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The ACHS EQuIP5 GUIDE

Book 1Accreditation, Standards and Guidelines

Clinical Function

Safety Quality Performance

The ACHS EQuIP5 Guide: Book 1 – Accreditation, Standards and Guidelines – Clinical Function

Published by The Australian Council on Healthcare Standards (ACHS)

Copies available from the ACHS Publications Service

Phone: +61 2 9281 9955 Fax: +61 2 9211 9633

Copyright © The Australian Council on Healthcare Standards (ACHS)

This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may be reproduced by any process without prior written permission from The Australian Council on Healthcare Standards. Requests and enquiries concerning reproduction and rights should be addressed to the Chief Executive, The Australian Council on Healthcare Standards, 5 Macarthur Street, ULTIMO NSW 2007 Australia

Recommended citation: The Australian Council on Healthcare Standards (ACHS), The ACHS EQuIP5 Guide: Book 1 – Accreditation, Standards and Guidelines – Clinical Function. Sydney Australia; ACHS; 2010.

The EQuIP Guide: First published 1996 Second edition 1998 Second edition revised 1999 Third edition 2002 Fourth edition 2006 Fifth edition 2010

5th Edition ISBN-13: 978 1 921806 00 1 (paperback) ISBN-10: 1 921806 00 1 (paperback) ISBN-13: 978 1 921806 02 5 (web) ISBN-10: 1 921806 02 8 (web)

October 2010  1

ForewordOn behalf of the Board of Directors, it is my pleasure to present the 5th edition of the Evaluation and Quality Improvement Program (EQuIP5). This edition will apply to all participating members from 1 July 2011.

Principles guiding the review process include emphasis on patient outcomes, the importance of measuring performance and the national agenda for safety and quality.

Alterations to the standards, criteria and elements for achievement have been largely editorial in nature, although the new provisions relating to nutritional services, separation of corporate and clinical records, and the separation of incidents and complaints management systems are significant.

The Australian Council on Healthcare Standards (ACHS) has engaged widely across the health industry seeking both strategic and technical input. The generous response of time and expertise is indicative of the esteem held within the health industry for ACHS. For this we are very grateful.

The Australian Commission on Safety and Quality in Health Care is well advanced in the development of National Standards relating to high-risk safety issues and applicable to all accreditation programs. ACHS strongly supports this initiative. The implementation of National Standards will impact on EQuIP, which must evolve to encompass the national compliance requirements.

This edition is introduced at an important time in the evolution of the national quality and safety health services agenda and incorporates many changes in how the program will function. Together with process efficiencies and improvements to electronic tools it remains comprehensive, robust and relevant to the needs of both consumers and health service providers.

On behalf of the Board and Council, I commend to you the Evaluation and Quality Improvement Program 5th edition.

Assoc. Professor Peter Woodruff President, ACHS

October 2010

2  The ACHS EQuIP5 Guide  Book 1  Accreditation, Standards and Guidelines  Clinical Function

Contents

Foreword 1

Introduction 4

Section 1 ACHS and accreditation 5

1.1 About the Australian Council on Healthcare Standards 5

1.2 What is accreditation? 6

Section 2 Overview of EQuIP 7

2.1 The EQuIP cycle 7

2.2 What is EQuIP? 8

2.3 The self assessment 8

2.4 Organisation-Wide Survey (OWS) 8

2.5 Periodic Review (PR) 9

2.6 EQuIP membership 9

2.6.1 ACHS EQuIP Certification Program 9

Section 3 EQuIP Surveys 10

3.1 The EQuIP Self-Assessment process 10

3.1.1 Benefits and objectives of the self assessment 10

3.1.2 The self-assessment process 10

3.1.3 The EQuIP Self-Assessment feedback report 11

3.1.4 Changes to the self-assessment format from EQuIP 4 to EQuIP5 11

3.1.5 Before starting a Pre-Survey Assessment 11

3.2 Pre-Survey Assessment (PSA) 12

3.2.1 How to start a PSA 12

3.2.2 The PSA format 12

3.2.3 Points to remember in preparing a PSA 15

3.2.4 The Electronic Assessment Tool (EAT) 15

3.3 EQuIP onsite surveys and processes 16

3.3.1 The survey schedule 16

3.3.2 Additional surveys 17

3.3.3 Getting ready for the survey − one page summaries 18

3.3.4 Survey timetables 19

3.3.5 Surveyors’ meeting with the leadership team 20

3.3.6 The survey presentation 20

3.3.7 The survey process 20

3.3.8 Verification 21

3.3.9 The Summation Conference 21

3.4 EQuIP survey reports 22

3.4.1 How to use the survey report 22

3.4.2 Public release of accreditation information 22

3.5 Accreditation levels, survey recommendations and achievement ratings 23

3.5.1 Accreditation outcomes 23

3.5.2 Criterion achievement ratings 23

3.5.3 Expectations for ratings 25

3.5.4 High Priority Recommendations (HPRs) 26

3.5.5 Achieving accreditation 27

3.5.6 Non-accreditation 27

3.5.7 An appeals process 27

October 2010  3

Section 4 How to use this EQuIP Guide 28

4.1 The EQuIP framework 28

4.2 Key changes in EQuIP5 29

4.2.1 EQuIP5 functions, standards, criteria 30

4.3 The criteria 32

4.3.1 Structure of the criteria (an example) 32

4.3.2 Mandatory criteria 34

4.3.3 Not applicable (NA) criteria / elements 34

4.4 Further information 34

4.4.1 Aboriginal and Torres Strait Islander people 34

4.4.2 Policies, procedures, protocols, guidelines and by-laws 35

4.4.3 Jurisdictions 36

4.4.4 Performance measures 36

4.4.5 Clinical indicators 37

4.4.6 National E-Health Transition Authority (NEHTA) 41

4.4.7 National Safety and Quality Health Service Standards (Australian Commission on Safety and Quality in Health Care) 41

Section 5 Standards, criteria, elements and guidelines 43

Book 1 Clinical Function (Standards 1.1 – 1.6) 43

Book 2 Support Function (Standards 2.1 – 2.5) 251

Corporate Function (Standards 3.1 – 3.2) 375

Section 6

6.1 Glossary and Acronyms Glossary (Book 1) 229 Glossary (Book 2) 463

Acronyms (Book 1) 245 Acronyms (Book 2) 479

6.2 Acknowledgements (Book 2) 482

4  The ACHS EQuIP5 Guide  Book 1  Accreditation, Standards and Guidelines  Clinical Function

IntroduCtIon

Information needs differ from one group of users to another, from one location to another and from one health sector to another. For example, clinicians need a different degree of detail and type of information from an organisation’s quality manager, EQuIP surveyors need information in a different format from an organisation’s chief executive, rural and remote organisations will have different processes than metropolitan, and private organisations will be different from public.

To accommodate the varying information needs of different groups and in response to our members’ request, The ACHS EQuIP5 Guide has new features. This printed guide contains the standards, criteria, elements and guidelines for EQuIP5. The guidelines have been arranged under subheadings to assist users to navigate through the information. In addition, ‘prompt points’ are provided under the information in each subheading. These are not checklists, but are ‘enabling’ questions, to assist organisations to consider the elements from a quality improvement perspective. To address the elements, an organisation describes its systems, processes, people and actions, which is really, “what the organisation does”. True understanding that will guide organisational quality improvement will come from asking, “How does it happen?”, “Why was this approach used?” and “What was the outcome?” These ‘how’, ‘why’ and ‘what’ questions are reflected in the prompt points, and are key steps before an organisation decides, “Perhaps we can do this better.”

At the front of the guide, there is information about the EQuIP program and the factors that may influence the way EQuIP5 is implemented and assessed. This includes an explanation of the meaning behind some inclusions, such as consideration of Aboriginal and Torres Strait Islander consumers / patients, the

meaning of policy requirements and acknowledgement of the Australian Commission on Safety and Quality in Health Care’s (the Commission’s) intended National Safety and Quality Health Service Standards.

The ACHS has also developed expanded versions of the guidelines for each criterion. These are available to members as an EQuIP5 resource that can be accessed from the ACHS website. The expanded guidelines contain more background information, and were developed for those instances where further information would assist users to better understand the requirements of the criterion or specific elements, and may provide more ideas for addressing the elements.

