Dental NS01* National Standard 1 - Governance for Safety and Quality in Health Service Organisations

• National Standard 1 - Governance for Safety and Quality in Health Service Organisations (for Dental Services)

• Client / Site

• Conducted on

  Date

• Conducted by Marrianne Beaty (DHSV Oral Health National Standards Advisor)

• Personnel

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  Address

Criterion 1 - Governance and quality improvement systems

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

  Not Met

  SM

  MM

  N/A

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

  Not Met

  SM

  MM

  N/A

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

  Not Met

  SM

  MM

  N/A

• 1.2.2 Action is taken to improve the safety and quality of patient care (Developmental)

  Not Met

  SM

  MM

  N/A

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

  Not Met

  SM

  MM

  N/A

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

  Not Met

  SM

  MM

  N/A

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

  Not Met

  SM

  MM

  N/A

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

  Not Met

  SM

  MM

  N/A

• 1.4.2 Annual mandatory training programs to meet the requirements of these Standards (Developmental)

  Not Met

  SM

  MM

  N/A

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

  Not Met

  SM

  MM

  N/A

• 1.4.4 Competency-based training is provided to the clinical workforce to improve safety and quality (Developmental)

  Not Met

  SM

  MM

  N/A

• 1.5.1 An organization-wide risk register is used and regularly monitored

  Not Met

  SM

  MM

  N/A

• 1.5.2 Actions are taken to minimize risks to patient safety and quality of care

  Not Met

  SM

  MM

  N/A

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

  Not Met

  SM

  MM

  N/A

• 1.6.2 Actions are taken to maximize patient quality of care

  Not Met

  SM

  MM

  N/A

Criterion 2 - Clinical practice

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

  Not Met

  SM

  MM

  N/A

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

  Not Met

  SM

  MM

  N/A

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

  Not Met

  SM

  MM

  N/A

• 1.8.2 Early action is taken to reduce the risks for at "risk" patients

  Not Met

  SM

  MM

  N/A

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

  Not Met

  SM

  MM

  N/A

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

  Not Met

  SM

  MM

  N/A

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

  Not Met

  SM

  MM

  N/A

Criterion 3 - Performance and skills management

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

  Not Met

  SM

  MM

  N/A

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

  Not Met

  SM

  MM

  N/A

• 1.10.3 Organizational clinical service capability, planning, and scope of practice is directly linked to the clinical service roles of the organization

  Not Met

  SM

  MM

  N/A

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

  Not Met

  SM

  MM

  N/A

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

  Not Met

  SM

  MM

  N/A

• 1.11.1 A valid and reliable performance review process is in place

  Not Met

  SM

  MM

  N/A

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

  Not Met

  SM

  MM

  N/A

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

  Not Met

  SM

  MM

  N/A

• 1.13.1 Analyze feedback from the workforce on their understanding and use of safety and quality systems (Developmental)

  Not Met

  SM

  MM

  N/A

• 1.13.2 Action is taken to increase workforce understanding and use of safety and quality systems (Developmental)

  Not Met

  SM

  MM

  N/A

Criterion 4 - Incident and complaints management

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

  Not Met

  SM

  MM

  N/A

• 1.14.2 Systems are in place to analyse and report on incidents

  Not Met

  SM

  MM

  N/A

• 1.14.3 Feedback on the analysis of reported incidents is provided to the workforce

  Not Met

  SM

  MM

  N/A

• 1.14.4 Action is taken to reduce risks to patients identified through the incident management system

  Not Met

  SM

  MM

  N/A

• 1.14.5 Incidents and analysis of incidents are reviewed at the highest level of governance in the organization

  Not Met

  SM

  MM

  N/A

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

  Not Met

  SM

  MM

  N/A

• 1.15.2 Systems are in place to analyze and implement improvements in response to complaints

  Not Met

  SM

  MM

  N/A

• 1.15.3 Feedback is provided to the workforce on the analysis of reported complaints

  Not Met

  SM

  MM

  N/A

• 1.15.4 Patient feedback and complaints are reviewed at the highest level of governance in the organization

  Not Met

  SM

  MM

  N/A

• 1.16.1 An open disclosure program is in place and is consistent with the national open disclosure standard (Developmental)

  Not Met

  SM

  MM

  N/A

• 1.16.2 The clinical workforce are trained in open disclosure processes (Developmental)

  Not Met

  SM

  MM

  N/A

Criterion 5 - Patient rights and engagement

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

  Not Met

  SM

  MM

  N/A

• 1.17.2 Information on patient rights is provided and explained to patients and carers

  Not Met

  SM

  MM

  N/A

• 1.17.3 Systems are in place to support patients who are at risk of not understanding their healthcare rights (Developmental)

  Not Met

  SM

  MM

  N/A

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

  Not Met

  SM

  MM

  N/A

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

  Not Met

  SM

  MM

  N/A

• 1.18.3 Mechanisms are in place to align the information provided to patients with their capacity to understand (Developmental)

  Not Met

  SM

  MM

  N/A

• 1.18.4 Patients and carers are supported to document clear advance care directives and/or treatment-limiting orders (Not Applicable for Dental Services)

  Not Met

  SM

  MM

  N/A

• 1.19.1 Patient clinical records are available at the point of care

  Not Met

  SM

  MM

  N/A

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

  Not Met

  SM

  MM

  N/A

• 1.20.1 Data collected from patient feedback systems are used to measure and improve health services in the organization

  Not Met

  SM

  MM

  N/A