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Inspection

Governance for Safety and Quality in Health Service Organisations

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

Establishing and maintaining a clinical governance framework

Identifying safety and quality risks

Collecting and reviewing performance data

Implementing prevention strategies based on data analysis

Analysing reported incidents

Implementing performance management procedures

Ensuring compliance with legislative requirements and relevant industry standards

Communicating with and informing the clinical and non-clinical workforce

Undertaking regular clinical audits

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

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

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

Patient safety and quality in their delivery of health care

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

1.4 Implementing training in the assigned safety and quality roles and responsibilities

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

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

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

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

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

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

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

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

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

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

1.15 Implementing a complaints management system that includes partnership with patients and carers

1.16 Implementing an open disclosure process based on the national open disclosure standard

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

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

1.19 Implementing procedures that protect the confidentiality of patient clinical records without compromising appropriate clinical workforce access to patient clinical information

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

Partnering with Consumers

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

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

Strategic and operational/services planning

Decision making about safety and quality initiatives

Quality improvement activities

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

2.4 Consulting consumers on patient information distributed by the organisation

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

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

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

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

2.9 Consumers and/or carers participating in the evaluation of patient feedback data and development of action plans

Preventing and Controlling Healthcare-Associated Infections

3.1 Developing and implementing governance systems for effective infection prevention and control to minimise the risks to patients of healthcare associated infections

3.2 Undertaking surveillance of healthcare associated infections

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

3.4 Undertaking quality improvement activities to reduce healthcare associated infections through changes to practice

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

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

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

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

3.9 Implementing protocols for invasive device procedures regularly performed within the organisation

3.10 Developing and implementing protocols for aseptic technique

3.11 Implementing systems for using standard precautions and transmissionbased precautions

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

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

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

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

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

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

3.18 Ensuring workforce who decontaminate reusable medical devices undertake competency-based training in these practices

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

Medication Safety

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

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

4.3 Authorising the relevant clinical workforce to prescribe, dispense and administer medications

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

4.5 Undertaking quality improvement activities to enhance the safety of medicines use

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

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

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

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

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

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

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

4.13 The clinical workforce informing patients and carers about medication treatment options, benefits and associated risks

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

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

Patient Identification and Procedure Matching

5.1 Developing, implementing and regularly reviewing the effectiveness of a patient identification system including the associated policies, procedures and/or protocols that:

Define approved patient identifiers

Require at least three approved patient identifiers on registration or admission

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

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

5.2 Implementing a robust organisationwide system of reporting, investigation and change management to respond to any patient care mismatching events

5.3 Ensuring that when a patient identification band is used, it meets the national specifications for patient identification bands

5.4 Developing, implementing and regularly reviewing the effectiveness of the patient identification and matching system at patient handover, transfer and discharge

5.5 Developing and implementing a documented process to match patients to their intended procedure, treatment or investigation and implementing the consistent national guidelines for patient procedure matching protocol or other relevant protocols5

Clinical Handover

6.1 Developing and implementing an organisational system for structured clinical handover that is relevant to the healthcare setting and specialities, including:

Documented policy, procedures and/ or protocols

Agreed tools and guides

6.2 Establishing and maintaining structured and documented processes for clinical handover

6.3 Monitoring and evaluating the agreed structured clinical handover processes, including:

Regularly reviewing local processes based on current best practice in collaboration with clinicians, patients and carers

Undertaking quality improvement activities and acting on issues identified from clinical handover reviews

Reporting the results of clinical handover reviews at executive level of governance

6.4 Implementing a robust organisationwide system of reporting, investigation and change management to respond to any clinical handover incidents

Blood and Blood Products

7.1 Developing governance systems for safe and appropriate prescription, administration and management of blood and blood products

7.2 Undertaking a regular, comprehensive assessment of blood and blood product systems to identify risks to patient safety and taking action to reduce risks