The ACHS EQuIP5 Guide is presented as two books with content as follows:

Book 1:

The EQuIP accreditation program The guide and the standards Clinical Function standards Glossary and acronyms

Book 2:

Support Function standards Corporate Function standards Glossary and acronyms Acknowledgements

The detailed operating rules and flow charts, which are associated with the processes, are available on the ACHS website for EQuIP members.

Additional resources will be available for EQuIP members on the ACHS website, including the expanded guidelines, further reading, and practical strategies for implementing quality improvement and risk management.

This table provides a breakdown of the information available through these media for each criterion:

within eAtIn the printed eQuIP5 guide

expanded guidelines at www.achs.org.au

Criterion table of elements listed Yes Yes

Intent Yes Yes Yes

Relationships with other criteria Yes Yes Yes

Guidelines information under subheadings Yes (short) Yes (short) Yes (expanded)

Prompt points by subheading No Yes Yes

Evidence Yes Yes Yes

Performance measures No Yes Yes

References Yes Yes Yes

Further reading No Some criteria Some criteria

October 2010  5

seCtIon 1ACHS and accreditation

1.1 About the Australian Council on Healthcare Standards

The Australian Council on Healthcare Standards (ACHS) is an independent, not-for-profit organisation dedicated to improving the quality of health care in Australia through the continual review of performance, assessment and accreditation. The ACHS was established in 1974 and is the leading independent authority on the measurement and implementation of quality improvement systems for Australian healthcare organisations.

The ACHS mission is to improve the quality and safety of health care. Its vision is to be recognised nationally and internationally as the leading Australian organisation that independently assesses performance and promotes and improves the quality and safety of health care.

ACHS accreditation programs are based on partnerships and consultations with key stakeholders and participants in the healthcare industry, so that the standards and accreditation services reflect their needs and encourage ownership of the program.

The ACHS Council is comprised of individuals who represent peak industry bodies in health, professional colleges and associations, governments and healthcare consumers. The ACHS is governed by a board of directors elected by and from Council members. The ACHS Board is supported by a corporate management structure that oversees standards development and the evaluation of health services against those standards by surveyors who have professional experience within relevant healthcare service sectors.

The principles upon which all ACHS programs are developed reflect the characteristics displayed by an improving organisation. These principles can be applied to all aspects of service within an organisation.

A consumer focus in care provision is demonstrated by:

• understanding the needs and expectations of present and potential consumers / patients

• ensuring consumers / patients are the priority

• evaluating the service from the consumer / patient perspective.

Effective leadership demonstrates responsibility and commitment to excellence in care provision, quality improvement and performance by:

• providing direction for the organisation / health service

• pursuing the ongoing development of strategies, systems and methods for achieving excellence

• inspiring and motivating the workforce and encouraging employees to contribute, develop and learn

• considering proposals that are innovative and creative.

Continuous improvement – management and staff demonstrate how they continually strive to improve the quality of care. Continuous improvement assists the organisation / health service through:

• looking for ways to improve as an essential part of everyday practice

• consistently achieving and maintaining quality care that meets consumer / patient needs

• monitoring outcomes in consumer / patient care and seeking opportunities to improve both the care and its results.

Evidence of outcomes – organisations depend on the measurement and analysis of performance. Indicators of good care processes or, wherever possible, outcomes of care, demonstrate a commitment to maintaining quality and striving for ongoing improvement by:

• providing critical data and information about key processes, outputs and results

• reflecting those factors that lead to improved health and/or quality of life for consumers / patients or to better operational performance.

6  The ACHS EQuIP5 Guide  Book 1  Accreditation, Standards and Guidelines  Clinical Function

Striving for best practice – the organisation compares its performance with, or learns from, others and applies best-practice principles. Organisations might demonstrate their efforts through:

• discovering new techniques and technologies, and using them to achieve world-class performance

• learning from others to increase the efficiency and effectiveness of processes

• improving consumer / patient satisfaction and outcomes.

1.2 What is accreditation?

Accreditation is public recognition by a healthcare accreditation body of the achievement of accreditation standards by a healthcare organisation, demonstrated through an independent external peer assessment of that organisation’s level of performance in relation to the standards.1

Accreditation systems are considered to comprise five key elements2:

1. A governance or stewardship function

2. A standards-setting process

3. A process of external evaluation of compliance against those standards

4. A remediation or improvement process following the review

5. Promotion of continuous quality improvement.

1 International Society for Quality in Health Care (ISQua). The ISQua surveyor training standards programme. Dublin IRL; ISQua; 2009.

2 Standards and accreditation framework working group. Standards setting and accreditation systems in health: consultation paper. Canberra; Australian Council for Safety and Quality in Health Care; 2003.

seCtIon 1ACHS and accreditation

October 2010  7

The following information provides an outline of the components of the ACHS EQuIP accreditation processes in which member organisations participate. The full details of the accreditation process and requirements are provided in Sections 2 and 3 of this guide.

2.1 The EQuIP cycle

The cycle of events in which healthcare organisations submit at least one activity every year of their four-year EQuIP membership period is shown below.

EQuIP Cycle

seCtIon 2Overview of EQuIP

ACHS Accreditation

EQuIP Quality Program Begins

Phase 1  Self assessment

¼ New members provide a self assessment against all criteria.

¼ Existing members provide a self assessment of progress against the recommendations from the Periodic Review.

¼ Organisations update and submit their register of key organisation risks (risk register).

Phase 2  Organisation-Wide Survey (OWS)

¼ Members provide a Pre-Survey Assessment against all criteria and an updated risk register approximately 6 weeks prior to the organisation-wide onsite survey.

¼¼ All¼criteria are surveyed and progress on recommendations from the PR is reviewed.

Phase 4  Periodic Review (PR)

¼ Members provide a Pre-Survey Assessment against all mandatory criteria, progress against recommendations and an updated risk register.

¼ Mandatory criteria are surveyed and progress on recommendations from the Organisation-Wide Survey is reviewed.

Phase 3  Self assessment

¼ Members provide a self assessment of progress against the recommendations from the Organisation-Wide Survey.

¼ Organisations update and submit their register of key organisation risks (risk register).

8  The ACHS EQuIP5 Guide  Book 1  Accreditation, Standards and Guidelines  Clinical Function

2.2 What is EQuIP?

EQuIP is the Evaluation and Quality Improvement Program, developed and conducted by the ACHS. This framework for managing health services to ensure quality and safe care and services and for achieving quality improvement has been used in Australian health services since 1996. Every four years, the EQuIP program is reviewed and revised; EQuIP5 will apply to performance assessment from July 2011.

EQuIP is a four-year quality assessment and improvement program for organisations / health services that supports excellence in consumer / patient care and services. If this is achieved, accreditation will follow. The arrangement of elements under graded ratings that reflect increasing maturity of quality improvement activity has been designed to assist and support organisations / health services in their quality improvement efforts.

This guide contains the standards, criteria, elements and guidelines that constitute EQuIP5.

The key components of EQuIP are:

• the standards that organisations work to achieve

• a yearly self assessment to evaluate performance against the standards

• ACHS assistance and guidance around the organisation’s self assessment

• biennial onsite surveys by an external, experienced team of accreditation surveyors to provide an independent assessment of the organisation’s performance against the standards

• the improvement process undertaken by organisations to address the recommendations from the onsite surveys.

2.3 The self assessment

Self assessment is an important component of the EQuIP cycle and is designed to assist organisations to monitor their progress in partnership with the ACHS. The self assessment is a regular and continual part of the EQuIP process and is undertaken during all phases of the EQuIP cycle.

In Phases 1 and 3, the self assessment is a review of progress against the recommendations of the previous survey.

During Phases 2 and 4, the self assessment becomes a Pre-Survey Assessment completed prior to the onsite Organisation-Wide Survey or Periodic Review.

2.4 Organisation-Wide Survey (OWS)

Within the four-year EQuIP cycle, there are two onsite surveys. The first of these is the Organisation-Wide Survey. The aims of the Organisation-Wide Survey are:

• to verify the organisation’s self assessment

• to conduct an external peer assessment of the organisation’s performance

• to review the progress on recommendations given at a previous survey

• to provide feedback and offer advice to the organisation that may assist with further improvement

• to award accreditation.

