NSQHSS 1Governance for safety and quality in healthcare

Department

Personnel

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

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.

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

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

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