7.3 Ensuring blood and blood product adverse events are included in the incidents management and investigation system

7.4 Undertaking quality improvement activities to improve the safe management of blood and blood products

7.5 As part of the patient treatment plan, the clinical workforce accurately documenting:

Relevant medical conditions

Indications for transfusion

Any special product or transfusion requirements

Known patient transfusion history

Type and volume of product transfusion

Patient response to transfusion

7.6 The clinical workforce documenting any adverse reactions to blood or blood products

7.7 Ensuring the receipt, storage, collection and transport of blood and blood products within the organisation are consistent with best practice and/or guidelines

7.8 Minimising unnecessary wastage of blood and blood products

7.9 The clinical workforce informing patients and carers about blood and blood product treatment options, and the associated risks and benefits

7.10 Providing information to patients about blood and blood product use and possible alternatives in a format that can be understood by patients and carers

7.11 Implementing an informed consent process for all blood and blood product use

Preventing and Managing Pressure Injuries

8.1 Developing and implementing policies, procedures and/or protocols that are based on current best practice guidelines

8.2 Using a risk assessment framework and reporting systems to identify, investigate and take action to reduce the frequency and severity of pressure injuries

8.3 Undertaking quality improvement activities to address safety risks and monitor the systems that prevent and manage pressure injuries

8.4 Providing or facilitating access to equipment and devices to implement effective prevention strategies and best practice management plans

8.5 Identifying risk factors for pressure injuries using an agreed screening tool for all presenting patients within timeframes set by best practice guidelines

8.6 Conducting a comprehensive skin inspection in timeframes set by best practice guidelines on patients with a high risk of developing pressure injuries at presentation, regularly as clinically indicated during a patient’s admission, and before discharge

8.7 Implementing and monitoring pressure injury prevention plans and reviewing when clinically indicated

8.8 Implementing best practice management and ongoing monitoring as clinically indicated

8.9 Informing patients with a high risk of pressure injury, and their carers, about the risks, prevention strategies and management of pressure injuries

8.10 Developing a plan of management in partnership with patients and carers

Recognizing and Responding to Clinical Deterioration in Acute Health Care

9.1 Developing, implementing and regularly reviewing the effectiveness of governance arrangements and the policies, procedures and/or protocols that are consistent with the requirements of the National Consensus Statement

9.2 Collecting information about the recognition and response systems, providing feedback to the clinical workforce, and tracking outcomes and changes in performance over time

9.3 Implementing mechanism(s) for recording physiological observations that incorporates triggers to escalate care when deterioration occurs

9.4 Developing and implementing mechanisms to escalate care and call for emergency assistance where there are concerns that a patient’s condition is deteriorating

9.5 Using the system in place to ensure that specialised and timely care is available to patients whose condition is deteriorating

9.6 Having a clinical workforce that is able to respond appropriately when a patient’s condition is deteriorating

9.7 Ensuring patients, families and carers are informed about, and are supported so that they can participate in, recognition and response systems and processes

9.8 Ensuring that information about advance care plans and treatmentlimiting orders is in the patient clinical record, where appropriate

9.9 Enabling patients, families and carers to initiate an escalation of care response

Preventing Falls and Harm from Falls

10.1 Developing, implementing and reviewing policies, procedures and/or protocols, including the associated tools, that are based on the current national guidelines for preventing falls and harm from falls

10.2 Using a robust organisation-wide system of reporting, investigation and change management to respond to falls incidents

10.3 Undertaking quality improvement activities to address safety risks and ensure the effectiveness of the falls prevention system

10.4 Implementing falls prevention plans and effective management of falls

10.5 Using a best practice-based tool to screen patients on presentation, during admission and when clinically indicated for the risk of falls

10.6 Conducting a comprehensive risk assessment for patients identified at risk of falling in initial screening processes

10.7 Developing and implementing a multifactorial falls prevention plan to address risks identified in the assessment

10.8 Patients at risk of falling are referred to appropriate services, where available, as part of the discharge process

10.9 Informing patients and carers about the risk of falls, and falls prevention strategies

10.10 Developing falls prevention plans in partnership with patients and carers

Completion
Full name and signature of auditor

National Safety and Quality Health Service Standards Audit

Created by: SafetyCulture Staff | Industry: General | Downloads: 5

This National Safety and Quality Health Service Standards Audit is a tool used by safety officers to evaluate governance, processes, and policies established in the organization to help protect the public from harm and improve quality of health care. This audit checklist is divided into 10 sections that detail all of the essential areas to assess if the organization has met the safety and quality health service standards.