The OWS involves the review of progress and achievement of the organisation against all the EQuIP criteria determined to be relevant to the organisation. (Refer to not applicable (NA) criteria / elements in Section 4.3.3)

seCtIon 2Overview of EQuIP

October 2010  9

2.5 Periodic Review (PR)

The Periodic Review is an onsite survey conducted in Phase 4 of the EQuIP cycle.

The aims of the Periodic Review are:

• to verify that levels of consumer / patient care remain satisfactory

• to maintain momentum for continuous quality improvement beyond the Organisation-Wide Survey

• to assess progress against recommendations from the Organisation-Wide Survey

• to adjust accreditation status if necessary.

At the Periodic Review the organisation is surveyed against the mandatory criteria and progress on the recommendations from the Organisation-Wide Survey is assessed.

2.6 EQuIP membership

Membership occupies a four-year period during which, as a member, an organisation works towards achieving and maintaining accreditation under the Evaluation and Quality Improvement Program.

By working within the EQuIP framework, members create a quality improvement culture within which to implement, monitor and continually improve processes and systems. EQuIP provides an evidence-based structure of standards, criteria and elements, however it is the way in which members utilise the program that will build quality and result in improvement.

Through regular self assessment and scheduled external review (surveys), organisations monitor their progress as they develop integrated systems and processes, evaluate their impact and adapt to change.

2.6.1 ACHS EQuIP Certification ProgramThe ACHS EQuIP Certification Program is a quality management program for newly established healthcare organisations, and for healthcare organisations that are not currently EQuIP members.

The Certification Program assists these organisations to establish the structures, systems, policies and procedures that will assist them with improving performance.

It is expected that healthcare organisations will have structures and processes that meet the mandatory criteria to an SA level.

The award of Certification is an acknowledgement by the ACHS of an organisation’s commitment to ensuring that appropriate systems and structures are established to provide quality care and services.

The Certification award is for 18 months. The membership contact is 12 months, during which time the organisation will be invited to join the full accreditation program.

To achieve Certification, organisations will be required to achieve:

• an SA in all mandatory criteria, and

• fewer than six LAs in the non-mandatory criteria with a low risk rating.

10  The ACHS EQuIP5 Guide  Book 1  Accreditation, Standards and Guidelines  Clinical Function

seCtIon 3EQuIP Surveys

3.1 The EQuIP Self-Assessment process

Self assessment is an important component of the EQuIP cycle and is designed to assist organisations to monitor their progress in partnership with the ACHS. The self assessment is a regular and continual part of the EQuIP process and is undertaken during all phases of the EQuIP cycle.

In Phases 1 and 3, the self assessment is a review of progress against the recommendations of the previous survey. This allows all organisations to continue to improve in the areas that were identified at the previous survey as needing development. In addition, the organisation submits an updated register of key organisational risks, which includes a risk rating and action plan for the key risks to the organisation as a whole. This demonstrates that the major risk areas to the organisation are being proactively managed and that this is contributing to the overall safety of the organisation and to quality improvement.

During EQuIP Phases 2 and 4, the self assessment becomes a Pre-Survey Assessment completed prior to the onsite OWS or PR. This assessment against the EQuIP standards provides the outline for the evidence that the surveyors will verify at survey. Pre-Survey Assessments provide the ACHS surveyors with an understanding of the organisation, its current achievements and the way in which it operates.

3.1.1 Benefits and objectives of the self assessment

The main benefit of the self assessment is to provide a formal and systematic assessment of an organisation’s progress against recommendations from the previous survey. Other benefits include:

• to provide an internal tool for quality improvement

• to increase consumer / patient satisfaction by showing the organisation’s commitment to safety and quality

• to focus and energise the organisation using identified goals

• to increase involvement of staff in continuous quality improvement

• to provide a communication and support channel with the ACHS

• to prepare for the accreditation survey.

3.1.2 The self-assessment process

new eQuIP members

New members of the EQuIP5 program begin their quality management process in Phase 1 by undertaking an initial self assessment. This initial self assessment is against all of the EQuIP5 standards. The self assessment provides a gap analysis that the organisation can use as a basis for planning, by identifying opportunities for improvement and providing a starting point for an organisation to measure and improve performance.

existing eQuIP members

During a four-year EQuIP cycle, an organisation will complete a self assessment during Phases 1 and 3. These self assessments report the progress against recommendations from the previous survey. In addition, the organisation provides an updated risk register of the key organisational risks.

When addressing recommendations from the previous survey, organisations will be required to use the Recommendations from the previous survey section in the Electronic Assessment Tool (EAT). The following information is included in the Action taken section when addressing the recommendations: the position of the person responsible for the recommendation, target or completion date of the recommendation, and the actual action taken to address the recommendation.

October 2010  11

when addressing the recommendations from a previous survey, the following guidelines are important:

¼ Who is involved in addressing the recommendation?

¼ What is the intent of the recommendation?

¼ What is the timeframe for addressing the recommendation? – timeframes and priorities will ensure a realistic action plan is developed.

¼ Maintain a focus on outcomes / results. What outcomes / results do you expect to achieve by addressing the recommendation?

¼ How have you incorporated the principles of EQuIP in the response? – that is, consumer / patient focus, effective leadership, culture of improving, striving for best practice.

¼ How do you know the actions you implemented are effective?

¼ How can you be confident that the steps you have taken have led to an improvement in your services? What measures or indicators will you use to monitor these actions?

3.1.3 The EQuIP Self-Assessment feedback report

The self assessment from each organisation is reviewed by ACHS staff or a consultant and a written feedback report is provided. This review mechanism assists organisations to identify areas for improvement and aids in the preparation for future surveys. Organisations may also request a scheduled telephone discussion to further discuss the self-assessment report.

3.1.4 Changes to the self-assessment format from EQuIP 4 to EQuIP5

The self-assessment format has undergone some important changes and improvements since EQuIP 4, which are summarised in the following table.

eQuIP 4 self-Assessment

replaced by eQuIP5 self-Assessment

In EQuIP 4, members were required to document a summary of supportive evidence against each EQuIP 4 criterion.

In EQuIP5, the self assessment addresses only the progress against the recommendations and the key organisational risks. It is only in the Pre-Survey Assessment that members are required to address each criterion.

3.1.5 Before starting a Pre-Survey Assessment

Prior to commencing the Pre-Survey Assessment, there are some key issues to be considered. These include:

• ensuring there is executive support and commitment

• ensuring resources such as expertise and time are available

• facilitating a climate of trust, with open participatory management and an organisational desire to improve

• using staff training and education to empower staff in quality and improve their input to the self assessment.

12  The ACHS EQuIP5 Guide  Book 1  Accreditation, Standards and Guidelines  Clinical Function

3.2 Pre-Survey Assessment (PSA)

3.2.1 How to start a PSAThe organisation should begin the process as early as possible. The Pre-Survey Assessment will need to be submitted six weeks prior to the survey.

The Pre-Survey Assessment is an opportunity for the organisation to ensure as many staff and stakeholders as possible contribute to the preparation for survey. This can be assisted by circulating information about EQuIP and the Pre-Survey Assessment to all staff and developing systems to empower and encourage them to contribute.

Many organisations have found it useful to appoint an appropriate person to take responsibility for each standard / criterion. In some cases, this will be the chair of a committee or a designated member of staff with an interest in the area. It is suggested that ‘champions’ are selected to assist in preparing responses to each criterion.

Alternatively, some organisations form working groups with responsibility for the EQuIP process, or a working group for each function or standard.

Note that it is the quality coordinator’s responsibility to coordinate the submission of the Pre-Survey Assessment report, rather than to create it.

Well-prepared Pre-Survey Assessments will greatly assist the organisation in continuous quality improvement, and will also assist the ACHS surveyors in the verification procedures required for onsite surveys.

3.2.2 The PSA format

summary of supportive evidence

The Summary of supportive evidence is a list of all the elements of each criterion with a section allowing a brief summary of how the organisation demonstrates that it fulfils those elements. This section assists an organisation to rate itself against each criterion and forms a gap analysis against the criteria.

