers can be traced outside the building if an evacuation has been called?
¼ Regardless of whether they are permanent staff or contractors, what guidance is provided to operating theatre staff on the appropriate response to an alarm during surgery?
Fire officersFire�safety�officers,�or�fire�wardens,�as�appropriate�to�the�size�and�type�of�the�organisation,�should�be�appointed�from�amongst�the�staff.�In�a�small�organisation�a�single�warden�may�be�sufficient,�while�larger�organisations�/�facilities�will�require�the�involvement�of�more�individuals�with�differing�levels�of�responsibility�(for�example,�Floor�Warden,�Deputy�Chief�Fire�Warden,�Chief�Fire�Warden).�
Various�companies�provide�accredited�training�for�those�individuals�willing�to�accept�the�position�of�fire�warden,�and�the�organisation�should�provide�the�funds�and�the�time�for�such�training�to�be�completed.�The�identity�and�internal�contact�details�of�all�fire�wardens�should�be�clearly�posted�within�all�areas�of�the�organisation.
Prompt points
¼ How many fire wardens / safety officers does the organisation have? Where are the wardens’ details posted?
First aidHealthcare�organisations�must�meet�jurisdictional�requirements�in�terms�of�numbers�of�trained�first�aid�officers�and�access�to�appropriate�first�aid�kits.�Kits�should�reflect�the�type�and�level�of�risk�in�that�workplace�and�should�be�regularly�checked�to�ensure�items�are�replenished�and�within�their�expiry�dates.
First�aid�supplies�and�trained�personnel�should�be�available�to�all�facilities�in�the�organisation,�including�non-clinical�areas.�Availability�and�positioning�of�the�kits�is�of�particular�importance�in�areas�distant�from�consumer�/�patient�care�areas�and�where�there�is�a�risk�of�physical�injury,�such�as�kitchens,�sterilising�departments,�maintenance�workshops,�gardening�sheds�and�laundries.
Prompt points
¼ Where are first aid kits situated within the organisation?
¼ Who is responsible for checking them?
October 2010 453
Staff training in case of an emergencyThe�organisation�must�not�only�plan�for�emergencies�and�disasters,�but�ensure�that�its�staff,�and�any�other�individuals�working�on�the�premises�while�employed�by�a�different�organisation,�are�educated�in�all�aspects�of�those�plans,�and�trained�in�putting�them�into�effect.�Emergency�procedures�as�reflected�in�the�organisation’s�fire�safety�plan�should�be�presented�to�all�staff�at�orientation,�and�at�least�annually�in�education�sessions.�The�training�should�reiterate�the�components�of�the�various�plans�and�the�stages�of�response.�Education�of�all�staff,�regardless�of�designation,�location�or�shift,�in�the�correct�responses�to�an�emergency�situation�is�a�vital�component�of�the�organisation’s�preparedness,�with�theoretical�exercises�supported�by�regular�practical�training�and�drills.�Compliance�is�crucial,�and�comprehensive�records�should�be�kept�of�staff�completion�of�both�the�theoretical�and�practical�aspects�of�evacuation�and�emergency�response�training,�including�first�aid�certification.
Prompt points
¼ What emergency rehearsals does the organisation use to ensure preparedness? What staff take part in these rehearsals? How does the organisation ensure that night shift and contract staff are adequately trained in emergency and evacuation procedures?
¼ How does the organisation ensure that all staff are familiar with the components of its fire safety plan, including the communications system and the position and correct use of fire walls / doors?
¼ Did all of the organisation’s staff complete fire drill and fire-fighting training within the last calendar year? How is non-compliance followed up and what action is taken? What actions ensure that casual and visiting staff are familiar with the emergency response and their responsibilities within the area that they are working?
Evidence commonly presented
Consider whether the following will help to address criterion 3.2.4
¼ Disaster management plan
¼ Policies, including information on both internal and external emergencies
¼ Appointment of personnel in preparation for an emergency, for example, fire wardens
¼ Staff education, including:
– fire training – CPR training
¼ Evidence of full fire inspection
¼ Annual essential services reports
seCtion 5Standards, criteria, elements and guidelinesstandard 3.2:�The�organisation�maintains�a�safe�environment�for�employees,�consumers�/�patients�and�visitors
454 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 3.2.4
Emergencyanddisastermanagementsupportssafepracticeandasafeenvironment.�(continued)
Performance managementThis�criterion�states�that:�“Emergency�and�disaster�management�supports�safe�practice�and�a�safe�environment”.�The�organisation�should�be�able�to�demonstrate�its�preparedness�in�terms�of�policies�and�procedures,�staff�education�and�training,�business�continuity�planning�and�other�contingency�arrangements,�that�will�allow�it�to�continue�to�meet�its�duty�of�care�and�maintain�a�safe�environment�even�in�the�event�of�an�emergency.�
Some�common�suggested�performance�measures�are�as�follows:
Average response time to emergency calls
Comment:considerdefiningbyemergencycodesuchasRED,BLACK,BLUEcodes
Number�of�staff�who�have�attended�fire�training,�including�an�evacuation�drill
Total number of staff
Number�of�staff�who�have�demonstrated�their�understanding�of�emergency�procedures
Total number of staff
Number�of�false�fire�alarms�during�designated�period
Total number of fire alarms during designated period
Comment:organisationtodefinetimeframe
Number�of�separate�facilities�/�areas�within�the�organisation�for�which�one�or�more�fire�drills�have�been�conducted
Total number of separate facilities / areas within the organisation
Number�of�designated�fire�wardens�who�have�completed�specialised�fire�training
Total number of designated fire wardens
Number�of�emergency�/�disaster�plans�developed�in�consultation�with�relevant�external�authorities
Total number of emergency / disaster plans
Number�of�first�aid�kits�audited�within�appropriate�timeframe
Total number of first aid kits
October 2010 455
References1.� Emergency�Management�Australia.TheAustralian
emergencymanagementglossary.�Canberra�ACT;�Australian�Government;�1998.
2.� AS�4083:1997�Planningforemergencies–healthcarefacilities.
3.� Attorney-General’s�Department.�EmergencymanagementAustralia.Canberra�ACT;�Australian�Government.�Accessed�from�http://www.ag.gov.au/www/agd/agd.nsf/Page/OrganisationalStructure_EmergencyManagementAustralia�on�7�July�2010.
4.� Dept�of�Transport�and�Regional�Services.�NaturalDisastersinAustralia:Reformingmitigation,reliefandrecoveryarrangements.�A�report�to�the�Council�of�Australian�Governments�by�a�high�level�officials’�group.�Canberra�ACT;�Council�of�Australian�Governments�(COAG);�2004.
5.� Paton�D�and�Johnston�D.�Disasters�and�communities:�vulnerability,�resilience�and�preparedness.�DisasterPrevandMgmt�2001;�10�(4):�270-277.
6.� Government�of�Western�Australia.�Emergencymanagementstrategicframework2006–2011.�Perth�WA;�State�Emergency�Management�Committee;�2006.
7.� Bushfire�Cooperative�Research�Centre�(CRC).�Resilienceattheurbaninterface:astudyofNewSouthWalesfirebrigadescommunityfireunits.�Vol.�21.�Melbourne�VIC;�Bushfire�CRC;�2007.
8.� Attorney-General’s�Department.�EmergencymanagementinAustralia:Businesscontinuity.Canberra�ACT;�Australian�Government.�Accessed�from�http://www.ema.gov.au/www/emaweb/emaweb.nsf/Page/Emergency_ManagementPreparing_for_EmergenciesBusiness_Continuitiy�on�7�July�2010.
9.� Itzwerth�RL,�Macintyre�CR,�Shah�S�and�Plant�AJ.�Pandemic�influenza�and�critical�infrastructure�dependencies:�possible�impact�on�hospitals.MedJAust2006;�185(10):�S70-S72.
Standards and guidelinesAS�3745�(incorporating�Amdt�Nos�1�and�2):2002�Emergencycontrolorganizationandproceduresforbuildings,structuresandworkplaces.�Third�edn.
AS�1670.4:2004Firedetection,warning,controlandintercomsystems–Systemdesign,installationandcommissioning–Soundsystemsandintercomsystemsforemergencypurposes.
Standards�Australia�HB221:2004�Handbook:�Businesscontinuitymanagement.Second�edn.
Further readingNSW�State�Emergency�Management�Committee.�On-siteemergencyplanning.�Aguidetohelporganisationsdevelopon-siteemergencyplansinaheightenedsecurityenvironment.�Sydney;�NSW�Office�of�Emergency�Services;�2004.
Aged�and�Community�Services�WA.�Pandemicinfluenza.Businesscontinuityplan.AguideforagedcareprovidersPerth�WA;�Aged�and�Community�Services;�2006.
Emergency�Management�Australia.Hazards,disastersandyourcommunity.�7th�edn.�Canberra�ACT;�Australian�Government;�2006.
Richardson�DB�and�Kumar�S.�Emergency�response�to�the�Canberra�bushfires.�MedJAust2004;�181(1):�40-42.
Bartley�BH,�Stella�JB�and�Walsh�LD.�What�a�disaster?!�Assessing�utility�of�simulated�disaster�exercise�and�educational�process�for�improving�hospital�preparedness.�PrehospitalDisasterMed2006;�21(4):�249-255.
Rosenfeld�JV,�Fitzgerald�M,�Kossman�T�etal.�Is�the�Australian�hospital�system�adequately�prepared�for�terrorism?�MedJAust2005;�183(11/12):�567-570.
seCtion 5Standards, criteria, elements and guidelinesstandard 3.2:�The�organisation�maintains�a�safe�environment�for�employees,�consumers�/�patients�and�visitors
456 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion LA – Awareness sA – implementationLA plus the following
MA – evaluationSA plus the following
eA – excellenceMA plus the following
oA – LeadershipEA plus the following
Criterion 3.2.5
Security�management�supports�safe�practice�and�a�safe�environment.
a)� There�is�an�organisation-wide�security�policy.
b)� Major�security�risks�are�identified.
c)� Staff�are�educated�and�provided�with�information�in�relation�to�security�risks�and�responsibilities.
d)� External�service�providers�are�supplied�with�relevant�information�and�comply�with�the�organisation’s�security�controls.
a)� There�is�an�organisation-wide�system�to�assess�security�risks,�determine�priorities�and�eliminate�risks�or�implement�controls.
b)� The�system�to�manage�security�risks�and�violence�and�aggression�prevention�operates�with�reference�to�any�relevant:
� (i)� Australian�standards
� (ii)� legislation�
� (iii)� codes�of�practice
� (iv)� industry�guidelines.
c)� Service�planning�includes�strategies�for�security�management.
d)� Staff�are�consulted�in�decision�making�that�affects�organisational�and�personal�risks.
e)� There�is�an�organisation-wide�violence�and�aggression�prevention�program.
f)� Security�management�plans�are�coordinated�with�relevant�external�authorities.
a)� Performance�indicators�are�used�to�evaluate�the�security�management�system,�and�improvements�are�made�as�required.
b)� The�violence�and�aggression�prevention�program�is�evaluated,�and�improved�as�required.
a)� Performance�indicators�for�security�and�violence,�and�aggression�prevention�management�are�measured�and�compared�internally�and�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.
and/or
b)� The�organisation�demonstrates�that�security,�and�violence�and�aggression�prevention�systems�ensure�that�security�breaches�and�incidents�are�minimised.
a)� The�organisation�demonstrates�it�is�a�leader�in�security�management.
IntentThe�intent�of�this�criterion�is�to�ensure�that�the�organisation�manages�all�aspects�of�security�so�as�to�meet�its�commitment�to�support�best�practice�and�to�maintain�a�safe�environment�for�employees,�consumers�/�patients�and�visitors.
Relationships of 3.2.5 with other criteriaMaintenance�of�a�safe�environment�by�the�organisation�compliments�its�implementation�of�employee�support�systems�(Criterion�2.2.5).�It�is�also�a�part�of�the�organisation’s�management�of�its�buildings,�plant�and�equipment�(Criterion�3.2.2).�Some�aspects�of�security�management�will�require�the�utilisation�of�information�and�communication�technology�(Criterion�2.3.4).�Security�management,�particularly�the�management�of�physical�security,�is�an�important�aspect�of�the�
organisation’s�integrated�risk�management�framework�(Criterion�2.1.2).�Failure�to�manage�security�so�as�to�maintain�a�safe�environment�may�result�in�incidents�and�complaints�(Criteria�2.1.3�and�2.1.4).�
Procedural securitySecurity�can�be�divided�into�four�broad�areas.�Procedural�security�concerns�the�policies�and�procedures�put�in�place�by�the�organisation�to�provide�an�environment�that�enhances�the�safety�of�employees,�consumers�/�patients�and�visitors.�Physical�security�refers�to�the�steps�taken�to�prevent�and/or�minimise�the�incidence�of�verbal�and�physical�acts�of�aggression�and�violence�within�the�workplace,�either�by�or�towards�employees,�consumers�/�patients�and�visitors.�Personal�security,�in�a�healthcare�setting,�refers�to�the�right�of�consumers�/�patients�and�visitors�to�be�confident�of�
October 2010 457
Criterion LA – Awareness sA – implementationLA plus the following
MA – evaluationSA plus the following
eA – excellenceMA plus the following
oA – LeadershipEA plus the following
Criterion 3.2.5
Security�management�supports�safe�practice�and�a�safe�environment.
a)� There�is�an�organisation-wide�security�policy.
b)� Major�security�risks�are�identified.
c)� Staff�are�educated�and�provided�with�information�in�relation�to�security�risks�and�responsibilities.
d)� External�service�providers�are�supplied�with�relevant�information�and�comply�with�the�organisation’s�security�controls.
a)� There�is�an�organisation-wide�system�to�assess�security�risks,�determine�priorities�and�eliminate�risks�or�implement�controls.
b)� The�system�to�manage�security�risks�and�violence�and�aggression�prevention�operates�with�reference�to�any�relevant:
� (i)� Australian�standards
� (ii)� legislation�
� (iii)� codes�of�practice
� (iv)� industry�guidelines.
c)� Service�planning�includes�strategies�for�security�management.
d)� Staff�are�consulted�in�decision�making�that�affects�organisational�and�personal�risks.
e)� There�is�an�organisation-wide�violence�and�aggression�prevention�program.
f)� Security�management�plans�are�coordinated�with�relevant�external�authorities.
a)� Performance�indicators�are�used�to�evaluate�the�security�management�system,�and�improvements�are�made�as�required.
b)� The�violence�and�aggression�prevention�program�is�evaluated,�and�improved�as�required.
a)� Performance�indicators�for�security�and�violence,�and�aggression�prevention�management�are�measured�and�compared�internally�and�with�external�systems,�and�improvements�are�made�to�ensure�better�practice.
and/or
b)� The�organisation�demonstrates�that�security,�and�violence�and�aggression�prevention�systems�ensure�that�security�breaches�and�incidents�are�minimised.
a)� The�organisation�demonstrates�it�is�a�leader�in�security�management.
the�credentials�and�background�of�the�individuals�with�whom�they�interact�in�that�setting.�Logical�security�is�that�aspect�of�security�management�that�utilises�communications,�information�technology�(IT)�and�information�management�(IM).
Security�management�is�a�vital�and�wide-ranging�issue�in�any�healthcare�setting,�encompassing�not�only�the�physical�and�emotional�safety�of�individuals,�but�the�protection�of�buildings,�plant,�equipment�and�other�assets.�Policy�should�consider�the�following�issues:
• security�and�safety�of�staff,�consumers�/�patients�and�visitors
• security�of�information
• security�of�staff�off-site,�for�example�on�home�visits
• security�in�geographically�remote�areas�or�in�isolation
• security�of�personal�belongings
• security�of�assets
• security�of�pharmaceuticals
• security�of�payroll
• defined�responsibilities�for�management�and�staff,�and�delegated�responsibility�for�the�security�system
• security�assessment,�as�required�by�jurisdictional�guidelines,�undertaken�by�an�accredited�consultant.
Organisations�are�required�to�identify�their�major�security�risks.�Consideration�needs�to�be�given�to�the�environment,�work�practices,�work�arrangements�and�equipment�used.
seCtion 5Standards, criteria, elements and guidelinesstandard 3.2:�The�organisation�maintains�a�safe�environment�for�employees,�consumers�/�patients�and�visitors
458 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 3.2.5
Security�management�supports�safe�practice�and�a�safe�environment.�(continued)
When�identifying�where�the�organisation�may�be�at�risk,�the�nature�and�source�of�the�harm�that�could�occur�needs�to�be�identified.�Organisations�should�consider:
• What�could�happen�(or�what�could�go�wrong)?