Signup for a free iAuditor account to download and edit this checklist. It will be added to your free account and you will be able to conduct inspections from your mobile device.

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Inspection

Governance for Safety and Quality in Health Service Organisations

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

Establishing and maintaining a clinical governance framework

Identifying safety and quality risks

Collecting and reviewing performance data

Implementing prevention strategies based on data analysis

Analysing reported incidents

Implementing performance management procedures

Ensuring compliance with legislative requirements and relevant industry standards

Communicating with and informing the clinical and non-clinical workforce

Undertaking regular clinical audits

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

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

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

Patient safety and quality in their delivery of health care

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

1.4 Implementing training in the assigned safety and quality roles and responsibilities

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

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

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

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

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

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

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

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

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

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

1.15 Implementing a complaints management system that includes partnership with patients and carers

1.16 Implementing an open disclosure process based on the national open disclosure standard

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

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

1.19 Implementing procedures that protect the confidentiality of patient clinical records without compromising appropriate clinical workforce access to patient clinical information

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

Partnering with Consumers

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

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

Strategic and operational/services planning

Decision making about safety and quality initiatives

Quality improvement activities

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

2.4 Consulting consumers on patient information distributed by the organisation

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

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

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

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

2.9 Consumers and/or carers participating in the evaluation of patient feedback data and development of action plans

Preventing and Controlling Healthcare-Associated Infections

3.1 Developing and implementing governance systems for effective infection prevention and control to minimise the risks to patients of healthcare associated infections

3.2 Undertaking surveillance of healthcare associated infections

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

3.4 Undertaking quality improvement activities to reduce healthcare associated infections through changes to practice

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

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

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

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

3.9 Implementing protocols for invasive device procedures regularly performed within the organisation

3.10 Developing and implementing protocols for aseptic technique

3.11 Implementing systems for using standard precautions and transmissionbased precautions

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

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

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

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

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

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

3.18 Ensuring workforce who decontaminate reusable medical devices undertake competency-based training in these practices

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

Medication Safety

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

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

4.3 Authorising the relevant clinical workforce to prescribe, dispense and administer medications

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

4.5 Undertaking quality improvement activities to enhance the safety of medicines use

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

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

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

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

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

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

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

4.13 The clinical workforce informing patients and carers about medication treatment options, benefits and associated risks

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

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

Patient Identification and Procedure Matching

5.1 Developing, implementing and regularly reviewing the effectiveness of a patient identification system including the associated policies, procedures and/or protocols that:

Define approved patient identifiers

Require at least three approved patient identifiers on registration or admission

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

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

5.2 Implementing a robust organisationwide system of reporting, investigation and change management to respond to any patient care mismatching events

5.3 Ensuring that when a patient identification band is used, it meets the national specifications for patient identification bands

5.4 Developing, implementing and regularly reviewing the effectiveness of the patient identification and matching system at patient handover, transfer and discharge

5.5 Developing and implementing a documented process to match patients to their intended procedure, treatment or investigation and implementing the consistent national guidelines for patient procedure matching protocol or other relevant protocols5

Clinical Handover

6.1 Developing and implementing an organisational system for structured clinical handover that is relevant to the healthcare setting and specialities, including:

Documented policy, procedures and/ or protocols

Agreed tools and guides

6.2 Establishing and maintaining structured and documented processes for clinical handover

6.3 Monitoring and evaluating the agreed structured clinical handover processes, including:

Regularly reviewing local processes based on current best practice in collaboration with clinicians, patients and carers

Undertaking quality improvement activities and acting on issues identified from clinical handover reviews

Reporting the results of clinical handover reviews at executive level of governance

6.4 Implementing a robust organisationwide system of reporting, investigation and change management to respond to any clinical handover incidents

Blood and Blood Products

7.1 Developing governance systems for safe and appropriate prescription, administration and management of blood and blood products

7.2 Undertaking a regular, comprehensive assessment of blood and blood product systems to identify risks to patient safety and taking action to reduce risks