Each criterion needs to be self-rated as LA, SA, MA, or EA (the levels of achievement are detailed in Section 3.5.2 Criterion achievement ratings). The rating for the criterion is determined by systematically working through all its elements and assessing whether the organisation has achieved the stated requirement in those elements. Where a specific element is not applicable, this can be flagged by clicking the NA option in the Electronic Assessment Tool (EAT), and where explanation is required, may be outlined in the Summary of supportive evidence section.

Handy hints when rating a criterion:

• Rate the criterion using the elements as a guide.

• Evaluate your progress against the elements of the criterion.

There are three response options provided for each element in the Summary of supportive evidence section: Yes, Work in Progress (WIP) and Not Applicable (NA). A brief explanation of the evidence needs to be entered into the Summary of supportive evidence section. There is a 1000 character limit for the supportive evidence sections. Organisations need to ensure that the brief evidence they include in the Pre-Survey Assessment is able to assist the survey team to verify the stated level of achievement.

The rating levels for the Pre-Survey Assessment are:

LA

Awareness

sA

Implementation

MA

evaluation

eA

excellence

oA

Leadership

LA elements LA elements plus SA elements

LA, SA elements plus MA elements

LA, SA, MA elements plus any ONE of the EA elements

This can only be rated by the surveyors at the survey

seCtIon 3EQuIP Surveys

October 2010  13

A variety of methods to collect the evidence can be used. These may include:

• routine data collections that are already under way, for example reports to State / Territory and Commonwealth governments or data to health insurance funds

• special data collections such as surveys and focus groups where applicable

• asking staff, including management, what improvements they have been involved with or how they can demonstrate quality service

• asking both staff and managers from different areas a set of questions to verify that processes have in fact been implemented

• finding out from staff what they would like to improve and if they have a workable plan for that improvement

• asking managers to ensure they can verify evidence of meeting the elements of the criteria in their area

• use of clinical indicators or performance indicators.

Summary of Supportive Evidence screen

Note that an organisation may be achieving in areas other than the listed elements under each criterion as the elements are not limiting. Evidence that does not respond directly to the wording of the elements, but is relevant to the criterion statement, may be included in the Summary of supportive evidence section.

14  The ACHS EQuIP5 Guide  Book 1  Accreditation, Standards and Guidelines  Clinical Function

Key Improvements

The Key improvements section is designed to provide an organisation with the opportunity to summarise its quality or safety implementation initiatives in high-volume, high-risk or significant areas within the member organisation. Up to ten of the most significant results / outcomes with verifying data for each criterion are required. This means that, particularly in larger and more complex organisations, the Pre-Survey Assessment will need to be selective and target issues of the greatest volume, risk and significance in relation to the criterion. There is a 1000 character limit for this section.

The Key improvements section allows members and surveyors to obtain an overview of achievement against the criterion since the last onsite survey by showing:

• the improvement project

• what the organisation changed

• the outcomes / results of the project.

Plans for Improvement

The Plans for improvement section will provide members and surveyors with an indication of how the organisation is progressing against each criterion since the last onsite survey by providing the major areas for future improvement.

Up to ten organisational plans for improvement can be recorded against each criterion. There is a 1000 character limit for this section.

If you need help to complete the Pre-Survey Assessment or assistance with understanding EQuIP, the Customer Services Manager appointed to your organisation will be able to assist you.

seCtIon 3EQuIP Surveys

October 2010  15

3.2.3 Points to remember in preparing a PSA• Ensure that you are familiar with the EQuIP

Pre-Survey Assessment system and the format of the Pre-Survey Assessment.

• Consult your Customer Services Manager if you need advice.

• Plan your reporting process carefully, involving staff and stakeholders.

• Delegate areas of responsibility for completion.

• Ensure the reporting processes are systematic and accurate.

• Begin the Pre-Survey Assessment process as early as possible, as evaluation can take longer than estimated.

• Keep the summary of supportive evidence brief.

• Ensure that the evidence noted in the Pre-Survey Assessment is cross-referenced and is able to be verified during the onsite survey by the survey teams.

The due date for the submission of the Pre-Survey Assessment will be advised in writing by the Customer Services Manager at the commencement of the accreditation contract. It will be six weeks before the onsite survey.

3.2.4 The Electronic Assessment Tool (EAT)The ACHS Electronic Assessment Tool (EAT) is a web-based application used by ACHS member organisations and surveyors to capture data as part of the ACHS accreditation program. The latest version of EAT is designed to accommodate the specifications of EQuIP5 standards and related accreditation survey processes.

EAT data are transmitted using 128 bit SSL encryption to ensure confidentiality and the tool is available 24 hours per day with the exception of maintenance periods.

EAT is designed to perform on various current operating systems and popular internet browsers. It requires a reliable direct internet connection (not via proxy server) to ensure optimal performance.

survey submission

EAT users can submit their survey data electronically online. There are data submission requirements in EAT and they are designed according to the EQuIP5 program requirements, to ensure sufficient information is provided from the organisation and the survey team.

Member details

Member details data should always be updated for all survey phases. An organisation will not be able to submit their data if they do not enter a physical address or identify sites for survey.

organisation-wide survey (ows)

Data are required for all standard and criterion sections, and for recommendations from the last onsite survey.

Periodic review (Pr)

Data are required for mandatory standards and criterion sections, and for recommendations from the last onsite survey.

self assessment phases

Data are required for recommendations from the last onsite survey. The risk register should also be submitted.

ratings

Rating requirements must be satisfied prior to submission.

eAt resources

For further information on EAT please refer to the EAT login screen for:

• Overview EAT access

• Frequently Asked Questions (FAQ)

• EAT Help Manual.

eAt support

Please notify ACHS immediately if you are experiencing difficulties with the Electronic Assessment Tool:

Telephone: +61 2 9281 9955 8:30am – 5:30pm (Australian Eastern Standard Time)

Email: eat@achs.org.au

16  The ACHS EQuIP5 Guide  Book 1  Accreditation, Standards and Guidelines  Clinical Function

3.3 EQuIP onsite surveys and processes

An ACHS survey is an objective and evidence-based assessment of a healthcare organisation’s performance against a set of standards, undertaken by surveyors who are from the healthcare industry.

There are two scheduled onsite surveys within the EQuIP cycle. These are conducted during Phase 2 and Phase 4.

The accreditation surveys consist of an Organisation-Wide Survey in Phase 2 and a Periodic Review during Phase 4.

An Organisation-Wide Survey (OWS) is a review of the achievements of the healthcare organisation against all of the ACHS EQuIP5 standards and criteria, including the recommendations that were made at the last survey.

The Periodic Review (PR) is a review of the achievements of a healthcare organisation against the 15 mandatory criteria and the recommendations from the last onsite survey.

In addition, if the survey team finds a ‘risk’ in a non-mandatory criterion during the PR, this will need to be included in the survey report.

The surveyors will verify the organisation’s Pre-Survey Assessment against the standards by reviewing the evidence presented to them. This will be in the form of interviews with staff, reviewing documentation such as policies, and other information such as clinical indicator reports, incidents and complaints management.

In most cases, the two onsite surveys will differ in the number of days and surveyors allocated.

The survey length and the number and selection of surveyors are determined by several criteria including:

• the size of the organisation

• the type of care and services offered

• whether the organisation is public or private

• whether the organisation is rural or metropolitan.

The ACHS aims to match surveyor expertise and experience with the organisation.

ACHS survey teams are made up of professionals from the healthcare industry. The Survey Coordinator will be the main contact point between the ACHS survey team and the organisation. If an organisation is relatively small – such as a day procedure centre – there will always be at least two surveyors, with one surveyor coordinating the entire onsite process. However, if the organisation is large with multiple sites of operation, the ACHS will appoint a Survey Coordinator to manage

the activities with a team perhaps as large as 8 to 10 surveyors. It is very important to make contact with the Survey Coordinator as early as possible. The Survey Coordinator will be able to assist during the survey preparation period with timetable drafting, presentations and evidence for the survey.

The ACHS has a formal selection process for surveyors. All ACHS-appointed surveyors participate in initial training and annual refresher courses, and are expected to ensure the currency of their expertise. Evaluation forms are completed by the organisation and by the surveyors after every survey to assist in continuous improvement within the surveyor workforce and of the ACHS policies and procedures.