• How�would�it�happen?
• What�harm�would�it�cause?
• Who�or�what�would�be�harmed?
Information�to�assist�organisations�on�identification,�risk�rating,�elimination�or�control�of�risks�and�monitoring�is�available�in�the�ACHS�RiskManagementHandbook1,�available�from�the�ACHS�website:�http://www.achs.org.au�and�AS�4485:1997�Securityforhealthcarefacilities.2
Strategies�for�security�management�should�be�included�in�service�planning.�This�will�involve�allowing�for�the�resources�needed�to�ensure�the�organisation’s�security,�such�as�provision�of�personal�/�duress�alarms,�installation�of�panic�buttons�and�their�connection�to�police�or�a�security�company,�appropriate�lighting,�video�surveillance�and/or�the�provision�of�security�staff�if�needed.
Healthcare�organisations�should�consider�architectural�design3�that�improves�surveillance�of�critical�service�areas�such�as�plant�rooms,�and�the�protection�of�personnel,�for�example�service�counter�design�and�access�to�treatment�rooms,�as�well�as�the�location�of�other�security�risks�areas�such�as�ATMs�and�pharmacies.
Prompt points
¼ What legislation / standards / codes of practice are referenced in the organisation’s security policy?
¼ How often is the organisation’s risk register updated?
¼ How does the organisation ensure that confidential information is secure?
¼ Does the organisation have staff who work off-site? How does it manage their safety?
Physical and personal securityOrganisations�should�have�an�effective�risk�management�plan�to�address�violence�and�aggression�in�the�workplace.�The�focus�should�be�on�prevention.�However,�when�a�violent�incident�does�occur,�action�should�be�taken�to�minimise�its�impact�and�prevent�its�recurrence�as�far�as�possible,�regardless�of�its�source.�Appropriate�support�should�be�provided�for�affected�staff,�such�as�debriefing,�and�encouragement�to�access�professional�counselling�and�assistance�from�the�organisation’s�employee�support�program.
The�term�‘violence�and�aggression’�encompasses�any�incident�in�which�an�individual�is�abused,�threatened�or�assaulted.�Such�an�incident�may�involve�verbal,�physical�or�psychological�abuse,�threats�or�other�intimidating�behaviours,�intentional�physical�attacks,�aggravated�assault,�threats�with�an�offensive�weapon,�sexual�harassment,�or�sexual�assault.
A�policy�of�zero�tolerance�should�be�adopted�by�the�organisation.�Zero�tolerance�means�that�in�all�violent�or�aggressive�incidents,�appropriate�action�will�be�taken�to�protect�staff,�consumers�/�patients�and�visitors�from�the�effects�of�such�behaviour.4
Organisations�should�have�in�place�a�violence�and�aggression�prevention�program.�This�program�should�include:
• policies�addressing�zero�tolerance,�internal�(intra-organisational)�violence,�aggression�and�bullying,�between�staff�at�all�levels�as�well�as�visitors
• a�focus�on�the�elimination�of�violent�behaviour�and,�where�risks�cannot�be�eliminated,�the�reduction�of�risk�to�the�lowest�possible�level
• control�strategies�for�violence�and�aggression,�developed�in�consultation�with�staff
• protocols�for�reporting�violent�incidents
• a�working�environment�that�supports�zero�tolerance�and�management�commitment�to�the�program
• staff�education�about�responding�to�violent�incidents.
Physical�security�includes�alarms,�guards,�lighting,�locks,�safes,�closed�circuit�television�(CCTV),�etc.�As�part�of�its�commitment�to�providing�a�safe�working�environment,�the�organisation�should�ensure�that�lighting�is�adequate�in�areas�such�as�car�parks,�corridors,�access�paths�and�storage�facilities.�An�access�control�system�for�registering,�managing�and�monitoring�individual�levels�of�access,�including�the�allocation�and�use�of�key�and/or�swipe�cards,�should�be�in�place,�kept�up�to�date�and�regularly�reviewed.
October 2010 459
Access�controls�to�specific�areas,�including�locks�on�drug�storage�areas,�reduced�face-to-face�contact�during�supply�of�pharmaceuticals,�designated�escape�routes,�and�swipe�card�access�for�relevant�individuals�can�improve�the�physical�safety�of�staff.
Where�CCTV�is�in�use,�a�large�sign�indicating�that�the�site�is�being�monitored�continuously�should�be�displayed.
Personal�security�includes�pre-employment�checking�and�human�resources�policies�and�procedures.�Relevant�credentials�should�be�provided�by�all�staff�and�copies�kept�in�personal�records.�In�settings�where�staff�are�working�with�or�in�contact�with�children,�appropriate�checks�should�be�completed.5�Identification�should�be�worn�by�all�staff,�including�volunteers.�Identification�should�consider�visibility,�culture,�safety,�security�and�customer�focus.
Logical securityThe�term�logical�security�refers�to�those�security�features�that�are�built�into�communications,�IT�and�IM�systems.�More�extensive�information�about�logical�security�and�its�implementation�and�management�can�be�found�in�criterion�2.3.4.
Prompt points
¼ When a violent incident is reported, what is the average response time? Is a risk assessment subsequently undertaken and an action plan developed?
¼ Does the organisation have areas to which access is restricted? How is access to those areas monitored and/or controlled? For example, if consumers / patients or carers can access the main facility after hours, is the kitchen secure? Are knives or other potential weapons secured?
¼ If the organisation has an Emergency Department, how are consumers / patients and in particular, carers, contained within the ED after hours, when staffing and other resources are limited?
Education, consultation and procedural reviewSecurity�and�consumer�/�patient�safety�are�key�concerns�in�any�healthcare�organisation.�Management�should�demonstrate�its�support�for�zero�tolerance�to�all�levels�of�staff�through�a�commitment�to�education�and�training,�and�an�effective�response�when�incidents�are�reported.�The�integrity�of�policies�and�procedures�can�only�be�assured�by�the�methods�employed�to�train�staff�in�current�procedures�and�by�continuously�reviewing�and�updating�those�procedures�as�required�following�consultation�with�staff.�The�procedures�developed�in�any�organisation�must�be�understood,�with�relevant�staff�training�provided�where�necessary.�A�mechanism�to�guarantee�that�policies�and�procedures�have�been�read�and�understood�should�be�in�place.�This�can�be�in�the�form�of�a�register�or�part�of�the�annual�review�of�key�performance�indicators.
The�organisation’s�responsibility�to�provide�a�safe�working�environment�extends�to�all�individuals�entering�the�workplace,�including�any�external�service�providers�or�contractors.�The�organisation�must�provide�these�individuals�with�all�relevant�security�information,�both�in�order�that�they�may�be�protected,�and�to�ensure�that�in�turn�they�comply�with�all�security�policies�and�procedures.
The�issue�of�staff�working�alone�should�be�considered�under�Occupational�Health�&�Safety�legislation,�and�other�relevant�Regulations,�Acts�and�codes�of�practice.�Employers�must�take�all�reasonably�practicable�steps�to�protect�the�health�and�safety�at�work�of�all�employees.�The�best�way�to�ensure�that�all�reasonably�practicable�steps�have�been�taken�is�to�apply�a�consultative�risk�management�process�to�the�identification,�assessment�and�control�of�risks�involved�in�working�alone�or�in�remote�areas.�National,�State�and�Territory�legislation�requires�that�employers�consult�with�employees�to�identify�hazards,�assess�the�risk,�determine�and�implement�control�measures,�develop�policies�and�procedures�to�minimise�the�risk,�decide�on�training�requirements�and�supervise�and�monitor�the�risk�control�measures.�
When�staff�are�required�to�visit�consumers�/�patients�in�their�own�homes,�a�risk�assessment�that�occurs�over�the�phone�may�not�be�sufficient�to�identify�all�of�the�risks�involved�in�that�visit.�Apart�from�risks�within�the�home�environment,�such�as�pets,�other�persons�/�residents�in�attendance,�and�the�physical�environment,�there�are�also�risks�in�the�surrounding�area�or�complex�where�the�consumer�/�patient�resides.�
seCtion 5Standards, criteria, elements and guidelinesstandard 3.2:�The�organisation�maintains�a�safe�environment�for�employees,�consumers�/�patients�and�visitors
460 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 3.2.5
Security�management�supports�safe�practice�and�a�safe�environment.�(continued)
Organisations�need�to�ensure�that:
• there�is�a�risk�management�policy�and�procedure�in�place�that�addresses�risks�to�employees�who�visit�consumers�/�patients�in�their�own�homes
• the�risk�management�policy�and�procedure�has�been�developed�in�consultation�with�the�employees�performing�that�function
• risk�assessments�of�consumers�/�patients�occur,�with�alternate�care�options�provided�for�those�who�are�excluded�on�the�basis�of�risk�assessment�or�those�where�a�risk�assessment�is�not�an�option�due�to�time�constraints
• risks�and�risk�control�strategies�that�are�implemented�are�communicated�to�staff
• the�effectiveness�of�the�policies�and�the�controls�that�are�in�place�is�demonstrated
• policies�and�procedures�to�support�staff�in�these�situations�are�in�place�and�monitored
• appropriate�training�for�staff�occurs�including�training�in�aggressive�behaviour�management�and�manual�handling�/�task,�commensurate�with�the�working�conditions�of�the�employee
• back-up�protocols�are�in�place�to�support�staff�on�consumer�/�patient�home�visits,�taking�into�consideration�issues�such�as�roadside�assistance�for�vehicle�travel;�‘call�in’�to�staffed�office�with�monitoring�of�return�times;�or�in�remote�locations,�GPS�monitoring�and�duress�alarm�availability�connected�to�a�24�hour�monitoring�centre�(such�as�a�commercial�security�contractor)�and�emergency�response�times
• appropriate�emergency�support�equipment,�such�as�mobile�phones�or�other�communication�equipment,�is�made�available�to�staff�suitable�to�the�location�of�the�service.
Prompt points
¼ How does the organisation educate its staff about security matters? How often is this information updated and disseminated?
¼ How often are staff consulted regarding matters of security in the workplace? What form does this consultation take?
¼ How does the organisation ensure that external service providers act in compliance with the organisation’s security policies?
¼ What back-up protocols are in place for staff undertaking home visits? How is the safety of staff in remote areas ensured?
Evidence commonly presented
Consider whether the following will help to address criterion 3.2.5
¼ Evidence of pre-employment checks
¼ Identification of security risks and plans to manage those risks
¼ Security audits (internal, e.g. OH&S Committee, as well as external)
¼ Evidence of violence and aggression prevention plans
¼ Reported incidents and action taken on:
– aggression – theft – breaches of secure areas
¼ Policies and procedures
¼ Evidence of staff training
¼ Evidence of staff consultation
¼ Privacy audits
¼ Property and property check audits
¼ Security licences
October 2010 461
Performance measurementThis�criterion�states�that:�“Security�management�supports�safe�practice�and�a�safe�environment”.�The�organisation�should�demonstrate�its�commitment�to�maintaining�a�safe�environment�via�its�implementation�of�security�policies�and�procedures,�its�adoption�of�a�zero�tolerance�approach�towards�workplace�violence�and�aggression,�the�provision�of�appropriate�education�to�its�staff,�and�its�consultation�with�staff�during�its�evaluation�and�improvement�of�its�security�program.
Some�common�suggested�performance�measures�are�as�follows:
Number�of�reported�incidents�that�relate�to�theft�/�risk�/�security
Total number of reported incidents
Number�of�reported�incidents�that�relate�to�aggression
Total number of reported incidents
Number�of�reported�breaches�of�security�doors
Total number of security incidents
Number�of�workers�compensation�claims�related�to�aggression
Total number of workers compensation claims
Number�of�incidents�involving�staff�working�off-site
Total number of reported incidents
seCtion 5Standards, criteria, elements and guidelinesstandard 3.2:�The�organisation�maintains�a�safe�environment�for�employees,�consumers�/�patients�and�visitors
462 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Criterion 3.2.5
Security�management�supports�safe�practice�and�a�safe�environment.�(continued)
References1.� Australian�Council�on�Healthcare�Standards�(ACHS).�Risk
managementandqualityimprovementhandbook.Sydney�NSW;�ACHS;�2007.�Accessed�from�http://www.achs.org.au/RiskMgmtQIHandbook/�on�27�July�2010.
2.� AS�4498.1:1997�Securityforhealthcarefacilities.Part1:Generalrequirements.
3.� AHIA�(formerly�Health�Capital�and�Asset�Management�Consortium)�and�University�of�NSW�Centre�for�Health�Assets�Australasia.�AustralasianHealthFacilityGuidelines(AusHFG).Sydney;�UNSW.�Accessed�from�http://www.healthfacilityguidelines.com.au/guidelines.htm�on�11�December�2009.
4.� NSW�Health.Zerotolerance.ResponsetoviolenceintheNSWhealthworkplace.Policyandframeworkguidelines.Sydney;�NSW�Health;�2003.
5.� Australian�Institute�of�Family�Studies.�Pre-employment�screening:�Working�with�children�checks�and�police�checks.Resourcesheet2010;�13.�Accessed�from�http://www.aifs.gov.au/nch/resources/police/policechecks.html�on�1�September�2010.
Standards and guidelinesAS/NZS�ISO�31000:2010�Riskmanagement–Principlesandguidelines.
AS�4485.1:1997�Securityforhealthcarefacilities.Part1:Generalrequirements.
AS�4485.2:1997�Securityforhealthcarefacilities.Part2:Proceduresguide.
Victorian�Department�of�Human�Services.�PreventingoccupationalviolenceinVictorianhealth�services.�A�policy�framework�and�resource�kit.�Melbourne;�Victorian�Government�2007.
�
Further readingDepartment�of�Commerce.�Handbookforworkplaces.Preventionandmanagementofaggressioninhealthservices.Perth�WA;�Government�of�Western�Australia;�2009.
Forster�JA,�Petty�MT,�Schleiger�C�and�Waters�HC.�kNOw�workplace�violence:�Developing�programs�for�managing�the�risk�of�aggression�in�the�health�care�setting.�MedJAust2005;�183(7):�357-361.
Remote�Health�Branch,�NT�Department�of�Health�and�Families.Aggressionmanagementpolicy.Information�sheet.�Darwin�NT;�Northern�Territory�Government;�2005.
Comcare.�TheCommonwealthoccupationalhealthandsafetyjurisdiction.Canberra�ACT;�Commonwealth�government.�Accessed�from�http://www.comcare.gov.au/forms__and__publications/fact_sheets/the_commonwealth_occupational_health_and_safety_jurisdiction�on�14�September�2010.
Comcare.�Laws®ulations.Canberra�ACT;�Australian�Government.�Accessed�from�http://www.comcare.gov.au/laws__and__regulations�on�14�September�2010.
SafeWork�SA.�Safeworkforhomeandcommunityworkers.Adelaide�SA;�Government�of�South�Australia.�Accessed�from�http://www.safework.sa.gov.au/contentPages/Industry/AgedCare/agedHomeCommunityWorkers.htm�on�14�September�2010.
Worksafe�Victoria.�Ahandbookforworkplaces:Workingsafelyinvisitinghealthservices.�Melbourne�VIC;�Worksafe;�2006.
October 2010 463
Definitions in this glossary are for use in the context of the ACHs eQuiP5 standards, criteria, elements and guidelines.
access the�various�pathways�and�processes�via�which�the�consumer�/�patient�may�enter�the�health�system�and�obtain�required�services�
accessibility the�ability�of�consumers�/�patients�or�potential�consumers�/�patients�to�obtain�required�or�available�services�when�needed�within�an�appropriate�time1
accountability responsibility�and�requirement�to�answer�for�tasks�or�activities.�This�responsibility�may�not�be�delegated�and�should�be�transparent1
accreditation a�public�recognition�by�a�healthcare�accreditation�body�of�the�achievement�of�accreditation�standards�by�a�healthcare�organisation,�demonstrated�through�an�independent�external�peer�assessment�of�that�organisation’s�level�of�performance�in�relation�to�the�standards1
advance care plan / directive
instructions�that�consent�to,�or�refuse,�the�future�use�of�specified�medical�treatments.�It�becomes�effective�in�situations�where�the�consumer�/�patient�no�longer�has�the�capacity�to�make�treatment�decisions2
AC60: Advanced Completion in 60 days survey
in�the�context�of�EQuIP5:�
an�opportunity�for�an�organisation�to�promptly�address�outstanding�issues�to�achieve�an�acceptable�level�of�performance�within�60�days�from�an�EQuIP�survey�date.
