Information

  • Document No.

  • Department

  • Conducted on

  • Prepared by

  • Personnel

Governance and quality improvement system

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

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

  • 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

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

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

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

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

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

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

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

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

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

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

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

  • 1.6.2 Actions are taken to maximize patient quality of care

Clinical practice

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

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

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

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

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

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

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

Performance and skills management

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

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

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

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

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

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

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

  • 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

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

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

Incident and complaint management

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

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

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

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

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

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

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

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

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

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

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

Patient rights and engagement

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

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

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

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

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

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

  • 1.18.4 (D) Patients and carers are supported to document clear advance care directives and/or treatment-limiting orders

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

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

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

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