Consumer surveyors

An additional option for member organisations is the inclusion of a consumer surveyor at one of the onsite surveys. Although surveys of mental health organisations regularly use consumer surveyors, there are also significant benefits to organisations outside this speciality in having a consumer surveyor on survey:

• greater focus on patient-centred care

• better engagement with local consumer groups and community groups

• access to a consumer perspective on standards of care.

3.3.1 The survey schedule The dates for onsite surveys are pre-determined at the commencement of the EQuIP contract period. While these dates are negotiable to some degree, it is important to be aware of when the next events in the EQuIP cycle occur. ACHS Customer Services Managers work with the organisation to determine convenient dates for the survey, the locations to be surveyed, the duration of the survey and any associated costs at the set up of the membership. The duration of the survey may be one day for small organisations, and up to five days for large organisations.

If an organisation needs to change the dates of any EQuIP event, particularly an onsite survey, the ACHS should be notified as soon as possible. Refer to the EQuIP Terms and Conditions of Membership for information regarding fees for deferring surveys. Each member organisation has a designated Customer Services Manager backed up by a support team that is able to provide coordination and assistance throughout the membership period. The Customer Services Manager will be in contact with the healthcare organisation prior to a survey to discuss issues in relation to the upcoming survey.

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3.3.2 Additional surveysIn addition to the OWS and the PR, there are other surveys that your organisation may be involved in and they include the following:

Advanced Completion in 60 days survey

An Advanced Completion in 60 days (AC60) survey may be offered to an organisation in up to four criteria in order to address:

• High Priority Recommendations (HPRs), and/or

• an SA rating in mandatory criteria, and/or

• an SA rating in non-mandatory criteria.

If the Survey Coordinator, during discussion with the organisation being surveyed, believes that an organisation would benefit from 60 days from the survey date to achieve an acceptable level of performance, an Advanced Completion survey will be offered. This provides the organisation with an opportunity to promptly address issues prior to the completion of survey report processing and the subsequent accreditation decision. Costs associated with the AC60 must be met by the member organisation.

Conditional survey

Following either an OWS or PR, the survey team may recommend a Conditional Survey to allow an organisation a year to achieve an acceptable level of performance; this provides the organisation with an opportunity to address issues which require some time and resources to achieve an acceptable level of performance.

A Conditional Survey may be offered to an organisation in up to two criteria in order to address:

• High Priority Recommendations (HPRs), and/or

• a SA rating in mandatory criteria.

In addition, a Conditional Survey may be offered to an organisation in order to address:

• SA / LA ratings in from 6 to 11 non-mandatory criteria.

For issues in which a 60-day framework is too short to achieve the level of change required, a Conditional Survey gives the organisation one year to achieve the required level of performance.

At the end of this time, the survey team will assess the organisation’s performance against the criteria which led to the Conditional Survey. They may also, at the request of the organisation, survey additional criteria to assist the organisation in its quality journey.

If, at the Conditional Survey, the organisation meets the required standard, the organisation will regain its full accreditation status. The accreditation expiry date will remain as it was following the last OWS.

If, at the Conditional Survey, the organisation has not resolved the identified areas of poor performance, the organisation will become non-accredited.

Costs associated with the Conditional Survey will be met by the member organisation.

Alignment survey

The Alignment Survey assists organisations to maintain their accreditation status if several organisations amalgamate their membership. An Alignment Survey may also be conducted if there is a restructure of related organisations. The Alignment Survey allows the ACHS to ensure that quality and safety continue to be addressed throughout the organisation’s transition.

An Alignment Survey will be a review of:

• all mandatory criteria

• all Clinical Function criteria

• Criterion 3.1.4 External service providers

• recommendations from the previous onsite survey.

The Alignment Survey may be conducted as a reduced OWS or as an expanded PR. The extent of the Alignment Survey will be discussed with the organisation and agreed with the Customer Services Manager. If the organisation demonstrates an appropriate level of achievement, a two-year accreditation status will be granted.

In-depth review

An In-Depth Review is a more detailed review of particular services within an organisation using the ACHS standards and relevant specialty standards and guidelines for that particular service. The In-Depth Review, undertaken by a surveyor or surveyors with a background in the particular specialty, is valuable in helping to improve services and to demonstrate to consumers and funders that the service provides high quality care. Services undertaking an In-Depth Review may be awarded a Certificate of Recognition of the application of the specialty standards. The In-Depth Review is conducted at an additional cost to the member organisation and is conducted at the same time as the OWS.

18  The ACHS EQuIP5 Guide  Book 1  Accreditation, Standards and Guidelines  Clinical Function

Specialty standards and guidelines are used in In-Depth Reviews of:

• mental health services

• pharmacotherapy clinics

• palliative care services.

unscheduled surveys

To ensure that organisations continue to meet the ACHS standards and to provide the required standard of care and service, the ACHS has introduced the possibility of an Unscheduled Survey. There are certain circumstances under which such a survey will occur, including the failure on the part of an organisation to provide sufficient evidence that previous recommendations are being progressed. The next survey in the organisation’s EQuIP cycle will be rescheduled to an earlier date to accommodate this onsite survey. This survey will be conducted to ascertain whether the healthcare organisation is meeting the EQuIP standards to the required level.

3.3.3 Getting ready for the survey – one page summaries

Before an onsite survey, it is recommended that larger organisations complete one page summaries.

One page summaries provide a useful tool for surveyors and organisations to identify and focus on the major achievements made in each of the EQuIP5 functions (Clinical, Support and Corporate) by individual departments, divisions or service streams. It is an excellent tool to showcase major achievements that are not covered in the organisation’s Pre-Survey Assessment document.

One page summaries should be exactly that – a concise, single page of listed achievements under each function, prepared by individual departments, divisions or service streams. A summary needs to clearly identify the department, division or stream, and to be dated and submitted to the survey team six weeks prior to the survey – together with the Pre-Survey Assessment.

An example of a one page summary prepared by a department; it provides an instant understanding of the service and notes the major achievements in the department for each function.

radiology department: summary of Achievements 11 october, 2007

The Radiology department underwent re-location and renovation during 2005. This enabled a review of the department’s facilities, in particular its outpatient services and information systems. A review was also undertaken on volunteer staffing levels and training.

Clinical support Corporate

A re-designed layout of facilities, additional consumer / patient support equipment and procedures have resulted in improved falls management

A revised consumer / patient record transfer has improved information security and efficiency

Signage at appropriate external and internal sites has been improved

Partnerships with consumer focus groups identified areas for improvement

Public health information is better presented and accessible within the consumer / patient waiting area

Waste management systems have been reviewed for safety and efficiency

A staff awareness program has been introduced to better identify and appropriately manage CALD consumers / patients

Participating volunteers in the hospital system now provide support services in the consumer / patient waiting area

Improved documentation provides consumers / patients with clearer information on procedures and x-ray systems

Small, single-function facilities are not required to complete one page summaries prior to onsite surveys.

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3.3.4 Survey timetablesOne of the first preparation activities for an onsite survey is the development of an agreed survey timetable. A survey timetable allows efficient time management for the survey team and the organisation. It is helpful to have an initial discussion with the Survey Coordinator prior to drafting the timetable, to clarify any specific issues and requirements. The draft timetable can then be prepared well in advance and forwarded to the Survey Coordinator for comment. The Survey Coordinator will assess its workability and may suggest some practical changes. The timetable may go through several adjustments before a final version is decided upon.

When preparing the survey timetable organisations need to consider the key people to be identified and included.

This will depend on the size and type of the organisation. For example, for a day hospital, the

surveyors will need to meet with the director, nursing staff and medical staff. For larger organisations, this will include the executive team, the quality and risk teams, the lead clinicians, heads of departments and so on. The focus needs to be on teams for most of the interviews for large organisations. Some of these teams will include service delivery / frontline staff rather than management. Many teams will be the committees that are responsible for particular criteria. For example, the Occupational Health and Safety committee would meet regarding the safety management criteria. In large organisations, the surveyors will always need to meet with the senior medical staff, and with the junior medical staff as a group. At a rural organisation, it is expected that the survey team will meet with the local GPs. It is also usual for the survey team to meet with the Medical Advisory Council.