May�be�offered�to�an�organisation�in�up�to�four�criteria�in�order�to�address:
• High�Priority�Recommendations�(HPRs),�and/or
• an�SA�rating�in�mandatory�criteria,�and/or
• an�SA�rating�in�non-mandatory�criteria
admission the�point�in�the�care�journey�at�which�an�organisation�acknowledges�a�consumer�/�patient�as�a�client,�and�accepts�responsibility�for�his�or�her�care3;�in�some�contexts,�the�term�‘registration’�may�be�used�rather�than�admission.�The�point�at�which�admission�is�considered�to�have�occurred,�and�the�processes�by�which�it�happens,�vary�considerably�according�to�the�nature�of�an�organisation.
In�the�first�instance,�admission�refers�to�the�administrative�process�by�which�an�individual’s�details�are�entered�into�the�organisation’s�systems�so�that�the�care�journey�may�begin.�However,�it�is�important�to�recognise�that,�depending�upon�the�nature�and�sector�of�the�organisation,�admission�does�not�necessarily�require�the�provision�of�accommodation,�or�access�to�a�specific�facility.
adverse event an�incident�that�results�in�harm�to�a�consumer�/�patient,�where�harm�includes�disease,�injury,�suffering,�disability�and�death4
adverse reaction unexpected�harm�arising�from�a�justified�treatment5
agreement a�mutually�agreed�arrangement�describing�the�scope�for�cooperative�ventures�between�parties�and�documenting�relevant�responsibilities
analysis presentation�of�the�essential�features�into�simple�elements,�such�as�a�summary,�outline�or�identification�of�the�essence�of�an�issue
antimicrobial a�chemical�substance�that�inhibits�or�destroys�bacteria,�fungi�or�parasites.4�These�include�antibiotics,�antivirals�and�disinfectants
appropriate service�that�is�consistent�with�a�consumer�/�patient’s�expressed�requirements�and�is�provided�in�accordance�with�current�best�practice1
in�the�context�of�EQuIP5:�is�suitable,�or�fitting,�to�do
seCtion 6Glossary
464 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
seCtion 6Glossary
appropriateness doing�what�is�necessary,�and�not�doing�what�is�not�necessary.�Occurs�when�consumers�/�patients�receive�appropriate�and�necessary�care,�interventions�and�services�in�the�most�appropriate�setting
artificial nutritional support
parenteral�and/or�enteral�nutrition�therapy6
(parenteral�nutrition:�intravenous�administration�of�nutrients�into�a�central�or�peripheral�vein.�Enteral�nutrition:�feeding�provided�through�the�gastrointestinal�tract�via�a�tube,�catheter,�or�stoma�that�delivers�nutrients�distal�to�the�oral�cavity)6
as required when�required�by�obligation
assessment a�process�by�which�the�characteristics�and�needs�of�consumers�/�patients,�groups�or�situations�are�evaluated�or�determined�so�that�they�can�be�addressed.�Assessment�forms�the�basis�of�a�plan�for�services�or�action.1�While�assessment�may�be�known�by�different�names�and�occurs�in�a�broad�variety�of�contexts,�such�as�triage�in�an�emergency�department,�comprehensive�assessment�by�an�Aged�Care�Assessment�Service,�or�screening�and�intake�by�a�community�health�or�outreach�service,�the�process�remains�consistent�and�as�defined�above
‘at-risk’ consumer / patient
a�consumer�/�patient�characterised�by�a�high�risk�or�susceptibility�to�a�disease7�or�event,�e.g.�falls�
Australian standards national�standards�developed�by�Standards�Australia
benchmarking the�continuous�measurement�of�a�process,�product,�or�service�compared�to�those�of�the�toughest�competitor,�to�those�considered�industry�leaders,�or�to�similar�activities�in�the�organisation,�in�order�to�find�and�implement�ways�to�improve�it.�One�of�the�foundations�of�both�total�quality�management�and�continuous�quality�improvement.�Internal�benchmarking�occurs�when�similar�processes�within�the�same�organisation�are�compared.�Competitive�benchmarking�occurs�when�an�organisation's�processes�are�compared�with�best�practices�within�the�industry.�Functional�benchmarking�refers�to�benchmarking�a�similar�function�or�process,�such�as�scheduling,�in�another�industry6
best practice an�approach�that�has�been�shown�to�produce�superior�results,�selected�by�a�systematic�process,�and�judged�as�exemplary,�or�demonstrated�as�successful.�It�is�then�adapted�to�fit�a�particular�organisation1
blood homologous�and�autologous�whole�blood,�blood�including�red�blood�cells,�platelets,�fresh�frozen�plasma,�cryoprecipitate�and�cryo-depleted�plasma4
blood component fresh�blood�components�including�red�cells,�platelets,�fresh�frozen�plasma,�cryoprecipitate�and�cryodepleted�plasma8
blood products plasma�derivatives�and�recombinant�products�
business plan the�current�action�plan�for�achieving�organisation�goals1
by-laws rules,�regulations�or�legislation�adopted�by�the�organisation�for�the�regulation�of�both�its�internal�and�external�affairs
carbon emissions generally�an�abbreviation�of�emissions�of�greenhouse�gases.�Greenhouse�gases�are�a�number�of�different�gases�that�all�have�the�ability�to�influence�the�global�energy�balance�of�the�Earth;�the�greenhouse�effect9
October 2010 465
care plan the�documentation�of�items�agreed�to�in�a�care�planning�process.�This�should�include:
• date�of�development
• participants�in�development�of�care�plan
• consumer�/�patient-stated�and�agreed�issues�or�problems
• consumer�/�patient-stated�and�agreed�goals
• agreed�actions�and�the�name�of�person�or�service�responsible�for�each�action
• timeframe�for�attaining�goals�and�actions
• planned�review�date
• consumer�/�patient�acknowledgement�of�the�care�plan�(signed�or�verbal)
• actual�review�date10
carers / support persons people�who�provide�unpaid�care�and�support�to�family�members�and�friends�who�have�a�disability,�mental�illness,�chronic�condition,�terminal�illness�or�who�are�frail.11�Carers�include�parents�and�guardians�caring�for�children4.�
in�the�context�of�EQuIP5:�
a�carer�/�support�person�is�any�person�elected�by�a�consumer�/�patient�to�accompany�or�assist�the�consumer�/�patient�during�an�episode�of�care
change management the�process�of�managing�the�effective�implementation�of�organisational�strategies,�ensuring�that�permanent�changes�in�goals,�behaviours,�relationships,�processes�and�systems�are�achieved�to�the�organisation’s�advantage.�It�is�the�key�competence�required�for�managing�all�strategic�initiatives
clinical audit a�systematic�independent�examination�and�review�to�determine�whether�actual�activities�and�results�comply�with�planned�arrangements1
clinical classification the�process�of�translating�data,�such�as�for�diseases,�conditions,�injuries�and�interventions,�from�a�consumer�/�patient�record�into�a�coded�format�using�a�relevant�classification�system
clinical governance the�system�by�which�the�governing�body,�managers�and�clinicians�share�responsibility�and�are�held�accountable�for�consumer�/�patient�care,�minimising�risks�to�consumers�/�patients�and�for�continuously�monitoring�and�improving�the�quality�of�clinical�care12�
clinical handover the�transfer�of�professional�responsibility�and�accountability�for�some�or�all�aspects�of�care�for�a�consumer�/�patient,�or�group�of�consumers�/�patients,�to�another�person�or�professional�group�on�a�temporary�or�permanent�basis.4,�13�The�efficient�and�effective�transfer�of�high�quality�clinical�information�from�one�healthcare�provider�to�another�facilitates�safe�transfer�of�care14�
clinical indicator a�measure�of�the�clinical�management�and/or�outcome�of�care�that�should�screen,�flag�or�draw�attention�to�a�specific�clinical�issue.�Clinical�indicators�identify�the�rate�of�occurrence�of�an�event�and�are�used�to�assess,�compare�and�determine�the�potential�to�improve�care.�They�assist�in�assessing�whether�or�not�a�standard�in�consumer�/�patient�care�is�being�met�by�indicating�potential�problems�that�might�need�addressing15�
clinical pathway sometimes�called�a�care�map,�a�consumer�/�patient�management�tool�that�organises,�sequences�and�times�the�major�care�activities�and�interventions�of�the�entire�interdisciplinary�team�for�a�consumer�/�patient�with�a�particular�diagnosis�or�need�for�a�procedure16�
466 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
seCtion 6Glossary
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.4�The�term�encompasses�medical�practitioners,�nurses,�dentists,�paramedics�and�allied�health�professionals�such�as�physiotherapists,�occupational�therapists,�speech�pathologists,�dieticians,�radiographers,�social�workers,�psychologists,�pharmacists�and�all�others�in�active�clinical�practice17,�but�excludes�clinicians-in-training�and�junior�practitioners�who�must�work�under�supervision18
code of practice a�published�document�that�sets�out�commonly�agreed�sets�of�guidelines�and�informs�all�parties�of�responsibilities�and�expectations�under�the�code.�Codes�of�practice�can�be19:
• voluntary�agreements�where�a�group�of�companies�or�an�industry�sector�agree�to�abide�by�a�particular�code
• quasi-regulation�where�the�code�may�be�developed�by�industry�in�cooperation�with�government
• co-regulation�where�the�code�describes�required�performance�or�behaviour,�or�specifies�acceptable�means�of�meeting�broader�performance-based�obligations,�and�where�there�are�penalties�for�non-compliance�with�the�code
community a�group�of�people�who�share�a�common�interest�or�background�(e.g.�cultural,�social,�political,�economic,�health),�which�may�also�be,�but�is�not�necessarily,�geographic20
competence a�guarantee�that�an�individual’s�knowledge�and�skills�are�appropriate�to�the�service�provided�and�an�assurance�that�the�knowledge�and�skill�levels�are�regularly�evaluated1
complaint expression�of�a�problem,�an�issue,�or�dissatisfaction�with�services�that�may�be�verbal�or�in�writing1
conditional survey in�the�context�of�EQuIP5:�
an�additional�survey�that�is�undertaken�one�year�following�an�Organisation-Wide�Survey�or�a�Periodic�Review,�during�which�issues�were�identified�as�needing�to�be�addressed�rapidly.�A�recommendation�for�a�Conditional�Survey�is�made�for�issues�for�which�a�60-day�framework�is�too�short�to�achieve�the�level�of�change�required,�and�provides�the�organisation�with�an�opportunity�to�address�issues�that�require�some�time�and�resources�in�order�to�achieve�an�acceptable�level�of�performance.
A�Conditional�Survey�may�be�offered�to�an�organisation�in�up�to�two�criteria�in�order�to�address:
• High�Priority�Recommendations�(HPRs),�and/or
• an�SA�rating�in�mandatory�criteria
In�addition,�a�Conditional�Survey�may�be�offered�to�an�organisation�in�order�to�address:
• LA/SA�ratings�in�from�six�to�eleven�non-mandatory�criteria
confidentiality guaranteed�limits�on�the�use�and�distribution�of�information�collected�from�individuals�or�organisations1�
consent, informed a�process�of�communication�between�a�consumer�/�patient�and�his�or�her�medical�officer�that�results�in�the�consumer�/�patient’s�authorisation�or�agreement�to�undergo�a�specific�medical�intervention.�This�communication�should�ensure�the�consumer�/�patient�has�an�understanding�of�all�the�available�options�and�the�expected�outcomes�such�as�the�success�rate�and/or�side�effects�for�each�option4
October 2010 467
consent, acknowledgement of
in�the�absence�of�a�completed�consent�form,�an�acknowledgement�of�consent�form�should�be�present�in�the�health�record,�signed�by�the�consumer�/�patient�and,�when�appropriate,�the�treating�physician,�stating�that�the�proposed�treatment,�the�benefits�and�risks�and�any�costs�involved�have�been�explained�to�the�consumer�/�patient
consumer / patient a�person,�however�titled,�who�makes�either�direct�or�indirect�use�of�health�services;�that�is,�a�current�or�potential�user�of�the�health�system,�and/or�their�carer(s).21,�22�This�encompasses�consumers�/�patients�receiving�health�care�from�a�clinician4,�those�with�specific�health�needs,�or�who�may�at�some�time�have�them,�and�those�who�have�a�general�interest�in�the�health�system�and�health�funding.�Many�consumers�/�patients�also�have�an�indirect�influence�upon�the�health�system�in�the�capacity�of�taxpayers�
consumer / patient participation
the�process�of�involving�consumers�/�patients�and�the�community�meaningfully�in�decision�making�about�their�own�health�care,�health�service�planning,�policy�development,�setting�of�priorities�and�quality�issues�in�the�delivery�of�services23
continuity of care the�ability�to�provide�uninterrupted,�coordinated�care�or�services�across�programs,�practitioners,�organisations�and�levels�over�time20
contract a�mutual�agreement�between�two�or�more�competent�parties�that�creates�a�legally�supportable�obligation�to�do�or�not�do�something�specified
coordinate to�bring�together�in�a�common,�ordered�and�harmonious�action�or�effort
corporate governance the�processes�by�which�the�organisation�is�directed,�controlled�and�held�to�account.�It�encompasses�the�systems,�processes�and�arrangements�by�which�authority,�accountability,�stewardship,�leadership,�direction�and�control�are�exercised�in�an�organisation.24�It�influences�how�objectives�are�set�and�achieved,�how�risk�is�monitored�and�assessed�and�how�performance�is�optimised25
credentialling the�formal�process�used�to�verify�the�qualifications,�experience,�professional�standing�and�other�relevant�professional�attributes�of�clinicians�for�the�purpose�of�forming�a�view�about�their�competence,�performance�and�professional�suitability�to�provide�safe,�high�quality�healthcare�services�within�specific�organisational�environments26
credentials documentation�that�an�individual’s�knowledge,�skills,�competence�and�qualifications�comply�with�specific�requirements1
criteria specific�steps�to�be�taken�or�activities�to�be�done,�to�reach�a�decision�or�a�standard1
cultural competence the�processes�and�practices�implemented�by�an�organisation�that�foster�inclusiveness�and�establish�the�progression�of�learning�about�diversity�and�differences,�and�their�impact�on�the�way�services�are�delivered,�received,�accessed�and�promoted.�In�the�context�of�health�care,�cultural�competence�focuses�on�the�capacity�of�the�organisation�to�improve�health�and�wellbeing�for�the�individual�and�the�community�by�integrating�culture�into�the�delivery�of�health�services27
culture, organisational the�prevailing�pattern�of�beliefs,�attitudes,�values�and�behaviours�within�an�organisation28
data unorganised�facts�from�which�information�can�be�generated
data collection a�store�of�data�captured�in�an�organised�way�for�a�specific�defined�purpose
data integrity accuracy,�consistency�and�completeness�of�data
data security protection�of�data�from�intentional�or�unintentional�destruction,�modification�or�disclosure
468 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
seCtion 6Glossary
defining the scope of clinical practice
the�process�that�follows�on�from�the�credentialling�of�medical�practitioners�and�other�clinicians,�which�involves�delineating�the�extent�of,�and�limits�to,�an�individual’s�clinical�practice�within�a�particular�organisation,�based�on�that�individual’s�credentials,�competence,�performance�and�professional�suitability,�and�the�needs�and�the�capability�of�the�organisation�to�support�the�individual’s�scope�of�clinical�practice26,�29
delegation the�devolution�of�authority�appropriate�to�individual�roles�and�responsibilities�within�an�organisation�for�the�operation�of�clinical�and�non-clinical�services.�A�formal�delegation�system�ensures�that�clear�lines�of�accountability�exist,�particularly�where�temporary�delegations�are�enacted�
deteriorating consumer / patient
a�consumer�/�patient�whose�physiological�condition�is�deteriorating.�May�apply�to�any�consumers�/�patients�receiving�medical,�surgical,�maternity�or�mental�health�care�and�is�determined�by�observing�and�documenting�changes�in�their�clinical�circumstances.�This�includes�both�the�absolute�change�in�physiological�measurements�and�abnormal�observations,�as�well�as�the�rate�of�change�over�time�for�an�individual30
disaster recovery a�disaster�recovery�strategy�is�a�set�of�pre-determined�procedures�that�provides�for�substitute�operations�and�a�quick�return�to�normal�after�any�disruption�
discharge / transfer of care
the�release�of�a�consumer�/�patient�from�care7�or�movement�of�a�consumer�/�patient�from�one�setting�of�care�to�another31
document control system a�planned�system�for�controlling�the�release,�change�and�use�of�important�documents�within�an�organisation,�particularly�policies�and�procedures.�The�system�requires�each�document�to�have�a�unique�identification,�and�to�show�dates�of�issue,�updates�and�authorisation.�Issue�of�documents�in�the�organisation�is�controlled�and�all�copies�of�all�documents�are�readily�traceable�and�obtainable32
diverse background the�breadth�of�social,�economic�and�cultural�factors�that�influence�an�individual�consumer�/�patient’s�experience�and�perspective.�This�encompasses�culturally�and/or�linguistically�diverse�backgrounds�
diverse needs the�range�of�consumer�/�patient�needs�that�may�be�found�within�the�community�that�an�organisation�serves,�and�which�may�form�a�barrier�to�health�care�if�not�addressed�by�the�organisation�in�meeting�its�duty�of�care.�Such�needs�may�be�cultural,�physical,�linguistic,�economic�or�health-status�related�
education systematic�instruction�and�learning�activities�to�develop�or�bring�about�change�in�knowledge,�attitudes,�values�or�skills1
effective producing�the�desired�result
effectiveness care,�intervention�or�action�that�is�relevant�to�the�consumer�/�patient’s�needs�and�based�on�established�standards.�This�care,�intervention�or�action�achieves�the�desired�outcome20
efficiency achieving�desired�results�with�the�most�cost-effective�use�of�resources20
electronic records a�record�on�electronic�storage�media�that�is�produced,�communicated,�maintained�and/or�accessed�by�means�of�electronic�equipment.�An�Electronic�Health�Record�(EHR)�is�a�repository�of�information�regarding�the�health�status�of�a�consumer�/�patient,�in�computer-processable�form33
elements in�the�context�of�EQuIP5:�
elements�identify�what�should�be�in�place�to�achieve�the�criterion�at�a�certain�rating�level:�a�description�of�what�is�required�to�achieve�the�criterion.�These�provide�prompts�for�improvement�and�best�practice
October 2010 469
employee assistance program
a�proven�strategy�for�assisting�employees�and�their�families�with�personal�and�work-related�problems,�difficulties�and�concerns�which�they�may�experience�from�time�to�time�and�which�can�affect�work�performance
entry a�process�by�which�a�consumer�/�patient�comes�into�a�healthcare�organisation�to�receive�healthcare�services
end-of-life care a�quality�management�approach�that�evaluates�the�individual�holistic�needs�of�a�consumer�/�patient,�his�or�her�family�and/or�carers,�and�coordinates�appropriate�care�at�the�end�of�life.�It�recognises�the�interdependent�physical,�social,�emotional,�cultural�and�spiritual�aspects�of�care�and�includes�the�combination�of�broad�health�and�community�services�that�care�for�a�person�at�the�end�of�his�or�her�life34
environmental sustainability
development�that�meets�the�needs�of�the�present�without�compromising�the�ability�of�future�generations�to�meet�their�own�needs.�The�ability�to�maintain�the�balance�between�resources,�such�as�water,�timber�and�solar�energy,�and�living�organisms�such�as�humans,�animals�and�plants35,�36
error unintentionally�being�wrong�in�conduct�or�judgement.�Errors�may�occur�by�doing�the�wrong�thing�(commission)�or�by�failing�to�do�the�right�thing�(omission)37
ethics acknowledged�set�of�principles�which�guide�professional�and�moral�conduct
evaluation assessment�of�the�degree�of�success�in�meeting�the�goals�and�expected�results�(outcomes)�of�the�organisation,�services,�program�or�consumers�/�patients1
evidence data�and�information�used�to�make�decisions.�Evidence�can�be�derived�from�research,�experimental�learning,�indicator�data,�and�evaluations.�Evidence�is�used�in�a�systematic�way�to�evaluate�options�and�make�decisions1
evidence-based the�use�of�systematically�reviewed�appraised�clinical�research�findings�to�aid�the�delivery�of�optimum�clinical�care�to�consumers�/�patients38;�the�transfer�of�knowledge�from�research�into�healthcare�practice
external entity a�body�/�establishment�external�to�the�organisation
externally based references
reference�and�research�information�generated�outside�the�organisation,�such�as�journals,�internet�information,�research�databases,�library�resources,�etc.
