Standard 8 - Audit Report

CLINICAL GOVERNANCE AND QUALITY IMPROVEMENT TO SUPPORT RECOGNITION AND RESPONSE SYSTEMS
Integrating clinical governance

8.1 Clinicians use the safety and quality systems from the Clinical Governance Standard when:
a. Implementing policies and procedures for recognising and responding to acute deterioration
b. Managing risks associated with recognising and responding to acute deterioration
c. Identifying training requirements for recognising and responding to acute deterioration

Applying quality improvement systems

8.2 The health service organisation applies the quality improvement system from the Clinical Governance Standard when:
a. Monitoring recognition and response systems
b. Implementing strategies to improve recognition and response systems
c. Reporting on effectiveness and outcomes of recognition and response systems

Partnering with consumers

8.3 Clinicians use organisational processes from the Partnering with Consumers Standard when recognising and responding to acute deterioration to:
a. Actively involve patients in their own care
b. Meet the patient’s information needs
c. Share decision-making

DETECTING AND RECOGNISING ACUTE DETERIORATION AND ESCALATING CARE
Recognising acute deterioration

8.4 The health service organisation has processes for clinicians to detect acute physiological deterioration that require clinicians to:
a. Document individualised vital sign monitoring plans
b. Monitor patients as required by their individualised monitoring plan
c. Graphically document and track changes in agreed observations to detect acute deterioration over time, as appropriate for the patient

8.5 The health service organisation has processes for clinicians to recognise acute deterioration in a mental state that requires clinicians to:
a. Monitor patients at risk of acute deterioration in mental state, including patients at risk of developing delirium
b. Include the person’s known early warning signs of deterioration in mental state in their individualised monitoring plan
c. Assess possible causes of acute deterioration in mental state, including delirium, when changes in behaviour, cognitive function, perception, physical function or emotional state are observed or reported
d. Determine the required level of observation
e. Document and communicate observed or reported changes in mental state

Escalating care

8.6 The health service organisation has protocols that specify criteria for escalating care, including:
a. Agreed vital sign parameters and other indicators of physiological deterioration
b. Agreed indicators of deterioration in mental state
c. Agreed parameters and other indicators for calling emergency assistance
d. Patient pain or distress that is not able to be managed using available treatment
e. Worry or concern in members of the workforce, patients, carers and families about acute deterioration

8.7 The health service organisation has processes for patients, carers or families to directly escalate care

8.8 The health service organisation provides the workforce with mechanisms to escalate care and call for emergency assistance

8.9 The workforce uses the recognition and response systems to escalate care

RESPONDING TO ACUTE DETERIORATION
Responding to deterioration

8.10 The health service organisation has processes that support timely response by clinicians with the skills required to manage episodes of acute deterioration

8.11 The health service organisation has processes to ensure rapid access at all times to at least one clinician, either on site or in close proximity, who can deliver advanced life support

8.12 The health service organisation has processes to ensure rapid referral to mental health services to meet the needs of patients whose mental state has acutely deteriorated

8.13 The health service organisation has processes for rapid referral to services that can provide definitive management of acute physical deterioration

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.