Information
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Version 2 * National Standard 1 - Clinical Governance Standard
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Client / Site
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Conducted on
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Conducted by:
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Personnel who participated in the gathering of specific evidence for this Standard
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Address / Location
Standard 1 - Audit Report
GOVERNANCE, LEADERSHIP AND CULTURE
Governance, leadership and culture
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1.1 The governing body:<br>a. Provides leadership to develop a culture of safety and quality improvement, and satisfies itself that this culture exists within the organisation<br>b. Provides leadership to ensure partnering with patients, carers and consumers<br>c. Sets priorities and strategic directions for safe and high-quality clinical care, and ensures that these are communicated effectively to the workforce and the community<br>d. Endorses the organisation’s clinical governance framework<br>e. Ensures that roles and responsibilities are clearly defined for the governing body, management, clinicians and the workforce<br>f. Monitors the action taken as a result of analyses of clinical incidents<br>g. Reviews reports and monitors the organisation’s progress on safety and quality performance
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1.2 The governing body ensures that the organisation’s safety and quality priorities address the specific health needs of Aboriginal and Torres Strait Islander people
Organisational leadership
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1.3 The health service organisation establishes and maintains a clinical governance framework, and uses the processes within the framework to drive improvements in safety and quality
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1.4 The health service organisation implements and monitors strategies to meet the organisation’s safety and quality priorities for Aboriginal and Torres Strait Islander people
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1.5 The health service organisation considers the safety and quality of health care for patients in its business decision making
Clinical leadership
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1.6 Clinical leaders support clinicians to: <br>a. understand and perform their delegated safety and quality roles and responsibilities <br>b. operate within the clinical governance framework to improve the safety and quality of health care for patients <br>
PATIENT SAFETY AND QUALITY SYSTEMS
Policies and procedures
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1.7 The health service organisation uses a risk management approach to:<br>a. Set out, review, and maintain the currency and effectiveness of, policies, procedures and protocols<br>b. Monitor and take action to improve adherence to policies, procedures and protocols<br>c. Review compliance with legislation, regulation and jurisdictional requirements
Measurement and quality improvement
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1.8 The health service organisation uses organisation-wide quality improvement systems that:<br>a. Identify safety and quality measures, and monitor and report performance and outcomes<br>b. Identify areas for improvement in safety and quality<br>c. Implement and monitor safety and quality improvement strategies<br>d. Involve consumers and the workforce in the review of safety and quality performance and systems
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1.9 The health service organisation ensures that timely reports on safety and quality systems and performance are provided to:<br>a. The governing body<br>b. The workforce<br>c. Consumers and the local community<br>d. Other relevant health service organisations
Risk management
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1.10 The health service organisation:<br>a. Identifies and documents organisational risks<br>b. Uses clinical and other data collections to support risk assessments<br>c. Acts to reduce risks<br>d. Regularly reviews and acts to improve the effectiveness of the risk management system<br>e. Reports on risks to the workforce and consumers<br>f. Plans for, and manages, internal and external emergencies and disasters
Incident management systems and open disclosure
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1.11 The health service organisation has organisation-wide incident management and investigation systems, and:<br>a. Supports the workforce to recognise and report incidents<br>b. Supports patients, carers and families to communicate concerns or incidents<br>c. Involves the workforce and consumers in the review of incidents<br>d. Provides timely feedback on the analysis of incidents to the governing body, the workforce and consumers<br>e. Uses the information from the analysis of incidents to improve safety and quality<br>f. Incorporates risks identified in the analysis of incidents into the risk management system<br>g. Regularly reviews and acts to improve the effectiveness of the incident management and investigation systems
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1.12 The health service organisation:<br>a. Uses an open disclosure program that is consistent with the Australian Open Disclosure Framework<br>b. Monitors and acts to improve the effectiveness of open disclosure processes
Feedback and complaints management
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1.13 The health service organisation:<br>a. Has processes to seek regular feedback from patients, carers and families about their experiences and outcomes of care<br>b. Has processes to regularly seek feedback from the workforce on their understanding and use of the safety and quality systems<br>c. Uses this information to improve safety and quality systems
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1.14 The health service organisation has an organisation-wide complaints management system, and:<br>a. Encourages and supports patients, carers and families, and the workforce to report complaints<br>b. Involves the workforce and consumers in the review of complaints<br>c. Resolves complaints in a timely way<br>d. Provides timely feedback to the governing body, the workforce and consumers on the analysis of complaints and actions taken<br>e. Uses information from the analysis of complaints to inform improvements in safety and quality systems<br>f. Records the risks identified from the analysis of complaints in the risk management system<br>g. Regularly reviews and acts to improve the effectiveness of the complaints management system
Diversity and high-risk groups