feedback a�communication�from�a�consumer�/�patient�relaying�how�delivered�products,�services�and�information�compare�with�consumer�/�patient�expectations
flexible work practices working�arrangements�that�assist�employees�to�meet�personal�responsibilities,�such�as�caring�for�a�child�or�other�family�member.�These�may�include39:
• changes�in�hours�of�work
• changes�in�patterns�of�work
• changes�in�location�of�work
follow-up processes�and�actions�taken�after�a�service�has�been�completed1
formalised follow-up documented�processes�and�actions�taken�after�a�service�has�been�completed
governance the�set�of�relationships�and�responsibilities�established�by�a�healthcare�organisation�between�its�executive,�workforce�and�stakeholders�(including�consumers).�It�incorporates�the�set�of�processes,�customs,�policy�directives,�laws,�and�conventions�affecting�the�way�a�healthcare�organisation�is�directed,�administered�or�controlled.�Governance�arrangements�specify�the�mechanisms�for�monitoring�performance4
governing body a�body�that�carries�legal�accountability�and/or�scope�of�organisational�responsibility�for�the�services�provided,�such�as�an�individual�owner�or�a�group�of�senior�managers,�a�governing�body�of�directors,�a�board,�a�group�of�senior�managers��and/or�a�chief�executive�appointed�by�a�government�agency�
470 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
seCtion 6Glossary
guidelines principles�guiding�or�directing�action.1�Clinical�practice�guidelines�are�systematically�developed�statements�to�assist�practitioner�and�consumer�/�patient�decisions�about�appropriate�health�care�for�specific�circumstances.40�Guidelines�in�the�EQuIP5�Guide�provide�essential�information�for�the�achievement�of�the�EQuIP5�standards
healthcare-associated infections
infections�acquired�in�healthcare�facilities�(nosocomial�infections)�and�infections�that�occur�as�a�result�of�healthcare�interventions�(iatrogenic�infections),�and�which�may�manifest�after�people�leave�the�healthcare�facility41
healthcare provider a�team�or�individuals�who,�in�cooperation�with�the�consumer�/�patient,�assume�responsibility�for�all�aspects�of�an�episode�of�care�in�response�to�the�diagnosis�and�needs�of�the�consumer�/�patient
health priority areas identified�health�areas�which�contribute�significantly�to�the�burden�of�illness�and�injury,�which�have�potential�for�health�gains�and�reduction�in�the�burden�of�disease.�These�priorities�sit�under�the�overarching�framework�of�the�National�Chronic�Disease�Strategy42–44
health record term�used�to�describe�many�types�of�data�and�reports�about�a�consumer�/�patient�stored�in�different�media45
health workforce the�workforce�that�provides�health�care�to�consumers�/�patients;�ranging�from�workers�with�no�formal�qualifications�providing�support�services�in�home-based�settings�through�to�highly�qualified�specialists�working�in�technology�intensive��super-acute�hospital�settings
High Priority Recommendation (HPR)
in�the�context�of�EQuIP5:�
a�recommendation�where�there�is�an�area�of�high�risk�identified�by�the�surveying�team�when:
• consumer�/�patient�care�is�compromised,�and/or
• the�safety�of�consumers�/�patients�and/or�staff�is�jeopardised
The�HPR�is�a�trigger�for�the�organisation�to�address�the�issue�either�at�an��AC60�or�at�a�Conditional�Survey
home ward outlier consumer / patient
a�consumer�/�patient�who�is�being�treated�in�an�area�of�the�organisation�that�normally�treats�a�different�casemix,�for�example,�a�consumer�/�patient�with�a�medical�condition�such�as�diabetes�who�may�be�admitted�to�a�surgical�ward�due�to�a�lack�of�available�medical�beds
iatrogenic arising�from�or�associated�with�health�care�rather�than�an�underlying�disease�or�injury37
ICD – 10 – AM a�system�of�codes,�from�a�set�of�defined�categories,�which�are�used�to�categorise�activity�in�a�consistent�and�systemised�way:�the�International�Classification�of�Diseases,�10th�Revision,�Australian�modification
incident an�event�or�circumstance�which�could�have�or�did�lead�to�unintended�and/or�unnecessary�harm�to�a�person,�and/or�complaint,�loss�or�damage4
include(s) a�list�that�provides�examples�and�is�not�limiting
indicator performance�measurement�tool,�screen�or�flag�that�is�used�as�a�guide�to�monitor,�evaluate,�and�improve�the�quality�of�services.�Indicators�relate�to�structure,�process�and�outcomes1
October 2010 471
infection control management plan
a�documented�plan�that�outlines�the�structure�of�an�infection�control�program,�its�overall�aims�and�objectives,�associated�quality�management�activities,�program�evaluation�criteria�and�timeframes�for�review.46�The�document�should�address�the�governance�of�infection�control�and�identify:
• who�is�at�risk�and�from�what
• the�hazards�involved
• the�procedures�for�minimising�risk
• appropriate�measures�for�infection�control,�based�on�standard�precautions�and�when�required,�additional�precautions
information management the�process�of�planning,�organising,�analysing�and�controlling�data�and�information.�The�management�of�information�applies�to�both�computer-based�and�manual�systems
information privacy the�right�of�a�person�to�control�the�use�and�disclosure�of�information�that�reveals�his�or�her�identity,�health�information�or�health�status
information system a�system�that�provides�access�to�information�using�hardware,�software,�supplies,�policies,�procedures�and�people�
information technology (IT)
mechanical�and�electronic�devices�designed�for�the�collection,�storage,�manipulation,�presentation�and�dissemination�of�information
integrated governance an�additional�approach�that�aims�to�strengthen�and�streamline�healthcare�organisation�governance�arrangements�by�focusing�on�quality4�as�the�driver�of�change�and�placing�clinical�governance�at�the�heart�of�governance�arrangements.�Considered�a�key�building�block�of�good�governance�in�health�care47
integrity, data the�characteristic�of�data�and�information�being�accurate�and�complete
interoperability the�ability�of�information�systems�to�reliably�exchange�information�without�error33
intervention any�act�performed�to�prevent�harming�of�a�consumer�/�patient�or�to�improve�the�mental,�emotional�or�physical�function�of�a�consumer�/�patient48
IT cost management a�mechanism�to�manage�IT�costs
IT security a�tangible�set�of�physical�and�logical�mechanisms�used�to�protect�information�held�in�hard�copy,�computer�systems�and�information,�and�telecommunication�infrastructure�from�unauthorised�access
IT system a�group�of�interacting,�interrelated�or�interdependent�elements�forming�or�regarded�as�forming�a�collective�entity
leadership the�ability�to�provide�direction�and�cope�with�change.�It�involves�establishing�a�vision,�developing�strategies�for�producing�the�changes�needed�to�implement�the�vision,�aligning�people,�and�motivating�and�inspiring�people�to�overcome�obstacles1�
legibility data�or�information�that�is�decipherable�or�readable16
legislation the�body�of�laws�made�by�Parliament.�These�consist�of:�acts�of�parliament;�and�regulations,�ordinances�and�rules�which�are�also�called�‘subordinate’�or�‘delegated’�legislation49
magnet hospital a�term�coined�in�the�United�States�from�research�that�sought�to�understand�why�certain�hospitals�were�able�to�attract�and�retain�staff�
management setting�targets�or�goals�for�the�future�through�planning�and�budgeting,�establishing�processes�for�achieving�those�targets�and�allocating�resources�to�accomplish�those�plans.�Ensuring�that�plans�are�achieved�by�organising,�staffing,�controlling�and�problem�solving1
472 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
seCtion 6Glossary
mandatory criterion in�the�context�of�EQuIP5:
one�where�it�is�considered�that�without�Marked�Achievement�(evaluation),�the�quality�of�care�or�the�safety�of�people�within�the�organisation�could�be�at�risk
malnutrition a�state�of�nutrition�in�which�a�deficiency�or�excess�(or�imbalance)�of�energy,�protein,�and�other�nutrients�causes�measurable�adverse�effects�on�tissue�/�body�form�(shape,�size�and�composition)�and�function�and�clinical�outcome50
manual handling / task a�task�comprised�wholly�or�partly�by�any�activity�requiring�a�person�to�use�any�part�of�their�musculoskeletal�system�in�performing�their�work.�These�tasks�can�include51:
• lifting,�lowering,�pushing,�pulling,�carrying�or�otherwise�moving,�holding�or�restraining�any�person,�animal�or�item
• repetitive�actions
• sustained�work�postures
• exposure�to�vibration
medication error any�preventable�event�that�may�cause�or�lead�to�inappropriate�medication�use�or�consumer�/�patient�harm�while�the�medication�is�in�the�control�of�the�healthcare�professional�or�consumer�/�patient4
medication management the�processes�of�dispensing,�prescribing,�storing,�administering�and�monitoring�the�effects�of�medicines4
medico legal requirements
requirements�of�or�relating�to�both�medicine�and�law7
mission a�broad�written�statement�in�which�an�organisation�states�what�it�does�and�why�it�exists.�The�mission�sets�apart�one�organisation�from�another1
monitor to�check,�supervise,�observe�critically,�measure�or�record�the�progress�of�an�activity,�action�or�system�on�a�regular�basis�in�order�to�identify�change�and/or�track�change37
morbidity a�diseased�state�or�symptom�or�the�incidence�of�disease;�the�rate�of�sickness�in�a�specified�community�or�group7
mortality the�number�of�deaths�in�a�given�time�or�place�or�the�proportion�of�deaths�to�a�given�population7
multidisciplinary care�or�a�service�given�with�input�from�more�than�one�discipline�or�profession
National Chronic Disease Strategy
the�overarching�framework�of�national�direction�for�improving�chronic�disease�prevention�and�care�across�Australia.�A�nationally�agreed�agenda�to�encourage�coordinated�action�in�response�to�the�growing�impact�of�chronic�disease�on�the�health�of�Australians�and�the�healthcare�system42
near miss an�incident�that�did�not�cause�harm,�but�had�the�potential�to�do�so4
needs physical,�mental,�emotional,�social�or�spiritual�requirement�for�wellbeing.�Needs�may�or�may�not�be�perceived�or�expressed�by�those�in�need.�They�must�be�distinguished�from�demands,�which�are�expressed�desires,�not�necessarily�needs1
non-clinical information information�that�is�not�direct,�personal�consumer�/�patient�information
non-surgical wounds in�the�context�of�EQuIP5:
wounds�that�may�arise�following�admission�to�a�health�service�and�only�whilst�the�consumer�/�patient�is�admitted.�This�encompasses�pressure�ulcers,�or�ulcers�that�may�develop�by�other�means;�skin�tears,�caused�by�friction�and/or�tearing;�skin�infections,�etc.�This�does�not�include�wounds�that�would�be�the�purpose�of�the�admission,�such�as�burns,�wounds�related�to�cancers,�radiation�injuries�etc.
