Standard 5 - Audit Report

CLINI8CAL GOVERNANCE AND QUALITY GOVERNAQNCE TO SUPPORT COMPREHENSIVE CARE
Integrating clinical governance

5.1 Clinicians use the safety and quality systems from the Clinical Governance Standard when:
a. Implementing policies and procedures for comprehensive care
b. Managing risks associated with comprehensive care
c. Identifying training requirements to deliver comprehensive care

Applying quality improvement systems

5.2 The health service organisation applies the quality improvement system from the Clinical Governance Standard when:
a. Monitoring the delivery of comprehensive care
b. Implementing strategies to improve the outcomes from comprehensive care and associated processes
c. Reporting on delivery of comprehensive care

Partnering with consumers

5.3 Clinicians use organisational processes from the Partnering with Consumers Standard when providing comprehensive care to:
a. Actively involve patients in their own care
b. Meet the patient’s information needs
c. Share decision-making

Designing systems to deliver comprehensive care

5.4 The health service organisation has systems for comprehensive care that:
a. Support clinicians to develop, document and communicate comprehensive plans for patients’ care and treatment
b. Provide care to patients in the setting that best meets their clinical needs
c. Ensure timely referral of patients with specialist healthcare needs to relevant services
d. Identify, at all times, the clinician with overall accountability for a patient’s care

Collaboration and teamwork

5.5 The health service organisation has processes to:
a. Support multidisciplinary collaboration and teamwork
b. Define the roles and responsibilities of each clinician working in a team

5.6 Clinicians work collaboratively to plan and deliver comprehensive care

DEVELOPING THE COMPREHENSIVE CARE PLAN
Planning for comprehensive care

5.7 The health service organisation has processes relevant to the patients using the service and the services provided:
a. For integrated and timely screening and assessment
b. That identify the risks of harm in the ‘Minimising patient harm’ criterion

5.8 The health service organisation has processes to routinely ask patients if they identify as being of Aboriginal and/or Torres Strait Islander origin, and to record this information in administrative and clinical information systems

5.9 Patients are supported to document clear advance care plans

Screening of risk

5.10 Clinicians use relevant screening processes:
a. On presentation, during clinical examination and history taking, and when required during care
b. To identify cognitive, behavioural, mental and physical conditions, issues, and risks of harm
c. To identify social and other circumstances that may compound these risks

Clinical assessment

5.11 Clinicians comprehensively assess the conditions and risks identified through the screening process

Developing the comprehensive care plan

5.12 Clinicians document the findings of the screening and clinical assessment processes, including any relevant alerts, in the healthcare record

5.13 Clinicians use processes for shared decision making to develop and document a comprehensive and individualised plan that:
a. Addresses the significance and complexity of the patient’s health issues and risks of harm
b. Identifies agreed goals and actions for the patient’s treatment and care
c. Identifies the support people a patient wants to be involved in communications and decision-making about their care
d. Commences discharge planning at the beginning of the episode of care
e. Includes a plan for referral to follow-up services, if appropriate and available
f. Is consistent with best practice and evidence

DELIVERING COMPREHENSIVE CARE
Using the comprehensive care plan

5.14 The workforce, patients, carers and families work in partnership to:
a. Use the comprehensive care plan to deliver care
b. Monitor the effectiveness of the comprehensive care plan in meeting the goals of care
c. Review and update the comprehensive care plan if it is not effective
d. Reassess the patient’s needs if changes in diagnosis, behaviour, cognition, or mental or physical condition occur

Comprehensive care at the end of life

5.15 The health service organisation has processes to identify patients who are at the end of life that are consistent with the National Consensus Statement: Essential elements for safe and high-quality end-of-life care

5.16 The health service organisation providing end-of-life care has processes to provide clinicians with access to specialist palliative care advice

5.17 The health service organisation has processes to ensure that current advance care plans:
a. Can be received from patients
b. Are documented in the patient’s healthcare record

5.18 The health service organisation provides access to supervision and support for the workforce providing end-of-life care