Survey time with consumers / patients and stakeholder groups also needs to be taken into account in the timetable.

Part of a survey timetable prepared for a large healthcare organisation. For a smaller organisation, there may only be two surveyors, although the principles remain the same. Each verification and meeting has a cross-reference to the ACHS criterion to which it applies.

time

survey

Coordinator

Mr Alex smith

surveyor 1

Ms Jill Brown

surveyor 2

Mr John other

8.30–8.45am Meet in main foyer with quality coordinator

Meet in main foyer with quality coordinator

Meet in main foyer with quality coordinator

8.45–9.15am Hospital tour Hospital tour Hospital tour

9.15–9.30am Escort to the surveyors’ work area

Escort to the surveyors’ work area

Escort to the surveyors’ work area

9.30–10.30am Welcome by organisation executive and presentation to survey team – Board room

Welcome by organisation executive and presentation to survey team – Board room

Welcome by organisation executive and presentation to survey team – Board room

10.30–11.00 am Verification time for survey team

Verification time for survey team

Verification time for survey team

11.00am–12.30pm 1.5.2

Meeting with Clinical Nurse Specialist, infection control committee – CNS office

1.2.1, 1.1.6

Meet with Mgr Cardiac Rehab Centre and team –Rehabilitation Centre

3.1.5

Meeting with Director of Nursing and policy committee – Board Room

12.30–1.00pm Lunch – Board Room

Before an onsite survey commences, ACHS survey teams will have familiarised themselves with the organisation through its Pre-Survey Assessment and the pre-survey discussions that the Coordinator has conducted with the organisation.

20  The ACHS EQuIP5 Guide  Book 1  Accreditation, Standards and Guidelines  Clinical Function

Essential tips for completing the survey timetable:

• Be prepared to adjust the timetable during the survey.

• Circulate the final timetable to everyone in the quality management team and to the various departments to be surveyed.

• List locations as well as names, position titles and times, and the criteria that will be of interest during the meeting.

• Take into account the time factor for surveyor travel from location to location.

• Ensure that the timetable includes all sites that need to be visited.

• Ensure that the survey timetable includes adequate time for verification of evidence and opportunities for the survey team to have unscheduled discussions and meetings with staff.

• Provide a location map with the timetable for the survey team.

• Carefully assess the complexity of each department’s functions and the time the surveyor / survey team will need. Clinical units will usually require a generous time allocation.

• Include the organisation’s presentation in the timetable.

• Check that your survey team has an accurate organisation map and a list of key personnel with contact details.

• Ensure that the survey team has appropriate security identification.

Include a scheduled meeting with the organisation’s leadership team and senior management on a daily basis. Some Survey Coordinators like to meet in the evening, while others would prefer an early morning meeting to discuss how the survey is progressing.

3.3.5 Surveyors’ meeting with the leadership team

An essential part of the opening phase of the survey is an informal meeting between the survey team and the organisation’s leadership team and senior management. This brief meeting should take place at the beginning of the first day, and provides an opportunity to discuss issues that may need to be raised, to review the objectives of the survey, to ensure that the management team is aware of the evaluation process and to discuss any areas of significance. A tour of the organisation may take place at this point. In addition, the survey team or Coordinator is required

to meet with the executive on a daily basis and this needs to be included in the timetable. The best time for this daily meeting should be determined with the Coordinator prior to the survey. This meeting is to ensure that any issues raised during the survey are immediately addressed.

3.3.6 The survey presentationThe survey presentation allows the organisation to showcase its improvements and achievements.

A formal presentation will follow the introductory meeting. Presentations provide an organisation with the opportunity to present an overview of outcomes and achievements since the last onsite survey. It is important to discuss with the Survey Coordinator the expectations of the presentations as early as possible, so that your preparation is appropriate.

Presentations may be in different forms, such as a PowerPoint presentation or simple documentation. A small organisation with a small quality management structure may prefer to produce a written overview that can be discussed with the survey team, rather than make a formal presentation. The total presentation should be brief, ideally running from 30 minutes to 1 hour, and needs to be outcome-based, providing a summary of the organisation’s quality initiatives and achievements.

Individual departments should be encouraged to discuss their own management strategies and accomplishments during the verification meetings with surveyors – this should not be in the form of a presentation in their own department.

3.3.7 The survey processAfter the introductory meetings with senior management and the presentation, the surveyors should be shown to their designated work room. Although the surveyors will be conducting meetings throughout the organisation, it is essential they be provided with a relatively quiet, private area in which they can work and meet. Surveyors will need to verify evidence. Ideally, the room should be lockable. Surveyors will need access to the internal telephone listing and be reasonably comfortable about finding their way around the organisation. Surveyors will also need to access a computer and the intranet if organisations have policies available electronically. If evidence is presented electronically, the surveyors will require one computer each, and the organisation should provide a timetabled session on navigating the electronic evidence at the beginning of the survey.

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October 2010  21

The quality manager / coordinator / designated staff member should be readily accessible throughout the survey to assist with any administration matters or to adjust the next day’s timetable if required.

The role of the quality manager / coordinator / designated staff member is to support the survey team but not participate in meetings. It is best to leave the surveyors to their own devices unless assistance is requested.

Members of the organisation executive should not accompany surveyors to departments.

The survey team will need to meet with the appropriate staff in each department. The departmental representative can review its operations with the surveyor(s) and identify quality initiatives and achievements. The surveyor(s) will then need to access information and records to verify the level of performance. Appropriate department staff will need to be accessible to the survey team.

3.3.8 VerificationVerification needs to be evidence-based. Throughout the survey, the survey team will:

• review documents

• observe how well the organisation and its various services are functioning

• conduct formal and informal discussions with staff, consumers / patients and carers.

The surveyors will continuously ask two questions:

“How have you improved?” and

“What evidence do you have to substantiate the improved outcomes?”

In each individual department throughout the organisation, the survey team will need to know what that department does, how it provides its services and how the performance levels have improved through the evaluation process.

Prior to the survey, the organisation will need to identify the documented evidence the survey team may require and verify its location. The Survey Coordinator will assist with this prior to the survey. Generic information such as meeting minutes could be categorised into the relevant EQuIP5 functions and located in the surveyor room. The policies and procedures that apply to clinical staff do not need to be copied and put into the survey room. As the survey team will determine the specific evidence needed, it is unnecessary to provide copies of documents in the surveyor room that may not be required. Surveyors will need to know how to access documentation and this should be discussed with the Survey Coordinator prior to the survey.

3.3.9 The Summation ConferenceAt the completion of the onsite survey the survey team will make a summation of the survey.

Throughout the survey, the surveyors will have discussed their findings with each other to obtain an accurate and balanced assessment of the organisation’s performance. During its daily meetings, the survey team will determine the ratings for each criterion. The team will also evaluate the progress from previous recommendations and determine any matters which require attention.

Before the Summation Conference, the survey team will discuss its findings with the organisation’s executive team and identify any areas of concern, and acknowledge achievements.

The organisation’s executive will then join the ACHS surveyors for the Summation Conference. The organisation itself will determine who attends the survey summation. Generally, any staff can be invited, as well as those who are part of the quality management team and heads of departments.

The surveyor summation is designed to:

• provide a generalised feedback on the organisation’s performance

• acknowledge quality initiatives and achievements

• provide recommendations for performance improvement

• provide an indication of any High Priority Recommendations.

The surveyor summation will NOT provide information on expected accreditation outcomes, as survey results require lengthy analysis and evaluation.

22  The ACHS EQuIP5 Guide  Book 1  Accreditation, Standards and Guidelines  Clinical Function

3.4 EQuIP survey reports

Each organisation receives an ACHS report following participation in a survey. The survey report can be used as a management tool to assist an EQuIP member to improve, and also to recognise its achievements. ACHS survey reports are a summary of an organisation’s performance at the onsite survey. The report will include evidenced findings, comments and recommendations, including suggestions for improvement. It is expected that the organisation will use the EQuIP survey report as a consultancy report.

The accreditation survey report is a statement of evidence on whether an organisation has met the appropriate standards to be awarded accreditation or to maintain its accreditation.

Any matters of concern that may appear in the survey report about the organisation’s performance are advised to the organisation’s executive prior to the Summation Conference and on a daily basis during the survey. In addition, if agreed by the executive, these issues will be discussed during the Summation Conference.