October 2010 473
nutrition care interventions,�monitoring,�and�evaluation�designed�to�facilitate�appropriate�nutrient�intake�based�upon�the�integration�of�information�from�the�nutrition�assessment6,�52
nutrition screening the�process�of�identifying�consumers�/�patients�with�characteristics�commonly�associated�with�nutrition�problems�who�may�require�comprehensive�nutrition�assessment�and�may�benefit�from�nutrition�intervention50
nutrition assessment a�comprehensive�approach�to�gathering�pertinent�data�in�order�to�define�nutritional�status�and�identify�nutrition-related�problems.�The�assessment�often�includes�consumer�/�patient�history,�medical�diagnosis�and�treatment�plan,�nutrition�and�medication�histories,�and�nutrition-related�physical�examination�including�anthropometry,�nutritional�biochemistry,�psychological,�social,�and�environmental�aspects50
objective target�that�must�be�reached�if�the�organisation�is�to�achieve�its�goals.�It�is�the�translation�of�the�goals�into�specific,�concrete�terms�against�which�results�can�be�measured1
ongoing care the�active�and�supportive�management�of�care�for�people�with�chronic�or�complex�conditions�as�well�as�the�process�that�follows�an�admission�to�a�healthcare�organisation�
open disclosure the�open�discussion�of�incidents�that�resulted�in�harm�to�a�consumer�/�patient�while�receiving�health�care.�The�criteria�of�open�disclosure�are�an�expression�of�regret,�a�factual�explanation�of�what�happened�and�the�potential�consequences,�and�the�steps�being�taken�to�manage�the�event�and�prevent�recurrence4
operational plan a�short-term�plan�that�details�how�aspects�of�a�strategic�plan�will�be�accomplished
organisation all�sites�/�locations�under�the�governance�of,�and�accountable�to,�the�governing�body�/�owner(s)1
orientation a�formal�process�of�informing�and�training�staff�on�entry�into�a�position�or�organisation,�covering�the�policies,�processes�and�procedures�applicable�to�that�healthcare�organisation4
outcome results�that�may�or�may�not�have�been�intended�that�occur�as�a�result�of�a�service�or�intervention
palliative care plan a�written�statement�developed�for�a�consumer�/�patient�who�is�suffering�from�a�life-limiting�illness,�with�little�or�no�prospect�of�a�cure,�and�for�whom�the�primary�treatment�goal�is�quality�of�life,�which�states�the�nursing�and�other�interventions�to�be�undertaken,�the�health�outcomes�to�be�achieved�and�the�review�of�care�which�will�occur�at�regular�intervals53
pathway a�multidisciplinary�plan�of�care�that�commences�before�or�on�admission�and�finishes�at�discharge�
patient master index permanent�listing�or�register�of�health�information�held�by�an�organisation�on�consumers�/�patients�who�have�received�or�are�scheduled�to�receive�services4�
performance measure in�the�context�of�EQuIP5:�
suggested�indicators�at�the�end�of�each�criterion�in�the�Guide�provided�to�assist�organisations�to�identify,�or�‘flag’,�an�issue�that�may�need�further�investigation�and�to�assist�in�the�evaluation�of�processes.�These�measures�are�distinct�from�clinical�indicators,�available�to�organisations�through�the�ACHS�Clinical�Indicator�Program
personal information information�or�an�opinion�(including�information�or�an�opinion�forming�part�of�a�database),�whether�true�or�not,�and�whether�recorded�in�a�material�form�or�not,�about�an�individual�whose�identity�is�apparent,�or�can�reasonably�be�ascertained,�from�the�information�or�opinion54
474 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
seCtion 6Glossary
policy written�statement(s)�which�acts�as�a�guideline�and�reflects�the�position�and�values�of�the�organisation�on�a�given�subject.1�All�procedures�and�protocols�should�be�linked�to�a�policy�statement4
pressure ulcer a�localised�injury�to�the�skin�and/or�underlying�tissue,�usually�over�a�bony�prominence�and�caused�by�unrelieved�pressure,�friction�or�shear.�Pressure�ulcers�occur�most�commonly�on�the�sacrum�and�heel�but�can�develop�anywhere�on�the�body.�Pressure�injury�is�a�synonymous�term�for�pressure�ulcer4
prevention and management
a�systematic�approach�adopted�by�all�sections�of�an�organisation�to�ensure�appropriate�identification�and�actions�for�consumers�/�patients�at�risk�of�an�illness�or�condition
procedure a�set�of�documented�instructions�conveying�the�approved�and�recommended�steps�for�a�particular�act�or�sequence�of�acts
process a�series�of�actions,�changes�or�functions�that�bring�about�an�end�or�a�result
psycho-social pertaining�to�a�combination�of�psychological�and�social�factors48
quality activities activities�which�measure�performance,�identify�opportunities�for�improvement�in�the�delivery�of�care�and�service,�and�include�actions�and�follow-up
quality framework an�overarching�approach�to�quality�improvement�that�promotes�integration�of�risk�management�with�quality�improvement�strategies�and�informs�decision�making�and�planning55
quality improvement ongoing�response�to�quality�assessment�data�about�a�service�in�ways�that�improve�the�processes�by�which�services�are�provided�to�consumers�/�patients1
quality use of medicines the�judicious,�appropriate,�safe�and�effective�use�of�medicines56
records all�records�within�the�organisation,�clinical�and�non-clinical
records management field�of�management�responsible�for�the�efficient�and�systematic�control�of�the�creation,�receipt,�maintenance,�use�and�disposition�of�records57
record safety the�physical�safety�of�records�such�as�from�light,�humidity,�vermin,�fire�and�moisture
record storage the�function�of�storing�records�for�future�retrieval�and�use57
recruitment and selection process�used�to�attract,�choose�and�appoint�qualified�staff32
referral the�process�of�directing�or�redirecting�a�consumer�/�patient�to�an�appropriate�specialist�or�agency�for�definitive�treatment7
relevant in�the�context�of�EQuIP�standards:
when�something�is�connected�with�a�matter;�when�there�is�a�logical�connection
research an�active,�diligent�and�systematic�process�of�inquiry�in�order�to�discover,�interpret�or�revise�facts,�events,�behaviours,�or�theories,�or�to�make�practical�applications�with�the�help�of�such�facts,�laws�or�theories�
risk the�effect�of�uncertainty�on�objectives�which�may�be�positive�and/or�negative.�Objectives�can�have�different�aspects,�such�as�financial,�health�and�safety,�and�environmental�goals�and�can�apply�at�different�levels,�such�as�strategic,�organisation-wide,�project,�product�and�process.�Risk�is�often�expressed�in�terms�of�a�combination�of�the�consequences�of�an�event�and�the�associated�likelihood�of�occurrence58
risk management coordinated�activities�to�direct�and�control�an�organisation�with�regard�to�risk,�such�as�activities�that�identify,�control�and�minimise�threats�to�the�ongoing�efficiency,�effectiveness�and�success�of�its�operations�to�deliver�desired�outcomes4,�58�
October 2010 475
risk management framework
a�set�of�components�that�provide�the�foundations�and�organisational�arrangements�for�designing,�implementing,�monitoring,�reviewing�and�continually�improving�risk�management�throughout�the�organisation.�The�framework�should�be�embedded�within�the�organisation's�overall�strategic�and�operational�policies�and�practices58
root cause analysis (RCA)
a�systematic�process�whereby�the�factors�which�contributed�to�an�incident�are�identified37
sample blood�samples�collected�from�a�consumer�/�patient�for�purposes�of�blood�or�blood�product�/�component�transfusion�/�infusion
sampling the�collection�of�a�sample�from�a�consumer�/�patient
scope of clinical practice the�extent�of�an�individual�medical�practitioner’s�clinical�practice�within�a�particular�organisation,�based�on�the�individual’s�credentials,�competence,�performance�and�professional�suitability,�and�the�needs�and�the�capability�of�the�organisation�to�support�the�medical�practitioner’s�scope�of�clinical�practice.59�This�is�delineated�after�the�process�of�credentialling
self identified Aboriginal or Torres Strait Islander person
a�person�of�Aboriginal�or�Torres�Strait�Islander�descent�who�identifies�as�an�Aboriginal�or�Torres�Strait�Islander�and�is�accepted�as�such�by�the�community�in�which�he�or�she�lives60
sentinel event an�unexpected�occurrence�involving�death�or�serious�physical�or�psychological�injury,�or�the�risk�thereof.�Serious�injury�specifically�includes�loss�of�limb�or�function.�The�phrase�"or�the�risk�thereof"�includes�any�process�variation�for�which�a�recurrence�would�carry�a�significant�chance�of�a�serious�adverse�outcome.�Such�events�signal�the�need�for�immediate�investigation�and�response6
services products�of�the�organisation�delivered�to�consumers�/�patients,�or�units�of�the�organisation�that�deliver�products�to�consumers�/�patients1
skillmix the�mix�of�posts,�grades�or�occupations�within�a�unit�/�organisation.�It�may�also�refer�to�the�combinations�of�activities�or�skills�needed�for�each�job�within�the�organisation61�
specialty ward area in�the�context�of�EQuIP5:
an�area�of�an�organisation�that�normally�treats�consumers�/�patients�with�a�specific�casemix,�for�example,�an�orthopaedic�ward,�a�paediatric�ward,�a�maternity�ward,�etc.
staff term�which�includes�employed,�visiting,�sessional,�contracted�or�volunteer�personnel
stakeholder individuals,�organisations�or�groups�that�have�an�interest�or�share�in�services1
standard a�desired�and�achievable�level�of�performance�against�which�actual�performance�is�measured1
statutory notifications any�notification�required�by�an�act�of�parliament�
statutory requirements any�requirement�laid�down�by�an�act�of�parliament�
strategic plan a�formalised�plan�that�establishes�an�organisation’s�overall�objectives�and�that�seeks�to�position�the�organisation�in�terms�of�its�environment1
strategy a�long-term�plan�of�action�designed�to�achieve�a�particular�objective
surveillance the�ongoing,�systematic�collection,�analysis�and�interpretation�of�health-related�data�essential�to�the�planning,�implementation�and�evaluation�of�public�health�practice62,�closely�integrated�with�the�timely�dissemination�of�these�data�to�those�responsible�for�prevention�and�control63
survey external�peer�review�which�measures�the�performance�of�the�organisation�against�an�agreed�set�of�standards32
476 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
seCtion 6Glossary
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49.� Law�Reform�Commission�NSW�(NSW�LRC).�DiscussionPaper30(1993)–ReviewoftheAnti-DiscriminationAct1977(NSW).Lawlink�NSW.�Sydney�NSW;�NSW�LRC.�Accessed�from�http://www.lawlink.nsw.gov.au/lrc.nsf/pages/DP30TOR�on�16�September�2010.
50.� Dietitians�Association�of�Australia.�Evidence�based�practice�guidelines�for�the�nutritional�management�of�malnutrition�in�adult�patients�across�the�continuum�of�care.�Nutr�Diet�2009;�66(Suppl.):�S1-S34.
51.� Australian�Safety�and�Compensation�Council�(ASCC).�Nationalstandardformanualtasks.Canberra�ACT;�ASCC;�2007.
52.� American�Society�for�Parenteral�and�Enteral�Nutriton�(ASPEN).�Definitionofterms.Silver�Spring�USA;�ASPEN.�Updated:�November�2009.�Accessed�from�http://www.nutritioncare.org/lcontent.aspx?id=546�on�14�September�2010.
53.� Palliative�Care�Australia�(PCA).�StandardsforprovidingqualitypalliativecareforallAustralians.�Canberra�ACT;�PCA;�2005.
54.� PrivacyAct�(1988)(Cth.)
55.� Australian�Council�on�Healthcare�Standards�(ACHS).�Riskmanagementandqualityimprovementhandbook.Sydney�NSW:�ACHS;�2007.�Accessed�from�http://www.achs.org.au/RiskMgmtQIHandbook/�on�27�July�2010.
56.� Australian�Council�for�Safety�and�Quality�in�Health�Care.�Thenationalstrategyforqualityuseofmedicines.Canberra�ACT;�Department�of�Health�and�Ageing;�2002.
57.� AS�ISO�15489.1:2002�Recordsmanagement:General.
58.� AS/NZS�ISO�31000:2010�Riskmanagement—Principlesandguidelines.
59.� Queensland�Health.�CredentialinganddefiningthescopeofclinicalpracticeformedicalpractitionersinQueensland:Apolicyandresourcehandbook.�Brisbane;�Queensland�Government;�2009.
60.� ‘The�Commonwealth�Definition’,�High�Court�judgement�in�the�case�of�CommonwealthvTasmania(1983)�46�ALR�625.
61.� Buchan�J�and�Dal�Poz�MR.�Skill�mix�in�the�health�care�workforce:�reviewing�the�evidence.�BullWorldHealthOrgan�2002;�80:�575-580.
62.� World�Health�Organization�(WHO).Publichealthsurveillance.�Geneva�CH;�WHO.�Accessed�from�http://www.who.int/immunization_monitoring/burden/routine_surveillance/en/index.html�on�2�September�2010.
63.� Thacker�S�and�Berkelman�R.�Public�health�surveillance�in��the�United�States.�Epidemiol�Rev�1988;�10:�164-190.
October 2010 479
A
ACHS Australian�Council�on�Healthcare�Standards
ADG Australian�Dangerous�Goods
AEC Animal�Ethics�Committee
AHMC Australian�Health�Ministers’�Conference
AHRQ Agency�for�Healthcare�Research�and�Quality
ALARA As�Low�As�Reasonably�Possible
ANZCMHN Australian�and�New�Zealand�College�of�Mental�Health�Nurses
ANZICS Australian�and�New�Zealand�Intensive�Care�Society
ANZSBT Australian�and�New�Zealand�Society�of�Blood�Transfusion
APAC Australian�Pharmaceutical�Advisory�Council
ARCBS Australian�Red�Cross�Blood�Service
ASERNIP-S Australian�Safety�and�Efficacy�Register�of�New�Interventional�Procedures–Surgical
ARPANSA Australian�Radiation�Protection�and�Nuclear�Safety�Agency�
AS/NZS Australian�and�New�Zealand�Standard
B
C
CABG Coronary�Artery�Bypass�Graft(s)
CCTV Closed�Circuit�Television
CEO Chief�Executive�Officer
CI Clinical�Indicator�
CIAP Clinical�Information�Access�Program
CJD Creutzfeldt-Jakob�Disease
CPD Continuing�Professional�Development
CPI Clinical�Practice�Improvement
CQI Continuous�Quality�Improvement
CPR Cardiopulmonary�Resuscitation�
CSM Customer�Services�Manager�
D
DNA Deoxyribonucleic�Acid
DRG Diagnosis�Related�Group
E
EA Excellent�Achievement�(EQuIP�Rating)
EAP Employee�Assistance�Program
ED Emergency�Department
EEO Equal�Employment�Opportunities
EPA Environmental�Protection�Authority�
EQuIP Evaluation�and�Quality�Improvement�Program
seCtion 6EQuIP5 Acronyms
480 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
seCtion 6EQuIP5 Acronyms
F
FTE Full�Time�Equivalent
G
g / L Haemoglobin�is�measured�in�grams�(g)�per�litre�(L)
GP General�Practitioner
H
HACC Health�and�Ageing�Home�and�Community�Care
Hb Haemoglobin
HIV Human�Immunodeficiency�Virus
HREC Human�Research�Ethics�Committee
HRM Human�Resources�Management
HSANZ Haematology�Society�of�Australia�&�New�Zealand
I
I&CT Information�and�Communication�Technology
ICMP Infection�Control�Management�Plan
ICU Intensive�Care�Unit
IM Information�Management
ISO International�Organization�for�Standardization
IT Information�Technology
J
JMO Junior�Medical�Officer
K
KPI Key�Performance�Indicator
L
LA Little�Achievement�(EQuIP�Rating)
LMCA Left�Main�Coronary�Artery
M
MA Marked�Achievement�(EQuIP�Rating)
MET Medical�Emergency�Team
MSDS Material�Safety�Data�Sheets
N
NA Not�Applicable
NATA National�Association�of�Testing�Authorities
NBA National�Blood�Authority
NCDDD National�Cardiovascular�Disease�and�Diabetes�Register
NEHTA National�E-Health�Transition�Authority
NFR Not�For�Resuscitation�
NHMRC National�Health�and�Medical�Research�Council
NHPA National�Health�Priority�Areas
NICS National�Institute�of�Clinical�Studies
NOHSC National�Occupational�Health�and�Safety�Commission
October 2010 481
NPAAC National�Pathology�Accreditation�Advisory�Council
NPP National�Privacy�Principles
NPS National�Prescribing�Service
NSQHS (STANDARDS)
National�Safety�and�Quality�Health�Service�(Standards)
O
OA Outstanding�Achievement�(EQuIP�Rating)
OH&S Occupational�Health�and�Safety
OWS Organisation-Wide�Survey�(ACHS�EQuIP�survey)
P
PBS Pharmaceutical�Benefits�Scheme
PDCA Plan,�Do,�Check,�Act
PDSA Plan,�Do,�Study,�Act
POS Performance�Outcomes�Service�(ACHS)
PR Periodic�Review�(ACHS�EQuIP�survey)
Q
QA Quality�Assurance
QI Quality�Improvement
QUM Quality�Use�of�Medicine
R
RACP Royal�Australasian�College�of�Physicians
RACS Royal�Australasian�College�of�Surgeons
RAND Corporation,�the�name�of�which�was�derived�from�a�contraction��of�the�termresearchanddevelopment
RANZCA Royal�Australian�and�New�Zealand�College�of�Anaesthetists
RCA Root�Cause�Analysis
RCBS Red�Cross�Blood�Service
RCNA Royal�College�of�Nursing,�Australia
S
SA Some�Achievement�(EQuIP�Rating)
SHPA Society�of�Hospital�Pharmacists�of�Australia
SIDS Sudden�Infant�Death�Syndrome
T
TQM Total�Quality�Management
U
UCLA University�of�California,�Los�Angeles
V
VA Veterans’�Affairs
VMO Visiting�Medical�Officer
VTE Venous�Thromboembolism
WXYZ
WHO World�Health�Organization
seCtion 6Acknowledgements
482 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
The�revision�of�the�Evaluation�and�Quality�Improvement�Program�(EQuIP)�is�a�major�undertaking�that�extends�over�several�years.�EQuIP5�represents�the�culmination�of�dedication�and�commitment�by�many�organisations�and�individuals�to�the�promotion�of�safety�and�quality�in�health�care.�
The�Australian�Council�on�Healthcare�Standards�(ACHS)�acknowledges�the�individuals�who�committed�their�knowledge,�experience�and,�more�significantly,�their�time�to�this�complex�task.