7.3 Ensuring blood and blood product adverse events are included in the incidents management and investigation system

7.4 Undertaking quality improvement activities to improve the safe management of blood and blood products

7.5 As part of the patient treatment plan, the clinical workforce accurately documenting:

Relevant medical conditions

Indications for transfusion

Any special product or transfusion requirements

Known patient transfusion history

Type and volume of product transfusion

Patient response to transfusion

7.6 The clinical workforce documenting any adverse reactions to blood or blood products

7.7 Ensuring the receipt, storage, collection and transport of blood and blood products within the organisation are consistent with best practice and/or guidelines

7.8 Minimising unnecessary wastage of blood and blood products

7.9 The clinical workforce informing patients and carers about blood and blood product treatment options, and the associated risks and benefits

7.10 Providing information to patients about blood and blood product use and possible alternatives in a format that can be understood by patients and carers

7.11 Implementing an informed consent process for all blood and blood product use

Preventing and Managing Pressure Injuries

8.1 Developing and implementing policies, procedures and/or protocols that are based on current best practice guidelines

8.2 Using a risk assessment framework and reporting systems to identify, investigate and take action to reduce the frequency and severity of pressure injuries

8.3 Undertaking quality improvement activities to address safety risks and monitor the systems that prevent and manage pressure injuries

8.4 Providing or facilitating access to equipment and devices to implement effective prevention strategies and best practice management plans

8.5 Identifying risk factors for pressure injuries using an agreed screening tool for all presenting patients within timeframes set by best practice guidelines

8.6 Conducting a comprehensive skin inspection in timeframes set by best practice guidelines on patients with a high risk of developing pressure injuries at presentation, regularly as clinically indicated during a patient’s admission, and before discharge

8.7 Implementing and monitoring pressure injury prevention plans and reviewing when clinically indicated

8.8 Implementing best practice management and ongoing monitoring as clinically indicated

8.9 Informing patients with a high risk of pressure injury, and their carers, about the risks, prevention strategies and management of pressure injuries

8.10 Developing a plan of management in partnership with patients and carers

Recognizing and Responding to Clinical Deterioration in Acute Health Care

9.1 Developing, implementing and regularly reviewing the effectiveness of governance arrangements and the policies, procedures and/or protocols that are consistent with the requirements of the National Consensus Statement

9.2 Collecting information about the recognition and response systems, providing feedback to the clinical workforce, and tracking outcomes and changes in performance over time

9.3 Implementing mechanism(s) for recording physiological observations that incorporates triggers to escalate care when deterioration occurs

9.4 Developing and implementing mechanisms to escalate care and call for emergency assistance where there are concerns that a patient’s condition is deteriorating

9.5 Using the system in place to ensure that specialised and timely care is available to patients whose condition is deteriorating

9.6 Having a clinical workforce that is able to respond appropriately when a patient’s condition is deteriorating

9.7 Ensuring patients, families and carers are informed about, and are supported so that they can participate in, recognition and response systems and processes

9.8 Ensuring that information about advance care plans and treatmentlimiting orders is in the patient clinical record, where appropriate

9.9 Enabling patients, families and carers to initiate an escalation of care response

Preventing Falls and Harm from Falls

10.1 Developing, implementing and reviewing policies, procedures and/or protocols, including the associated tools, that are based on the current national guidelines for preventing falls and harm from falls

10.2 Using a robust organisation-wide system of reporting, investigation and change management to respond to falls incidents

10.3 Undertaking quality improvement activities to address safety risks and ensure the effectiveness of the falls prevention system

10.4 Implementing falls prevention plans and effective management of falls

10.5 Using a best practice-based tool to screen patients on presentation, during admission and when clinically indicated for the risk of falls

10.6 Conducting a comprehensive risk assessment for patients identified at risk of falling in initial screening processes

10.7 Developing and implementing a multifactorial falls prevention plan to address risks identified in the assessment

10.8 Patients at risk of falling are referred to appropriate services, where available, as part of the discharge process

10.9 Informing patients and carers about the risk of falls, and falls prevention strategies

10.10 Developing falls prevention plans in partnership with patients and carers

Completion
Full name and signature of auditor