Organisations are provided with a copy of the completed survey report in draft format prior to the report being finalised. This allows an organisation to ensure that the report is factually correct and that the form of expression is appropriate to the environment in which the organisation operates. Organisations can also request clarification of recommendations where they may appear unclear or based on what appear to be incorrect facts.

Organisations will be provided with an opportunity to review the draft survey report for the following:

• any statements containing inaccurate information, errors of fact or omissions

• any statements which may be found to be misleading, for example, where the phrasing of a comment is expressed in a way which could be misinterpreted.

The draft survey report process supports the EQuIP consultative processes and encourages a continual collaboration from the initial assessment processes to the final product.

Should the ACHS receive a request for a clarification of fact in the draft survey report, the Survey Coordinator will be consulted by the Customer Services Manager regarding the proposed changes. The Survey Coordinator then liaises with the survey team members. The Survey Coordinator will endorse any final amendments to the draft survey report.

The survey reports are made up of a Function Summary, surveyor comments and recommendations, and surveyor ratings for each criterion.

A Function Summary identifies the organisation’s strengths, as well as opportunities for further improvement. Any areas requiring high priority improvement will also be identified in the Function Summary. Risk ratings and risk comments will be included where applicable.

The surveyors will make a comment on all the mandatory criteria, giving an indication of why the organisation is achieving at the given rating.

Identification of actions taken from previous recommendations will be reviewed and documented.

Surveyors are required to make a recommendation where an LA or SA rating has been assigned in a criterion, as guidance and to provide an organisation with an opportunity to improve.

3.4.1 How to use the survey reportAs the report provides a full quality and performance analysis it should be used to:

• provide feedback to staff

• identify where improvements are needed

• compare the organisation’s performance over time

• evaluate existing quality management procedures

• assist the monitoring of risks and their management

• highlight strengths and opportunities for improvement

• demonstrate evidence of achievement to stakeholders.

Upon receipt and authorisation from the organisation executive, it is a good idea to circulate the survey report throughout the organisation including to the quality team, consumer representatives and other stakeholder groups.

3.4.2 Public release of accreditation information

Information about the accreditation status of EQuIP members is made publicly available on the ACHS website.

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October 2010  23

Since July 2004, member organisations have been encouraged to publish a jointly agreed statement of their performance from the survey – an Agreed Performance Statement. The statement is made available on the ACHS website. Alternatively, an organisation may provide access to the full accreditation report on the organisation’s own website via a link from the ACHS website. The ACHS is also able to host the full report on its website if required.

3.5 Accreditation levels, survey recommendations and achievement ratings

3.5.1 Accreditation outcomesThe possible accreditation awards granted to organisations following an onsite survey (OWS or PR) in EQuIP are full accreditation, conditional accreditation or non-accreditation.

The accreditation awards for an Alignment Survey are the same as those for the OWS and PR except that full accreditation is for two years only.

FULL ACCREDITATION (4 Years)

¼ A Marked Achievement (MA) rating level or higher in ALL EQuIP mandatory criteria

¼ All previous recommendations are addressed

¼ Receive no High Priority Recommendations

¼ Have no significant risks

CONDITIONAL ACCREDITATION (1 Year)CONDITIONAL ACCREDITATION (1 Year)

¼¼¼¼ A Little Achievement (LA) or Some Achievement (SA) rating level in from 6 to 11 non-mandatory criteria irrespective of risk level

¼¼¼¼ High risk in any non-mandatory criteria

¼¼¼¼ Moderate risk recommendations from previous survey not addressed

¼¼¼¼ In a maximum of two criteria, High Priority Recommendations (HPRs) and/or SA ratings for mandatory criteria that are not able to be resolved within 60 days

NON-ACCREDITATION

¼ High Priority Recommendations (HPRs) from previous survey not addressed

¼ High Priority Recommendations (HPRs) or SA Ratings in mandatory criteria in more than two criteria that are not able to be resolved in 60 days

¼ LA ratings in any mandatory criteria

¼ 12 or more LA or SA ratings in non-mandatory criteria

3.5.2 Criterion achievement ratings Each of the 47 EQuIP5 criteria has five levels of achievement:

Level 1 Little Achievement (LA)

Organisations that achieve an LA rating will have an awareness or knowledge of responsibilities and systems that should be implemented, but may have only basic systems in place. At this level, compliance with legislation and policy that relates to the criterion would be expected.

Level 2 Some Achievement (SA)

An organisation that achieves an SA rating will have achieved all the elements of LA and will have implemented systems for the organisation’s activities. At this level there is little or no monitoring of outcomes, and so efforts at continuous improvement may be limited by a lack of understanding about the effectiveness of existing systems.

Level 3 Marked Achievement (MA)

The label for MA has changed from ‘Moderate Achievement’ to ‘Marked Achievement’ as the term ‘Moderate’ did not reflect the high standard of achievement that organisations reach within the MA award level. An MA rating requires that achievement against the elements of LA and SA has been demonstrated and that efficient systems have been established for collecting relevant data on processes and preferably outcomes, monitoring this information, evaluating current procedures and planning improvements in response.

24  The ACHS EQuIP5 Guide  Book 1  Accreditation, Standards and Guidelines  Clinical Function

Level 4 extensive Achievement (eA)

To achieve a rating of EA in EQuIP5, demonstrated achievement against the elements in LA, SA and MA must be met. In addition, response to EA elements will be reviewed and extensive achievement against the criterion statement and/or its elements is required.

Organisations will be able to demonstrate extensive achievement in a criterion if they satisfy one, and preferably more, of the following requirements:

• internal or external benchmarking and subsequent system improvement, and/or

• the conduct of research that relates to the particular criterion, and subsequent system improvement, and/or

• proven, excellent outcomes in the particular criterion.

Level 5 outstanding Achievement (oA)

All elements of LA, SA, MA and EA must be achieved, as well as a demonstration of leadership in this criterion. Leadership in a criterion does not necessarily mean that the organisation is a peer leader of performance and excellence in Australia. However, it does require an organisation to use concrete evidence to demonstrate

that it is one of the best and, more importantly, that it has taken a leadership stance in communicating its outcomes to other professionals, other organisations and/or consumers / patients, or that the organisation is being recognised and sought out for its knowledge by other professionals and organisations.

Further information on achieving MA, EA or OA ratings is covered in Section 3.5.3 Expectations for ratings.

How should organisations and surveyors rate achievement?

Organisations and surveyors will use the elements in each of the criteria to rate the level of the organisation’s achievement. The elements are not meant to be an audit checklist; they describe the practices that contribute to the achievement of each level. The manner in which the elements are implemented and the evidence presented may differ between organisations. However, organisations should demonstrate that their practices address the intent of the element, and their evidence responds to its aim or purpose.

The following figure will assist organisations to better understand how the elements can assist rating achievement. Surveyors will use this model when assigning ratings for organisations.

seCtIon 3EQuIP Surveys

The criterion rating format

Awareness

of basic requirements. Policy and legislative compliance is in place

Little Achievement

LA elements

Implementation

Systems have been developed and implemented

Some Achievement

LA elements plus the SA elements

evaluation

Data are collected; evaluation of the system occurs to ensure the system works effectively. Improvement efforts support better results

Marked Achievement

LA, SA elements plus the MA elements

excellence

Benchmarking and/or research and/or advanced implementation strategies and/or excellent outcomes are achieved

Extensive Achievement

LA, SA, MA elements plus any ONE of the EA elements

Leadership

The organisation is a peer leader in systems and outcomes

LA sA MA eA oAOutstanding Achievement

All elements in LA, SA, MA, EA and OA

October 2010  25

3.5.3 Expectations for ratings

Achieving MA

The Marked Achievement (MA) rating in each of the 47 criteria requires that organisations evaluate their systems. The goal is to determine whether the system(s) that the organisation has implemented works effectively, whether there is potential to improve, and perhaps to give insight into how this might be achieved. This applies not only to the evaluation of clinical systems but also to the evaluation of policy and programs.