The�revision�of�EQuIP�programs�is�led�by�the�ACHS�Standards�Committee,�whose�role�it�is�to�steer�the�direction�and�content�of�the�standards�review�and�to�advise�on�the�applicability�of�the�standards�for�implementation�and�accreditation.�The�Standards�Committee�is�a�subcommittee�of�the�ACHS�Board�and�reports�its�recommendations�directly�to�the�ACHS�Board.�
The�development�of�EQuIP5�involved�the�formation�of�nine�working�groups,�each�chaired�by�a�member�of�the�Standards�Committee.�The�membership�of�the�working�groups�also�included�representation�from�a�broad�cross-section�of�member�organisations,�and�an�ACHS�Customer�Services�Manager�(CSM).
In�addition,�Specialist�Reference�Groups�were�established�to�review�specific�EQuIP5�criteria�and�guidelines�and�assist�in�their�development.
ACHS Board of Directors Assoc Prof Peter Woodruff (President)MBBS, ChM, FRCS, FRACS, FACS
Ms Karen Linegar (Vice President)RN, RM, BAppSc(Nurs), BBus, MHA, Dip Comm Law, FRCNA, JP
Mr John Smith PSM (Treasurer)MHA, Grad Dip HSM, AFCHSM, CHE, FAHSFMA, AFAHRI, AFAIM, FHFM, FAICD
Ms Jennie Baker BHSc(Mgt), BBus(IR), MLegSt, MIR, FCHSM, CHE
Ms Helen DowlingBPharm, Dip Hosp Pharm (Admin), Grad Dip QI HCare, CHP, FSHP, AICD
Dr David Lord MBBS, DPM, FRANZCP
Mr Russell McGowan BA
Ms Kae MartinRN, RM, BHSc(Nurs), MHA, LLB, AFCHSM
Dr Leonard Notaras AMLLB, BA, Dip Comm, BMed, MHA, MA, AFCHSM
Dr Robert PorterMBBS, FRACGP, FRACMA, AFCHSE
Mr Michael RoffGrad Cert Mgt
Dr Dana Wainwright MBBS, FRACP
Mr Stephen Walker Ass Dip Eng, BBus, Grad Dip Acc, AFCHSM, AICD
ACHS Standards CommitteeMs Helen Dowling (Chair)BPharm, Dip Hosp Pharm (Admin), Grad Dip QI HCare, CHP, FSHP, AICDStandards�Committee�Chair�(2008–),�ACHS�Board�Member,�ACHS�SurveyorArea�Director�of�Pharmacy,�Hunter�New�England�Health,�NSW�
Ms Jackie BullockRN, BA(Govt Studies) Quality�Improvement�Manager,�Hollywood�Private�Hospital,�WA
Ms Margo CarberryRN, C&FHN, AFAAQHCACHS�Surveyor,�Acting�Community�Health�Manager,�Hunter�New�England�Health�Service,�NSW�
Assoc Prof Brett EmmersonMBBS, MHA, FRANZCP, FRACMAACHS�Councillor,�ACHS�SurveyorExecutive�Director,�Division�of�Mental�Health�Services,�Metropolitan�North�Service�District,�Qld�
Dr Philip HoyleMBBS, MHA, FRACMAACHS�SurveyorMedical�Director,�Royal�Adelaide�Hospital,�SA
Mr John KennyBSc, Grad Dip QAConsultant,�Representative�of�Quality�Health�New�Zealand,�NZ
Ms Maralyn MastersRN, Grad Dip HSMACHS�CouncillorDirector�of�Nursing,�Adelaide�Day�Surgery,�SA
October 2010 483
Ms Sue McKeanMHSc(Risk Man), Grad Dip OHS, Dip OHSCorporate�Risk�&�Quality�Manager,�UnitingCare�Health,�Qld
Ms Alison McMillanRN, BEd, MBAACHS�CouncillorDirector,�Quality,�Safety�&�Patient�Experience,�Department�of�Health,�Vic
Ms Sandra MillerBHSc(MRA), Grad Dip HSc (Epi & Bio)Director,�Safety�&�Quality�Performance,�Sir�Charles�Gairdner�Hospital,�WA
Mr Stephen Walker Ass Dip Eng, BBus, Grad Dip Acc, AFCHSM, AICDACHS�Board�memberChief�Executive�Officer,�St�Andrew’s�Hospital,�SA
Ms Patricia WarnBA Representative,�Consumers’�Health�Forum,�NSW�
Assoc Prof Peter Woodruff MBBS, ChM, FRCS, FRACS, FACSACHS�PresidentACHSI�Board�member�Director�of�Vascular�Surgery,�Princess�Alexandra�Hospital,�Qld�(2003–2009)
Working Group 1: Continuum of CareCriteria 1.1.1, 1.1.2, 1.1.3, 1.1.4, 1.1.5, 1.1.6, 1.1.7
Working Group Chair: Ms Helen Dowling
Ms�Brigitte�Kaiser,�CSM
Ms�Vijia�Chain,�Consultant,�NSW
Ms�Karen�Edwards,�ACHS�Surveyor.�Chief�Executive�Officer,�Calvary�Health�Care,�Sydney,�NSW
Assoc�Prof�Brett�Emmerson,�ACHS�Surveyor.�Executive�Director,�Division�of�Mental�Health�Services,�Metropolitan�North�Service�District,�Qld
Ms�Jacqueline�Flynn,�Director�of�Nursing�Services,�Christchurch�Hospital,�NZ
Mr�David�Henderson,�ACHS�Surveyor,�Qld
Ms�Beth�Hooper,�Clinical�Manager–Anaesthetics/Recovery,�Ashford�Hospital,�SA
Mr�Ahmed�Jamal,�Clinical�Practice�Improvement�Coordinator,�Westmead�Hospital,�NSW
Ms�Michaela�Kelleher,�Clinical�Nurse�Consultant–Renal�Services,�Prince�of�Wales�Hospital,�Randwick,�NSW
Ms�Denise�Lippiatt,�Acting�Quality�and�Risk�Manager,�Concord�General�Hospital,�NSW
Dr�Chris�Maxwell,�ACHS�Surveyor.�Clinical�Director,�ACHS�Performance�and�Outcomes�Service.�Director�Clinical�Services,�The�Northern�Hospital,�Vic
Ms�Janne�McMahon,�ACHS�Consumer�Surveyor.�Representative�of�the�Private�Mental�Health�Consumer�Carer�Network,�SA
Ms�Cheryl�McWilliams,�Education�Coordinator,�Mater�Private�Hospital,�Qld
Mr�Sasha�Mikulich,�Manager,�Medicolegal�Claims,�Royal�Perth�Hospital,�WA
Ms�Kerry�Plumer,�Director,�Child�and�Family�Community�Health,�Sydney�South�West�Area�Health�Service,�NSW
Ms�Kate�Roberts,�Allied�Health�Quality�and�Research�Coordinator,�Hampstead�Rehabilitation�Centre,�Royal�Adelaide�Hospital,�SA
Ms�Patricia�Warn,�ACHS�Standards�Committee.�Representative�of�Consumers’�Health�Forum,�NSW
Ms�Peta�Welten,�Community�Clinician�Nurse�Manager,�Child�and�Adolescent�Community�Health�(CACH),�Riverlands�Region�South�Inland�Zone,�WA
Ms�Tiffany�Whittington,�Clinical�Services�Coordinator,�Noarlunga�Health�Service,�SA
Working Group 2: Access, Appropriateness and EffectivenessCriteria 1.2.1., 1.2.2, 1.3.1, 1.4.1
Working Group Chair: Ms Alison McMillan
Ms�Anne�O’Loughlin,�CSM
Ms�Fiona�Allsop,�Divisional�Manager,�Medicine,�Emergency�And�Intensive�Care,�Northern�Beaches�Health�Service,�Northern�Sydney�and�Central�Coast�Area�Health�Service,�NSW�
Ms�Julie�Ashwell,�ACHS�Surveyor.�Regional�Quality�Coordinator�(Community),�Blue�Care�Southern�Region,�Qld�
Ms�Aileen�Bradley,�Nursing�Director,�Darling�Downs�–�West�Moreton�Health�Service�District,�Qld
Ms�Darlene�Cox,�Executive�Director,�Health�Care�Consumers’�Association,�ACT
Ms�Leonie�Hobbs,�ACHS�Surveyor.�Director,�Nursing�and�Midwifery�Services,�Logan-Beaudesert,�Qld
seCtion 6Acknowledgements
484 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Ms�Vicki�Hutchinson,�Clinical�Services�Coordinator,�Quality�Assurance�Coordinator,�Mental�Health�Repatriation�General�Hospital,�SA
Ms�Nanette�Jemmeson,�Accreditation�Coordinator,�Primary�&�Community�Networks�&�Mental�Health�Services,�Hunter�New�England�Health,�NSW
Mr�Paul�R�Kachel,�ACHS�Surveyor,�Qld
Ms�Ruth�Melville,�Nurse�Unit�Manager,�Operating�Theatre,�Nambour�General�Hospital,�Qld
Ms�Christine�Mitchell,�Quality�Projects�Manager,�Castlemaine�Health,�Vic�
Ms�Linda�Nolte,�Quality�Improvement�Manager,�Peter�MacCallum�Cancer�Centre,�Vic
Ms�Sally�Percy,�ACHS�Surveyor.�Manager,�Quality�and�Risk�Management�Coordinator,�Royal�District�Nursing�Service,�Vic
Ms�Cindi�Rees,�ACHS�Surveyor.�Mission�Australia,�NSW�
Mr�Hugh�Stern,�Quality�Manager,�Mental�Health,�Southern�Health,�Vic
Ms�Deirdre�Watson,�Quality�Manager,�Southern�Health,�Vic�
Working Group 3: Safety ManagementCriteria 1.5.1. 1.5.2, 1.5.3, 1.5.4, 1.5.5, 1.5.6
Working Group Chair: Dr Philip Hoyle
Ms�Cathy�Cavanagh,�CSM
Ms�Kim�Brookes,�Acting�Clinical�Quality�Manager,�St�George�Hospital,�NSW
Ms�Christine�Ceely,�Patient�Safety�Manager,�The�Children’s�Hospital,�Westmead,�NSW
Ms�Julianne�Clift,�Quality�Manager,�Lower�Hunter�Cluster,�Hunter�New�England�Area�Health�Service,�NSW
Ms�Jennifer�Dickson,�Quality�Manager,�Peninsula�Health,�Vic
Ms�Roisin�Dunne,�Service�Improvement�Coach,�Mater�Private�Hospital,�Qld
Ms�Pauline�Gaetani,�Southern�Hospitals�Network�Accreditation�Manager,�Wollongong�Hospital�and�Community�Health�Services,�NSW
Assoc�Prof�Robert�Gibberd,�Director�Health�Services�Research�Group�(HSRG),�University�of�Newcastle,�NSW�
Mr�David�Gunderson,�ACHS�Surveyor.�Principal�Project�Officer,�Centre�for�Healthcare�Related�Infection�Surveillance�and�Prevention�(CHRISP),�Qld�
Mr�James�Harrison,�Manager,�Clinical�Services,�St�Lukes�Health,�Tas
Ms�Nicole�Jones,�Advanced�Clinical�Services�Coordinator�Anaesthetics,�Royal�Adelaide�Hospital,�SA
Ms�Beth�McErlean,�Acting�Regional�Director,�Quality�Safety�&�Performance,�Southern�Area�Health�Service,�SA
Ms�Susan�McGregor,�Transfusion�Clinical�Nurse�Consultant,�Western�Health,�Vic
Mr�Russell�McGowan,�ACHS�Board�member,�ACHS�Surveyor.�Representative�of�Consumers’�Health�Forum,�ACT�
Ms�Patricia�Nicholson,�Coordinator�Postgraduate�Specialist�Programs,�Perioperative�Stream�Coordinator,�School�of�Nursing�and�Social�Work,�University�of�Melbourne,�Vic
Ms�Gaynor�Taylor,�Clinical�Nurse�Manager,�Mercy�Hospital,�WA
Ms�Solly�Toefy,�ACHS�Surveyor.�Nurse�Manager,�Vista�Eye�Clinics,�NSW
Ms�Jenny�Tuffin,�ACHS�Surveyor.�Vice�President,�Australasian�Association�for�Quality�in�Health�Care�(AAQHC),�Tas
Working Group 4: Consumers & Risk ManagementCriteria: 1.6.1, 1.6.2, 1.6.3, 2.1.1, 2.1.2, 2.1.3
Working Group Chair: Ms Sue McKean
Ms�Jo�Heaney,�CSM
Ms�Chen�Anderson,�Group�Clinical�Risk�Coordinator,�St�John�of�God�Healthcare,�WA
Ms�Elizabeth�Apps,�Clinical�Governance�Coordinator,�Alfred�Health,�Vic
Dr�Catherine�Crock,�ACHS�Surveyor.�Physician,�Adolescent�Health,�The�Royal�Children’s�Hospital,�Vic
Ms�Lynnette�Ford,�ACHS�Surveyor.�Quality�and�Accreditation�Coordination�Team�Leader,�Patient�Safety�&�Quality�Unit,�ACT�Health,�ACT
Ms�Mary�Fullick,�Quality�Improvement�&�Accreditation�Manager,�Northern�Beaches�Health�Service,�NSW
Mr�Allan�Hall,�Director�Clinical�Governance,�Sydney�South�West�Area�Health�Service,�Area�Mental�Health�Service,�NSW
Ms�Paula�Hanlon,�ACHS�Surveyor.�Coordinator�Consumer�Participation�Services,�North�Shore-Ryde�Mental�Health�Services,�NSW
October 2010 485
Ms�Wendy�James,�Quality�Manager�/�Consumer�Advocate,�Wimmera�Health�Care�Group,�Vic
Ms�Cathy�Jones,�National�Manager,�Quality�&�Compliance,�Healthscope�Ltd,�Vic�
Ms�Lynn�Kerr,�Safety�Quality�Project�Consultant,�Central�Northern�Adelaide�Health�Service,�SA
Ms�Helen�McDonald,�Senior�Consultant,�Quality�and�Consumer�Safety,�Mental�Health�Services,�Department�of�Health�and�Human�Services,�Tas
Mr�Joseph�Pendon,�Manager,�Area�Clinical�Governance,�South�Eastern�Sydney�Illawarra�Area�Health�Service,�NSW
Dr�Astrid�Perry,�Area�Manager�Multicultural�Health,�South�Eastern�Sydney�Illawarra�Area�Health�Service,�NSW
Ms�Robyn�Ware,�Quality�Coordinator,�St�Andrew’s�Hospital,�SA
Ms�Christine�Webb,�Transfusion�Medicine�Improvement�Projects,�Greater�Southern�Area�Health�Service,�NSW�
Ms�Shirleen�Wickham,�Director,�Safety�&�Quality,�Royal�Hobart�Hospital,�Tas
Mr�Allan�Wilson,�National�Risk�Manager,�Sisters�of�Charity�Health�Service,�Qld
Working Group 5: Human RelationsCriteria: 2.2.1, 2.2.2, 2.2.3, 2.2.4, 2.2.5
Chair: Mr John Kenny
Ms�Brigitte�Kaiser,�CSM
Ms�Christine�Arnold,�Quality�Manager�and�Director�of�Nursing,�Mercy�Health,�NSW
Ms�Melissa�Condon,�Clinical�Services�Coordinator,�Roxby�Downs�Health�Services,�Woomera�Community�Hospital,�SA�
Mr�Eric�Daniels,�Director�of�Nursing�and�Midwifery,�Wagga�Wagga�Base�Hospital,�Greater�Southern�Area�Health�Service,�NSW�
Ms�Kate�Furlong,�Nurse�Unit�Manager,�Neurosciences�Unit,�Melbourne�Private�Hospital,�Vic
Ms�Alison�Garrett,�Administration�Manager,��The�Hobart�Clinic,�Tas
Ms�Sheryl�Hampson,�Director�of�Nursing,�Lithgow�Community�Private�Hospital,�NSW
Ms�Angela�Hand,�Clinical�Nurse�Educator,�Ballarat�Health�Service,�Vic
Ms�Roslyn�Hewlett,�Associate�Clinical�Service�Coordinator,�Central�Northern�Adelaide�Health�Service,�SA
Ms�Kathy�Huett,�Chief�Executive�Officer,�Edenhope�&�District�Memorial�Hospital,�Vic
Ms�Veronica�Jamison,�Director,�Support�Services,�Southern�Health,�Vic
Dr�Helen�McArdle,�Medical�Adviser,�Safety�and�Quality,�Department�of�Health�and�Human�Services,�Tas
Dr�John�Monagle,�ACHS�Surveyor.�Director�Anaesthesia�and�Perioperative�Medicine,�Southern�Health,�Vic
Ms�Joan�Murphy,�Manager,�Community�&�Allied�Health,�Wellington�Health�Service,�NSW
Ms�Jane�O’Shannessy,�Quality�&�Risk�Management,�Mater�Misericordiae�Hospital,�Mackay,�Qld