5.19 The health service organisation has processes for routinely reviewing the safety and quality of end-of-life care that is provided against the planned goals of care

5.20 Clinicians support patients, carers and families to make shared decisions about end-of-life care in accordance with the National Consensus Statement: Essential elements for safe and high-quality end-of-life care

MINIMISING PATIENT HARM
Preventing and managing pressure injuries

5.21 The health service organisation providing services to patients at risk of pressure injuries has systems for pressure injury prevention and wound management that are consistent with best-practice guidelines

5.22 Clinicians providing care to patients at risk of developing, or with, a pressure injury conduct comprehensive skin inspections in accordance with best-practice time frames and frequency

5.23 The health service organisation providing services to patients at risk of pressure injuries ensures that:
a. Patients, carers and families are provided with information about preventing pressure injuries
b. Equipment, devices and products are used in line with best-practice guidelines to prevent and effectively manage pressure injuries

Preventing falls and harm from falls

5.24 The health service organisation providing services to patients at risk of falls has systems that are consistent with best-practice guidelines for:
a. Falls prevention
b. Minimising harm from falls
c. Post-fall management

5.25 The health service organisation providing services to patients at risk of falls ensures that equipment, devices and tools are available to promote safe mobility and manage the risks of falls

5.26 Clinicians providing care to patients at risk of falls provide patients, carers and families with information about reducing falls risks and falls prevention strategies

Nutrition and hydration

5.27 The health service organisation that admits patients overnight has systems for the preparation and distribution of food and fluids that include nutrition care plans based on current evidence and best practice

5.28 The workforce uses the systems for preparation and distribution of food and fluids to:
a. Meet patients’ nutritional needs and requirements
b. Monitor the nutritional care of patients at risk
c. Identify, and provide access to, nutritional support for patients who cannot meet their nutritional requirements with food alone
d. Support patients who require assistance with eating and drinking

Preventing delirium and managing cognitive impairment

5.29 The health service organisation providing services to patients who have cognitive impairment or are at risk of developing delirium has a system for caring for patients with cognitive impairment to:
a. Incorporate best-practice strategies for early recognition, prevention, treatment and management of cognitive impairment in the care plan, including the Delirium Clinical Care Standard, where relevant
b. Manage the use of antipsychotics and other psychoactive medicines, in accordance with best practice and legislation

5.30 Clinicians providing care to patients who have cognitive impairment or are at risk of developing delirium use the system for caring for patients with cognitive impairment to:
a. Recognise, prevent, treat and manage cognitive impairment
b. Collaborate with patients, carers and families to understand the patient and implement individualised strategies that minimise any anxiety or distress while they are receiving care

Predicting, preventing and managing selfharm and suicide

5.31 The health service organisation has systems to support collaboration with patients, carers and families to:
a. Identify when a patient is at risk of self-harm
b. Identify when a patient is at risk of suicide
c. Safely and effectively respond to patients who are distressed, have thoughts of self-harm or suicide, or have self-harmed

5.32 The health service organisation ensures that follow-up arrangements are developed, communicated and implemented for people who have harmed themselves or reported suicidal thoughts

Predicting, preventing and managing aggression and violence

5.33 The health service organisation has processes to identify and mitigate situations that may precipitate aggression

5.34 The health service organisation has processes to support collaboration with patients, carers and families to:
a. Identify patients at risk of becoming aggressive or violent
b. Implement de-escalation strategies
c. Safely manage aggression, and minimise harm to patients, carers, families and the workforce

Minimising restrictive practices: restraint

5.35 Where restraint is clinically necessary to prevent harm, the health service organisation has systems that:
a. Minimise and, where possible, eliminate the use of restraint
b. Govern the use of restraint in accordance with legislation
c. Report use of restraint to the governing body

Minimising restrictive practices: seclusion

5.36 Where seclusion is clinically necessary to prevent harm and is permitted under legislation, the health service organisation has systems that:
a. Minimise and, where possible, eliminate the use of seclusion
b. Govern the use of seclusion in accordance with legislation
c. Report use of seclusion to the governing body

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.