Standard 6 - Audit Report

Integrating clinical governance

6.1 Clinicians use the safety and quality systems from the Clinical Governance Standard when:
a. Implementing policies and procedures to support effective clinical communication
b. Managing risks associated with clinical communication
c. Identifying training requirements for effective and coordinated clinical communication

Applying quality improvement systems

6.2 The health service organisation applies the quality improvement system from the Clinical Governance Standard when:
a. Monitoring the effectiveness of clinical communication and associated processes
b. Implementing strategies to improve clinical communication and associated processes
c. Reporting on the effectiveness and outcomes of clinical communication processes

Partnering with consumers

6.3 Clinicians use organisational processes from the Partnering with Consumers Standard to effectively communicate with patients, carers and families during high-risk situations to:
a. Actively involve patients in their own care
b. Meet the patient’s information needs
c. Share decision-making

Organisational processes to support effective communication

6.4 The health service organisation has clinical communications processes to support effective communication when:
a. Identification and procedure matching should occur
b. All or part of a patient’s care is transferred within the organisation, between multidisciplinary teams, between clinicians or between organisations; and on discharge
c. Critical information about a patient’s care, including information on risks, emerges or changes

Correct identification and procedure matching

6.5 The health service organisation:
a. Defines approved identifiers for patients according to best-practice guidelines
b. Requires at least three approved identifiers on registration and admission; when care, medication, therapy and other services are provided; and when clinical handover, transfer or discharge documentation is generated

6.6 The health service organisation specifies the:
a. Processes to correctly match patients to their care
b. Information that should be documented about the process of correctly matching patients to their intended care

Clinical handover

6.7 The health service organisation, in collaboration with clinicians, defines the:
a. Minimum information content to be communicated at clinical handover, based on best-practice guidelines
b. Risks relevant to the service context and the particular needs of patients, carers and families
c. Clinicians who are involved in the clinical handover

6.8 Clinicians use structured clinical handover processes that include:
a. Preparing and scheduling clinical handover
b. Having the relevant information at clinical handover
c. Organising relevant clinicians and others to participate in clinical handover
d. Being aware of the patient’s goals and preferences
e. Supporting patients, carers and families to be involved in clinical handover, in accordance with the wishes of the patient
f. Ensuring that clinical handover results in the transfer of responsibility and accountability for care

Communicating critical information

6.9 Clinicians and multidisciplinary teams use clinical communication processes to effectively communicate critical information, alerts and risks, in a timely way, when they emerge or change to:
a. Clinicians who can make decisions about care
b. Patients, carers and families, in accordance with the wishes of the patient

6.10 The health service organisation ensures that there are communication processes for patients, carers and families to directly communicate critical information and risks about care to clinicians

Documentation of information

6.11 The health service organisation has processes to contemporaneously document information in the healthcare record, including:
a. Critical information, alerts and risks
b. Reassessment processes and outcomes
c. Changes to the care plan

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.