Ms�Leanne�Sice,�Regional�Clinical�Practice�Improvement�Coordinator,�Manager�Workforce�Development,�Western�Australian�Country�Health�Service�Midwest,�WA
Working Group 6: Information ManagementCriteria: 1.1.8, 2.3.1, 2.3.2, 2.3.3, 2.3.4
Chair: Ms Sandra Miller
Ms�Karen�Walkerden,�CSM
Mr�Rick�Austin,�ACHS�Surveyor,�Qld
Mr�Cameron�Barnes,�Manager�and�Privacy�Officer,�Health�Information�Services,�The�Royal�Children’s�Hospital,�Vic
Ms�Roslyn�Chataway,�Risk�Manager,�Acting�Manager,�Safety,�Quality�&�Risk�Management�Unit,�The�Queen�Elizabeth�Hospital,�SA
Ms�Maren�Jones,�Physiotherapy�Manager,�Rehabilitation,�Aged�&�Extended�Care�Services,�Port�Kembla�Hospital,�NSW
Ms�Tracy�Kerle,�Nurse�Manager,�Operating�Suite,�Gosford�Hospital,�NSW
Ms�Julia�Logan,�Head�of�Department,�Patient�Information�Management�Services,�Child�and�Adolescent�Health�Service,�WA
Ms�Tanya�Merinda,�Program�Manager,�Network�of�Alcohol�and�other�Drug�Agencies�(NADA),�NSW
Dr�Pam�Montgomery,�Director,�Fellowship�and�Standards,�Royal�Australasian�College�of�Surgeons,�Vic
seCtion 6Acknowledgements
486 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Ms�Carol�Moore,�Quality�Coordinator,�Program�Manager,�Adelaide�Community�Healthcare�Alliance,�SA
Ms�Kate�Morrissy,�Senior�Project�Officer,�Victorian�Quality�Council,�Vic
Ms�Catherine�O’Neill,�Acting�Clinical�Nurse�Manager,�Child�and�Adolescent�Health�Service,�South�Inland�Zone,�WA
Ms�Marilyn�Sneddon,�ACHS�Surveyor.�Consultant,�Vic
Dr�Susan�Shea,�Quality�Coordinator�Medical�Services,�Ballarat�Health�Service,�Vic
Ms�Jenny�Smith,�Clinical�Business�Analyst,�Clinical�Information�Systems,�Information�Management�Division,�Mater�Health�Services,�Qld
Ms�Karen�Steinhoff,�Service�Improvement�Project�Officer,�The�Children’s�Hospital,�Westmead,�NSW
Ms�Denyse�Stephens,�Quality�and�Risk�Manager,�Sydney�South�West�Area�Mental�Health�Service,�NSW
Ms�Belinda�Westlake,�Health�Information�and�Quality�Manager,�Moyne�Health�Service,�Vic
Working Group 7: GovernanceCriteria: 2.5.1, 3.1.1, 3.1.2, 3.1.3, 3.1.4, 3.1.5
Chair: Mr Stephen Walker
Ms�Karen�Walkerden,�CSM
Dr�Cathy�Balding,�ACHS�Surveyor.�Director,�Quality�Works,�Vic
Ms�Christina�Bygrave,�Program�Manager,�Department�of�Health,�WA
Mr�Wesley�Carter,�Chief�Executive�Officer,�Tallangatta�Health�Service,�Vic
Ms�Tracy�Cooke,�Risk�Manager,�Country�Health,�Whyalla�Eastern�Eyre�and�Far�North�Health�Services,�Whyalla�Hospital�and�Health�Services,�SA
Mr�Paul�Clenaghan,�Cluster�Manager,�Sydney�South�West�Area�Health�Service,�NSW
Ms�Marie�Dickinson,�Quality�Manager,�Tresillian�Family�Centres,�NSW
Ms�Margrit�Fleck,�Corporate�Quality�and�Accreditation�Manager,�Ramsay�Health�Care,�NSW
Ms�Eleri�Griffiths,�Manager,�Surgical�Services,�Armadale�Health�Services,�WA
Ms�Melissa�Harvey,�Accreditation�Coordinator,�Greater�Newcastle�Acute�Hospital�Network,�Hunter�New�England�Area�Health�Service,�NSW
Mr�Barrington�Kinnaird,�Director,�Planning,�Partnerships�and�Performance,�Sydney�South�West�Area�Mental�Health�Service,�NSW
Margaret�Lloyd-Jones,�Executive�Officer,�Mater�Hospitals,�Rockhampton,�Yeppoon,�Gladstone,�Qld
Dr�Christopher�May,�ACHS�Surveyor.�Director�of�Emergency�Services�(Bayside),�Metro�South�Health�Service�District,�Qld
Mr�Russell�McGowan,�ACHS�Board�member,�ACHS�Surveyor.�Representative�of�Consumers’�Health�Forum,�ACT
Ms�Karin�Mulligan,�Quality�Manager,�Department�of�Health�and�Families,�NT
Ms�Jenny�Rance,�ACHS�Surveyor.�National�Quality�and�Compliance�Officer,�Healthscope�Ltd,�Vic
Ms�Meredith�Rooke,�Perioperative�Services�Manager,�Cairns�Private�Hospital,�Qld
Ms�Anne�Young,�Director,�Quality�and�Risk�Management�Unit,�St�Vincent’s�Hospital,�NSW
Working Group 8: Workplace and EnvironmentCriteria: 3.2.1, 3.2.2, 3.2.3, 3.2.4, 3.2.5
Chair: Ms Jackie Bullock
Ms�Linda�Brennan,�CSM
Mr�Chris�Bone,�Director�of�Nursing,�Armadale�Health�Service,�WA
Ms�Vivienne�Bush,�Environmental�Risk�Manager,�Concord�Repatriation�General�Hospital,�NSW
Mr�John�England,�Manager,�Quality�and�Safety,�North�West�Regional�Hospital,�Tas
Ms�Josephine�Maprock,�ACHS�Surveyor.�Director,�HealthKare�Intelligence,�Vic
Dr�Forbes�McGain,�Anaesthetist,�Intensive�Care�Unit,�Western�Hospital,�Vic
Ms�Tonia�Naylor,�Nurse�Manager,�Emergency�Preparedness,�Swan�Kalamunda�Health�Service,�North�Metropolitan�Health�Service,�WA
Mr�Trevor�Nowak,�Director�of�Nursing�&�Midwifery,�Country�Health,�Barossa�Health,�SA
Ms�Jenny�Owen,�Manager,�Emergency�Management,�Southern�Health,�Vic
Ms�Sudha�Raju,�Clinical�Safety�and�Quality�Coordinator,�Sydney�West�Area�Health�Service�Oral�Health�Network,�NSW
October 2010 487
Ms�Di�Slater,�Quality�&�Risk�Manager,�Infection�Control�Coordinator,�Rehabilitation�&�RTW�Coordinator,�Caloundra�Private�Hospital,�Qld
Assoc�Prof�Richard�Smart,�Radiation�Safety�Officer,�St�George�Hospital�&�Community�Health�Service,�South�Eastern�Sydney�and�Illawarra�Area�Health�Service,�NSW
Ms�Carole�Steiner,�Nurse�Manager,�Quality�&�Safety,�Fremantle�Hospital�and�Health�Service,�WA
Mr�Phillip�Thorburn,�Director,�Biomedical�Engineering,�Royal�Adelaide�Hospital,�SA�
Ms�Karen�Wheeler,�Quality�and�Safety�Coordinator,�The�Hobart�Clinic,�Tas
Ms�Kim�White,�Human�Resources,�Quality�&�Safety�Manager,�St�John�of�God�Hospital,�Warrnambool,�Vic
Ms�Christine�Wolstenholme,�National�Occupation�Health�and�Safety�Officer,�Healthscope,�Qld
Working Group 9: Health PromotionCriterion: 2.4.1
Chair: Ms Margo Carberry
Ms�Anne�O’Loughlin,�CSM
Mr�Michael�Curry,�Clinical�Practice�Consultant,�Infectious�Diseases�Unit,�Internal�Medicine�Services,�Royal�Adelaide�Hospital,�SA
Ms�Melissa�Day,�Acting�Clinical�Practice�Consultant,�Multidisciplinary�Ambulatory�Consulting�Services,�Royal�Adelaide�Hospital,�SA
Ms�Kim�Gossage,�Zone�Director,�Community�Health,�Department�of�Health,�WA
Ms�Anne-Marie�Hayes,�Director,�Community�Health�Division,�Primary�and�Population�Health�Directorate,�Children,�Youth�and�Women’s�Health,�SA
Ms�Catherine�Hugo,�Information�Services�Manager,�Clinical�Nurse�Consultant,�Surveillance�and�Monitoring,�Hunter�New�England�Population�Health,�NSW
Ms�Gretchen�Long,�Primary�Health�Care�Coordinator,�North�Eastern�Soldiers�Memorial�Hospital�(NESM),�Scottsdale,�Tas
Ms�Jo�Anne�Rash,�Continuous�Improvement�–�Acute,�Latrobe�Regional�Hospital,�Vic
Ms�Dianne�Rudeforth,�Acting�After�Hours�Hospital�Coordinator,�Carnarvon�Hospital,�WA
Ms�Sharon�Simpson,�Health�Service�Manager,�Narrabri�Health�Service,�NSW
Mr�Robert�Stirling,�Senior�Project�Officer,�Network�of�Alcohol�and�other�Drugs�Agencies�(NADA),�NSW
Ms�Sandy�Thomson,�ACHS�Surveyor.�Consultant�/�Administrator,�Mount�Lawley�Private�Hospital,�WA
Pilot organisationsThe following healthcare organisations and facilities generously participated in the trialling of the standards as pilot organisations and provided invaluable information during the development of EQuIP5:
National�Capital�Private�Hospital�–�Healthscope�Ltd.,�Canberra,�ACT�(onsite�survey)
Calvary�Health�Care,�Sydney,�NSW�(onsite�survey)
Albury�Wodonga�Health�Service�(Wodonga�Campus),�Vic�(onsite�survey)
Greater�Newcastle�Acute�Hospital�Network,�NSW
Royal�District�Nursing�Service,�Melbourne,�Vic
Timboon�and�District�Healthcare�Service,�Vic
Child�and�Adolescent�Health�Service,�Perth,�WA
Lyell�McEwin�Hospital,�Adelaide,�SA
The�Prince�Charles�Hospital,�Brisbane,�Qld
The following ACHS surveyors kindly provided their knowledge and expertise to the onsite pilot surveys
Mr�Mark�Avery,�Qld
Mr�Sid�Ducket,�Vic
Dr�David�Henderson,�Qld
Ms�Kaye�Hogan,�ACT
Mr�Ian�Paterson,�NSW
Ms�Ros�Pearson,�Vic
Ms�Lesley�Seigloff,�SA
Ms�Maria�Stickland,�Vic
The EQuIP5 Guidelines were reviewed by a number of people, including relevant experts, surveyors, Chairs of the Working Groups, private hospital representatives and ACHS surveyors.
The ACHS gratefully acknowledges the generous contribution and dedication to quality in health of the following people and organisations that assisted in the review of the EQuIP5 guidelines:
Rev�Carl�Aiken,�President,�Spiritual�Care�Australia,�SA
Ms�Nicola�Askham,�Quality�Manager,�Toowong�Private�Hospital,�Qld�
seCtion 6Acknowledgements
488 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Dr�Cathy�Balding,�ACHS�Surveyor.�Director,�Quality�Works,�Vic
Mr�Cameron�Barnes,�Manager�and�RCH�Privacy�Officer,�Health�Information�Services,�The�Royal�Children’s�Hospital�Melbourne�/�Director,�Health�Information�Services,�Cabrini�Health,�Vic
Dr�Jenny�Bartlett,�Program�Clinical�Lead,�Quality�and�Safety,�National�E-Health�Transition�Authority�(NEHTA),�Vic
Ms�Debbie�Blanchfield,�Clinical�Nurse�Consultant�(Wound�Care),�Southern�Hospital�Network,�South�Eastern�Sydney�and�Illawarra�Area�Health�Service,�NSW
Mr�Beress�Brooks,�Executive�Director,�Safety,�Quality�&�Performance,�North�Metropolitan�Area�Health�Service,�WA
Ms�Olly�Campbell,�Manager,�Governance�and�Performance,�Safety,�Quality�and�Performance�Unit,�North�Metropolitan�Area�Health�Service,�WA
Ms�Julianne�Clift,�Quality�Manager,�Lower�Hunter�Cluster,�Hunter�New�England�Area�Health�Service,�NSW
College�of�Biomedical�Engineering�representatives,�Royal�Adelaide�Hospital,�SA
Cooperative�Research�Centre�for�Aboriginal�Health,�Improving�the�Culture�of�Hospitals�Project,�La�Trobe�University,�Vic
Ms�Lyn�David,�Acting�Director�of�Safety�&�Quality,�Department�of�Health,�WA
Mr�Sam�Dodd,�Director�of�Clinical�Services,�Linacre�Private�Hospital,�Vic
Ms�Tanya�Gawthorne,�Manager,�Clinical�Quality,�Office�of�Safety�and�Quality�in�Healthcare,�Performance�Activity�&�Quality�Division,�Department�of�Health,�WA
Mr�David�Gunderson,�ACHS�Surveyor.�Principal�Project�Officer,�Centre�for�Healthcare�Related�Infection�Surveillance�and�Prevention�(CHRISP),�Qld�
Ms�Sarah�Harper,�Senior�Project�Officer,�Clinical�Engagement,�Quality,�Safety�and�Patient�Experience,�Department�of�Health,�Vic
Prof�Ken�Hillman,�Professor�of�Intensive�Care,�University�of�NSW,�Director,�The�Simpson�Centre�for�Health�Services�Research,�NSW
Ms�Kaye�Hogan,�ACHS�Surveyor,�ACT
Rev�Cheryl�Holmes,�Chief�Executive�Officer,�Healthcare�Chaplaincy�Council�of�Victoria�Inc.,�Vic
Dr�Susan�Hooper,�Rehabilitation�Medical�Officer,�Brain�Injury�Rehabilitation�Unit,�Hampstead�Rehabilitation�Centre,�SA
Ms�Toni�Howell,�Quality�Use�of�Medicines�Pharmacist,�Quality�and�Safety�Manager,�Pharmacy�Department,�The�Royal�Melbourne�Hospital,�Vic
Dr�Paul�Hyland,�Assistant�Director,�Systems�and�Data�Development,�Blood�Sector�Clinical�Development,�National�Blood�Authority,�ACT�
Dr�Daryl�Jones,�Consultant�Intensive�Care�Specialist,�Austin�Health,�Vic
Ms�Sharon�Kendall,�Director�of�Business�Operations,�St�Andrews�Hospital,�SA
Ms�Lian�Kwa,�Coordinator,�Quality�and�Accreditation,�Child�and�Adolescent�Health�Service,�WA�
Ms�Lina�Lim,�Quality�&�Risk�Manager,��St�Vincent’s�Hospital,�Brisbane,�Qld
Ms�Julia�Logan,�Head�of�Department,�Patient�Information�Management�Services,�Child�and�Adolescent�Health,�WA
Dr�Yvonne�Luxford,�Chief�Executive�Officer,�Palliative�Care�Australia,�ACT
Ms�Mary�Ellen�Mickle,�Quality,�Risk�and�OH&S�Manager,�Executive,�Linacre�Private�Hospital,�Vic
Ms�Beth�McErlean,�Acting�Regional�Director,�Quality,�Safety�&�Performance,�Southern�Area�Health�Service,�SA
Dr�Forbes�McGain,�Anaesthetist,�Intensive�Care,�Western�Hospital,�Vic
Ms�Susan�McGregor,�Clinical�Nurse�Consultant,�Transfusion�Practice,�Western�Health,�Vic
Ms�Wendy�McIntosh,�Program�Manager,�WA�Country�Health�Service,�WA
Ms�Alison�McMillan,�Director,�Quality,�Safety�&�Patient�Experience,�Department�of�Health,�Vic�
Ms�Belinda�Newley,�Clinical�Governance�Officer,�Clinical�Safety�&�Quality�Unit,�Mater�Health�Services,�Qld