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1.15 The health service organisation: <br>a. Identifies the diversity of the consumers using its services <br>b. Identifies groups of patients using its services who are at higher risk of harm <br>c. Incorporates information on the diversity of its consumers and higher risk groups into the planning and delivery of care<br>
Healthcare records
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1.16 The health service organisation has healthcare record systems that: <br>a. Make the healthcare record available to clinicians at the point of care <br>b. Support the workforce to maintain accurate and complete healthcare records <br>c. Comply with security and privacy regulations <br>d. Support systematic audit of clinical information <br>e. Integrate multiple information systems, where they are used<br> Agreed and documented clinical guidelines and/or pathways are available to the clinical workforce
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1.17 The health service organisation works towards implementing systems that can provide clinical information into the My Health Record system that: <br>a. Are designed to optimise the safety and quality of health care for patients <br>b. Use national patient and provider identifiers <br>c. Use standard national terminologies<br>
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1.18 The health service organisation providing clinical information into the My Health Record system has processes that: <br>a. Describe access to the system by the workforce, to comply with legislative requirements <br>b. Maintain the accuracy and completeness of the clinical information the organisation uploads into the system
CLINICAL PERFORMANCE AND EFFECTIVENESS
Safety and quality training
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1.19 The health service organisation provides orientation to the organisation that describes roles and responsibilities for safety and quality for: <br>a. Members of the governing body <br>b. Clinicians, and any other employed, contracted, locum, agency, student or volunteer members of the organisation<br>
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1.20 The health service organisation uses its training systems to: <br>a. Assess the competency and training needs of its workforce <br>b. Implement a mandatory training program to meet its requirements arising from these standards <br>c. Provide access to training to meet its safety and quality training needs d. Monitor the workforce’s participation in training
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1.21 The health service organisation has strategies to improve the cultural awareness and cultural competency of the workforce to meet the needs of its Aboriginal and Torres Strait Islander patients<br>
Performance management
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1.22 The health service organisation has valid and reliable performance review processes that: <br>a. Require members of the workforce to regularly take part in a review of their performance <br>b. Identify needs for training and development in safety and quality <br>c. Incorporate information on training requirements into the organisation’s training system<br>
Credentialing and scope of clinical practice
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1.23 The health service organisation has processes to: <br>a. Define the scope of clinical practice for clinicians, considering the clinical service capacity of the organisation and clinical services plan <br>b. Monitor clinicians’ practices to ensure that they are operating within their designated scope of clinical practice <br>c. Review the scope of clinical practice of clinicians periodically and whenever a new clinical service, procedure or technology is introduced or substantially altered<br>
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1.24 The health service organisation: a. Conducts processes to ensure that clinicians are credentialed, where relevant b. Monitors and improves the effectiveness of the credentialing process
Safety and quality roles and responsibilities
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1.25 The health service organisation has processes to:<br>a. Support the workforce to understand and perform their roles and responsibilities for safety and quality<br>b. Assign safety and quality roles and responsibilities to the workforce, including locums and agency staff
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1.26 The health service organisation provides supervision for clinicians to ensure that they can safely fulfil their designated roles, including access to after-hours advice, where appropriate
Evidence-based care
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1.27 The health service organisation has processes that:<br>a. Provide clinicians with ready access to best-practice guidelines, integrated care pathways, clinical pathways and decision support tools relevant to their clinical practice<br>b. Support clinicians to use the best available evidence, including relevant clinical care standards developed by the Australian Commission on Safety and Quality in Health Care
Variation in clinical practice and health outcomes
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1.28 The health service organisation has systems to:<br>a. Monitor variation in practice against expected health outcomes<br>b. Provide feedback to clinicians on variation in practice and health outcomes<br>c. Review performance against external measures<br>d. Support clinicians to take part in the clinical review of their practice<br>e. Use the information on unwarranted clinical variation to inform improvements in safety and quality systems<br>f. Record the risks identified from unwarranted clinical variation in the risk management system
SAFE ENVIRONMENT
Safe environment
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1.29 The health service organisation maximises safety and quality of care:<br>a. Through the design of the environment<br>b. By maintaining buildings, plant, equipment, utilities, devices and other infrastructure that are fit for purpose
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1.30 The health service organisation:<br>a. Identifies service areas that have a high risk of unpredictable behaviours and develops strategies to minimise the risks of harm for patients, carers, families, consumers and the workforce<br>b. Provides access to a calm and quiet environment when it is clinically required
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1.31 The health service organisation facilitates access to services and facilities by using signage and directions that are clear and fit for purpose
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1.32 The health service organisation admitting patients overnight has processes that allow flexible visiting arrangements to meet patients’ needs, when it is safe to do so
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1.33 The health service organisation demonstrates a welcoming environment that recognises the importance of the cultural beliefs and practices of Aboriginal and Torres Strait Islander people