Dr�Gerry�O’Callaghan,�National�Medical�Director,�Australian�Organ�and�Tissue�Donation�and�Transplantation�Authority,�SA
Ms�Lyndall�Olsen,�Quality�Improvement�Coordinator,�Clinical�Quality�and�Safety�Unit,�Mater�Health�Services,�Qld
Ms�JoAnne�Oosen,�Quality�and�Risk�Manager,�Belmont�Private�Hospital,�Qld
October 2010 489
Mr�Glen�Pang,�Network�Manager�–�Nutrition,�Greater�Metropolitan�Clinical�Taskforce,�NSW
Dr�Astrid�Perry,�Area�Manager,�Multicultural�Health,�South�Eastern�Sydney�Illawarra�Area�Health�Service,�NSW
Dr�Grant�Phelps,�Clinical�Lead,�Clinical�Engagement�Program,�Victorian�Department�of�Health,�Vic
Mr�Paul�Philcox,�Nurse�Clinical�Services�Coordinator,�Orthopaedic,�Amputee�and�Burns�Rehabilitation�Unit,�Hampstead�Rehabilitation�Centre,�SA
Ms�Sandra�Polmear,�Performance�Evaluation�Manager,�Armadale�Health�Service,�WA
Ms�Jill�Porteous,�Director,�Safety�Quality�&�Performance,�WA�Country�Health�Service,�WA
Dr�Beverleigh�Quested,�Senior�Transfusion�Nurse�Educator,�Australian�Red�Cross,�SA
Ms�Trudi�Ruane,�Director�Safety,�Quality�and�Performance,�Child�and�Adolescent�Health�Service,�WA�
Ms�Carolyn�Saunders,�Manager,�South�Metropolitan�Area�Health�Service�Policy�Unit,�Royal�Perth�Hospital,�WA
Ms�Di�Slater,�Quality�&�Risk�Manager,�Infection�Control�Co-ordinator,�Rehabilitation�&�Return�to�Work�Coordinator,�Caloundra�Private�Hospital,�Qld
Assoc�Prof�Richard�Smart,�Radiation�Safety�Officer,�St�George�Hospital�&�Community�Health�Service,�South�Eastern�Sydney�and�Illawarra�Area�Health�Service,�NSW
Dr�Amanda�Thomson,�Expert�Working�Group,�Patient�Blood�Management�Guidelines,�National�Health�and�Medical�Research�Council�(NHMRC);�Representative�and�Co-Chair,�Australian�and�New�Zealand�Society�of�Blood�Transfusion�(ANZSBT),�National�Blood�Authority�(NBA),�NSW�
Ms�Lesley�Townsend,�Coordinator,�Research�Development�Office,�Royal�Prince�Alfred�Hospital,�NSW
Dr�Janet�Wale,�Representative�of�Consumers’�Health�Forum,�The�Cochrane�Collaboration�Consumer�Network,�Vic
Mr�Robert�Walsh,�ACHS�Surveyor.�Chief�Executive�Officer,�St.�Vincent’s�Private�Hospital,�Lismore,�NSW
Ms�Robyn�Ware,�Quality�Coordinator,�St�Andrews�Hospital,�SA
Mr�John�Willis,�Aboriginal�Health�Coordinator�and�Mission�Liaison,�St�Vincent’s�Hospital�Melbourne,�Vic
Mr�Allan�Wilson,�National�Risk�Manager,��Sisters�of�Charity�Health�Service,�Qld
The ACHS also gratefully acknowledges the generous contribution and dedication to quality in health of the following ACHS surveyors who assisted in the review of the EQuIP5 guidelines:
Mr�Mark�Avery,�ACHS�Surveyor.�Health�Services�and�Management�Consultant,�The�Consultancy�Bureau,�Qld
Mr�Peter�Barber,�ACHS�Surveyor.�Director�of�Nursing�&�Midwifery,�Executive�Officer,�Gloucester�District�Health�Service,�Hunter�New�England�Area�Health�Service,�NSW
Mr�Grant�Carey-Ide,�ACHS�Surveyor.�Executive�Director,�Aged�Care�&�Rehabilitation�Service,�ACT�Health,�ACT
Ms�Val�Coughlin-West,�ACHS�Surveyor,�Qld
Dr�Catherine�Crock,�ACHS�Surveyor.�Physician�Adolescent�Health,�The�Royal�Children’s�Hospital,�Vic
Ms�Karen�Edwards,�ACHS�Surveyor.�Chief�Executive�Officer,�Calvary�Health�Care,�Sydney,�NSW
Dr�Jacki�Flynn,�ACHS�Surveyor.�Director�of�Clinical�Services,�St�Vincent’s�Hospital,�Lismore,�NSW
Ms�Lynnette�Ford,�ACHS�Surveyor.�Quality�and�Accreditation�Coordination�Team�Leader,�Patient�Safety�&�Quality�Unit,�ACT�Health,�ACT
Mr�Vince�Gagliotti,�ACHS�Surveyor.�Manager,�Quality�and�Improvement,�Clinical�Governance�Unit,�St�Vincent’s�Hospital,�Melbourne,�Vic
Ms�Sharon�Godleman,�ACHS�Surveyor.�Executive�Officer,�Director�of�Nursing,�Country�Health,�SA
Ms�Robyn�Goffe,�ACHS�Surveyor,�NSW
Dr�Deane�Golding,�ACHS�Surveyor.�Clinical�Consultant,�Dental�&�Eyecare�Practices�AHM�(Australian�Health�Management),�NSW
Dr�Rob�Griffin,�ACHS�Surveyor.�Director�of�Medical�Services,�Calvary�Health�Care,�ACT
Dr�Lee�Gruner,�ACHS�Surveyor.�Director,�Quality�Directions�Australia,�Vic
Ms�Garda�Hemming,�ACHS�Surveyor.�Redevelopment�Manager�/�Administrator,�Townsville�Health�Service�District,�Qld
Ms�Marion�Holden,�ACHS�Surveyor.�Chief�Executive�Officer�/�Director�of�Nursing,�Whyalla�Aged�Care�Inc.,�SA
Ms�Judy�Hoskins,�ACHS�Surveyor.�Nursing�and�Healthcare�Consultant,�Qld
Mr�Graeme�Houghton,�ACHS�Surveyor,�Vic.�Hospital�Standards�&�Accreditation�Advisor,�Department�of�Health,�PNG
seCtion 6Acknowledgements
490 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Mr�Peter�Hurst,�ACHS�Surveyor,�NSW
Ms�Lesley�Innes,�ACHS�Surveyor.�Senior�Management�and�Leadership�Development�Consultant,�Centre�for�Education�and�Workforce�Development,�Sydney�South�West�Area�Health�Service,�NSW
Dr�Peter�Kendall,�ACHS�Surveyor.�Clinical�Assoc�Prof,�Respiratory�Medicine,�Fremantle�Hospital;�Clinical�Lead,�Health�Networks�Branch,�Department�of�Health;�Medical�Adviser,�Clinical�Governance,�South�Metropolitan�Area�Health�Service,�WA
Ms�Dianne�Knight,�ACHS�Surveyor,�Qld�
Dr�David�Lord,�ACHS�Board,�ACHS�Surveyor,�WA
Mr�Stuart�MacKinnon,�ACHS�Surveyor.�Commissioning�Manager,�Orange�Health�Service�Redevelopment,�Bloomfield�Hospital,�NSW
Ms�Jill�Michelson,�ACHS�Surveyor.�Operations�Manager,�Marie�Stopes�International,�SA
Ms�Helen�Milne,�ACHS�Surveyor.�Director�Innovation�and�Reform,�Hunter�New�England�Area�Health�Service,�NSW
Ms�Rosalind�O’Sullivan,�ACHS�Surveyor.�Clinical�Group�Manager,�South�Eastern�Sydney�and�Illawarra�Area�Health�Service,�NSW
Ms�Ros�Pearson,�ACHS�Surveyor.�Consultant,�Vic
Ms�Sally�Percy,�ACHS�Surveyor.�Manager,�Quality�and�Risk�Management�Coordinator,�Royal�District�Nursing�Service,�Vic
Mr�David�Plunkett,�ACHS�Surveyor.�Executive�Director�Nursing,�Access�&�Patient�Support�Services�(Chief�Nursing�&�Midwifery�Officer),�Eastern�Health,�Vic
Ms�Monica�Seth,�ACHS�Surveyor.�Community�Care�Manager,�Central�Queensland�Cluster,�Bluecare,�Qld
Ms�Susan�Shaw,�ACHS�Surveyor.�Manager�of�Corporate�Systems�Review�and�Redesign,�Consultant�to�the�Eastern,�Central�&�Western�Clusters�–�Mental�Health�&�Drug�&�Alcohol�Program,�Sydney�West�Area�Health�Service,�NSW
Ms�Lesley�Siegloff,�ACHS�Surveyor.�Associate�Dean,�Practice�Development,�Senior�Lecturer,�Nursing�&�Aged�Care,�School�of�Nursing�and�Midwifery,�Faculty�of�Health�Sciences,�Flinders�University,�SA
Ms�Heather�Brown,�ACHS�Surveyor.�Accreditation�/�Quality�Coordinator,�Quality�Improvement,�Royal�Prince�Alfred�Hospital,�NSW
Ms�Marilyn�Sneddon,�ACHS�Surveyor.��MSPS�Project�Services�(Consultancy),�Vic
Ms�Jean�Spurge,�ACHS�Surveyor,�NSW
Ms�Rosie�Taylor,�ACHS�Surveyor,�SA
Ms�Sandy�Thomson,�ACHS�Surveyor.�Consultant�/�Administrator,�Mount�Lawley�Private�Hospital,�WA
Ms�Wendy�Wood,�ACHS�Surveyor.�Deputy�Chief�Executive�Officer�/�Director�of�Cancer�Nursing,�Peter�MacCallum�Cancer�Centre,�Vic
Reference GroupsBlood
Ms�Sally�Francis,�Clinical�Nurse�Consultant,�Transfusion�Medicine,�Northern�Sydney�Central�Coast�Area�Health�Service,�NSW
Ms�Jo�Main,�Transfusion�Nurse�Consultant,�Peter�MacCallum�Cancer�Centre,�Vic�
Ms�Jennifer�Roberts,�Director,�Blood�Counts,�National�Blood�Authority,�Vic
Ms�Lisa�Stevenson,�Transfusion�Clinical�Nurse�Consultant,�Blood�Matters�–�better�safer�transfusion�program,�Statewide�Quality�Branch,�Department�of�Human�Services;�Australian�Red�Cross�Blood�Service,�Vic
Dr�Beverleigh�Quested,�Transfusion�Nurse�Educator,�BloodSafe,�Australian�Red�Cross�Blood�Services,�SA.
Ms�Kaye�Hogan,�ACHS�Surveyor,�ACT
Prof�James�Isbister,�University�of�Sydney,�Adj�Prof,�University�of�Technology,�Sydney;�Emeritus�Consultant�Haematologist,�Royal�North�Shore�Hospital,�NSW
Dr�Peter�Flanagan,�National�Medical�Director,�New�Zealand�Blood�Service,�past�President�Council�of�Australian�and�New�Zealand�Society�of�Blood�Transfusion,�NZ
Dr�James�Thyer,�Senior�Advisor�Blood�Governance�and�Policy,�Red�Cross�Australia,�Vic
infection control
Mr�David�Gunderson,�ACHS�Surveyor.�Principal�Project�Officer,�Centre�for�Healthcare�Related�Infection�Surveillance�and�Prevention�(CHRISP),�Qld
Ms�Judith�Flis,�Clinical�Nurse�Consultant,�Infection�Control,�Sydney�South�West�Area�Health�Service�Oral�Health�Service,�NSW
Ms�Di�Slater,�Quality�&�Risk�Manager,�Infection�Control�Co-ordinator,�Rehabilitation�&�Return�to�Work�Coordinator,�Caloundra�Private�Hospital,�Qld
October 2010 491
Ms�Sandra�Polmear,�Asst�Manager�Performance�Review,�SQuIRes�Project�Manager,�Department�of�Health,�WA�
Ms�Mary-Rose�Godsell,�South�West�Infection�Control�Nurse�Consultant,�Country�Health�Service�–�South�West,�WA�
nutrition
Ms�Rhonda�Matthews,�Nutrition�Matters�Program�Manager,�Clinical�Governance�Unit,�Northern�Sydney�Central�Coast�Health;�Co-chair�Nutrition�in�Hospitals�Group,�Greater�Metropolitan�Clinical�Taskforce,�Royal�North�Shore�Hospital,�NSW
Mr�Glen�Pang,�Network�Manager�–�Nutrition,�Greater�Metropolitan�Clinical�Taskforce,�NSW
Dr�Merrilyn�Banks,�Director,�Nutrition�&�Dietetics,�Royal�Brisbane�&�Women’s�Hospital;�Honorary�Fellow,�School�of�Public�Health,�Queensland�University�of�Technology,�Qld
Ms�Marie�Smith,�Director�of�Nutrition,�Calvary�Health�Care,�ACT
Assoc�Prof�Judy�Bauer,�Nutrition�Services�Manager,�The�Wesley�Hospital;�Assoc�Professor,�School�of�Human�Movement�Studies,�University�of�Queensland,�Qld
Ms�Cheryl�Watterson,�Director�of�Nutrition�and�Dietetics,�Greater�Newcastle�Acute�Hospital�Network,�John�Hunter�Hospital;�Conjoint�Lecturer,�School�of�Health�Sciences,�Faculty�of�Health,�University�of�Newcastle,�NSW
Ms�Kay�Gibbons,�Manager,�Nutrition�&�Food�Services,�The�Royal�Children’s�Hospital,�Vic�
Ms�Linda�Nolte,�Quality�Improvement�Manager,�Peter�MacCallum�Cancer�Centre,�Vic
Ms�Jacquie�Krassie,�Dietitian�and�Food�Service�Consultant,�Vic�
Dr�Karen�Walton,�Acting�Coordinator�Nutrition�and�Dietetics�Programs,�School�of�Health�Sciences,�University�of�Wollongong,�NSW
Dr�Elizabeth�Isenring,�Senior�Lecturer,�University�of�Queensland,�Qld
Ms�Vicki�Barrington,�Food�Services�Dietitian,�Peter�MacCallum�Cancer�Centre,�Vic�
Ms�Carolyn�Hankins,�Senior�Dietitian�–�Foodservice,�Repatriation�General�Hospital,�SA
Ms�Joanne�Prendergast,�Manager,�Nutrition�and�Dietetics,�Royal�North�Shore�Hospital,�NSW
Ms�Karen�Storer,�Senior�Dietitian,�St�Vincent’s�Hospital,�NSW
Ms�Rhonda�Anderson,�Manager,�Nutrition�and�Dietetics,�Concord�Hospital,�NSW
Ms�Dawn�Vanderkroft,�Manager,�Nutrition�and�Dietetics,�Gosford�Hospital,�NSW
Ms�Tanya�Hazlewood,�Manager,�Nutrition�and�Dietetics,�Liverpool�Hospital,�NSW
ACHS Executive Mr�Brian�Johnston,�Chief�Executive
Ms�Darlene�Hennessy,�Executive�Director�–�Development
Ms�Laurie�Leigh,�Executive�Director�–�Customer�Services
Ms�Lena�Low,�Executive�Director�–�Corporate�Services
ACHS EQuIP5 project teamMs�Darlene�Hennessy,�Executive�Director�–�Development
Ms�Deborah�Jones,�Senior�Project�Officer,�EQuIP5�Project�Manager,�Standards�and�Program�Development
Dr�Jen�Bichel-Findlay,�Coordinator,�Performance�and�Outcomes�Service
Ms�Bronwyn�Fleming,�Project�Officer,�Standards�and�Program�Development
Ms�Elizabeth�Kingsley,�Project�Officer,�Standards�and�Program�Development
Ms�Natasha�Lo,�Project�Officer,�Standards��and�Program�Development
Ms�Anne�McIntosh,�Project�Officer,�Development�Unit
Ms�Phoebe�Zhang,�Project�Officer,�Performance��and�Outcomes�Service
ACHS EQuIP5 project administrationMs�Lesley�Bateman�
Ms�Blanche�Wiseman�
492 The ACHS EQuIP5 Guide Book 2 Accreditation, Standards and Guidelines Support and Corporate Functions
Contact and Information
Inquiries regarding EQuIP5, other ACHS accreditation programs and program education and support, should be directed to:
The Australian Council on Healthcare Standards (ACHS) 5 Macarthur Street Ultimo NSW 2007 Australia
+61 2 9281 9955
+61 2 9211 9633
www.achs.org.au
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