Evaluation is judging the value of something by gathering valid information about it in a systematic way and by making a comparison. The purpose of evaluation is to help to decide what to do, to justify earlier actions or to contribute to scientific knowledge.1

There are many different methods of evaluation that can be used in health services. The ACHS Risk Management and Quality Improvement Handbook provides further information on assessing performance and evaluation.

Evaluation of a process or system involves a review of performance measures and other qualitative data including the opinions of those directly involved in, or affected by, a process. It may include comparisons against earlier times, other departments / organisations or classes of consumers / patients or personnel. Organisations should then assess whether the process or system is meeting the organisation’s and its consumers / patients’ goals, and whether there is scope for improvement. Areas identified for improvement may require further investigation before a decision is made to progress. Evidence of data collection, its evaluation, and action taken, or reasons for inaction, would be expected for an MA rating. There is more to evaluation and quality improvement than measuring a process or system.

Significant quality improvement projects with documented evidence of baseline measurement, considered options for improvement, and demonstrated positive outcomes from the changes implemented would be a good foundation for advancing to achievement of an EA rating.

Achieving eA

For organisations to achieve an EA rating, they must have implemented innovative systems. The use of ‘and/or’ in the EA elements means that organisations may select one or more elements to show improvement on a particular program or process.

Organisations will need to provide information on how any improvements have progressed over time. This is to say, that a program or process has been evaluated and where improvement was required, changes were made, and then evaluation of those changes occurred. However, the program or process must be implemented across the organisation, and not just in one department / ward, or where the program or process has been trialled in one department / ward, a plan should be provided on how the improvement from it will be implemented across the organisation.

To show that improvements have evolved over time, they should be documented and dated, so that surveyors can see how the organisation has progressed and that the same improvement is not presented again.

Benchmarking and research

Elements in the EA column generally address either benchmarking or research. For those elements that require benchmarking, an EA rating cannot be awarded for conducting only compulsory government benchmarking.

Benchmarking is the continuous measurement of a process, product, or service compared to those of the toughest competitor, to those considered industry leaders, or to similar activities in the organisation in order to find and implement ways to improve it. This is one of the foundations of both total quality management and continuous quality improvement. Internal benchmarking occurs when similar processes within the same organisation are compared.2

If an organisation participates in benchmarking activities, it is important to complete the requirements of a proper benchmarking exercise; that is, not only to compare processes and outcomes but to institute improvements.

1 Øvretveit J. Action evaluation of health programmes and changes: a handbook for a user-focused approach. Oxford UK; Radcliffe Medical Press; 2002.

2 Joint Commission on Accreditation of Healthcare Organisations (JCAHO). Sentinel event glossary of terms. Oakbrook Terrace USA: JCAHO. Accessed from http://www.jointcommission.org/SentinelEvents/se_glossary.htm on 9 September 2010.

26  The ACHS EQuIP5 Guide  Book 1  Accreditation, Standards and Guidelines  Clinical Function

If organisations do not have access to comparative data, they should seek alternative ways to gauge the efficiency and effectiveness of their systems / processes. Departments / wards may be able to compare processes with other departments / wards in the same organisation, considering the similarities and differences between their sites. Similar functions and processes, such as scheduling or the collection of customer feedback, could be compared against other industries. The objective of benchmarking is to consider and test alternative systems and processes, and adopt those that will best meet the organisation’s needs. Through benchmarking, an organisation will understand the advantages and recognise any compromises in its processes.

Research is defined as a contribution to an existing body of knowledge through investigation, aimed at the discovery and interpretation of facts.1

Where an element requires an organisation to conduct research, it is referring to high-level quality improvement projects that have a robust structure, and are about a redesign of systems, processes and performance, rather than a review. The organisation should address the research elements by highlighting these types of projects.

Organisations that wish to present their research to surveyors to evidence a self-rated EA should understand that surveyors have an expectation of a project conducted and presented at a ‘publishable’ standard.

Inclusions in a quality improvement report are:

• background of the project

• assessment of problems

• results of assessment / measurement

• strategies for quality improvement / change

• lessons and messages.

The British Medical Journal (BMJ) group journal, Quality and Safety in Health Care, provides an outline of the structure of a ‘publishable quality improvement report’ – see http://qshc.bmj.com/site/about/guidelines.xhtml, and scroll down to ‘Quality Improvement Reports’.

Achieving oA

To achieve an OA rating, all applicable EA elements need to be met.

The requirement for achieving the OA level is a demonstration of leadership in that criterion. Leadership does not necessarily mean that the organisation is the best in Australia. It may mean that the organisation can demonstrate that it is outstanding amongst peers.

In EQuIP5, organisations will not be able to self rate at an OA level, however, if an organisation believes that it is a leader in a criterion, surveyors should be provided with a brief (one page) submission summarising the steps taken to achieve this and proof that the organisation is considered to be a leader. Surveyors will then evaluate the submission and the evidence provided and determine whether an OA can be awarded.

Surveyors may also award an OA rating without a submission from the organisation. If surveyors consider an organisation is performing at an OA level, they will assist the organisation to develop a one-page summary describing the leadership status, which will then be included in the survey report.

3.5.4 High Priority Recommendations (HPRs)A High Priority Recommendation (HPR) is given to an organisation when:

• consumer / patient care is compromised, and/or

• the safety of consumers / patients and/or staff is jeopardised.

Surveyors complete a risk assessment to validate their decision to allocate an HPR, which should be addressed by the organisation in the shortest time possible.

1 International Society for Quality in Health Care (ISQua). The ISQua Surveyor Training Standards Programme. Dublin IRL; 2009.

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October 2010  27

3.5.5 Achieving accreditationAn organisation which is awarded accreditation status by the ACHS has reached a high level of achievement.

ACHS accreditation signals to the community and staff that an organisation is striving for best practice, and has a quality improvement culture and committed quality management systems in place. Accreditation also sends the important message that the organisation has a focus on consumer / patient needs and safety.

Accreditation success should be communicated throughout the organisation, to stakeholders and to the community. Organisations may choose to strategically announce accreditation achievement via their website, newsletters or other preferred means of communication. The ACHS publishes accreditation achievements on its website.

3.5.6 Non-accreditationThe ACHS provides an extensive support network for organisations that have not reached full accreditation. This includes additional support from the Customer Services Manager as well as customised EQuIP workshops and training days. Individual consultations can also be arranged to assist with the implementation of improvement practices.

Following non-accreditation, the organisation must go through a full OWS in order to become re-accredited. The Customer Services Manager will work with the organisation to determine the best time for that survey to occur.

3.5.7 An appeals processAccreditation decisions may be appealed, in writing, by current financial members. All appeals must be addressed according to the Terms and Conditions of the organisation’s EQuIP membership.

28  The ACHS EQuIP5 Guide  Book 1  Accreditation, Standards and Guidelines  Clinical Function

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4.1 The EQuIP framework

EQuIP5 focuses on the issues considered to be of the greatest importance in providing high quality and safe health care. The standards have been developed in consultation with the healthcare industry and address the Clinical, Support and Corporate Functions of the organisation.

The standards and criteria express goals that are common to different types of services. This means that although the evidence presented by different health services or service providers for a criterion may vary, consideration of evidence can be made in the context of organisational structure, geography, consumer / patient type and services.

EQuIP5 is structured in a hierarchy, as follows:

• functions

• standards

• criteria

• elements

• guidelines.

Function

A function is a group of standards.

standard

The standard describes the overall goal; for example,

Standard 1.1 Consumers / patients are provided with high quality care throughout the care delivery process.

Criteria

The criteria describe key components of the goal, which are necessary for meeting the goal; for example,

Criterion 1.1.1 Assessment ensures current and ongoing needs of the consumer / patient are identified.

elements

For each criterion there is a series of elements which:

• explain the criteria

• describe some important practices for each level of achievement

• should not limit practices; organisations are encouraged to undertake and present additional activities that respond to the criterion statement

• should be regarded as a framework for total quality rather than a checklist of compliance

• provide direction for improvement activities and for achieving better practice.

Each element identifies what should be in place to at least fulfil the requirements of the criterion at a certain rating level. (Refer to Expectations for Ratings on page 25 of this guide.)

Guidelines

The guidelines give definitions and provide more information and guidance on demonstrating achievement against the standards at the criterion level.

EQuIP5 has 3 functions, 13 standards, and 47 criteria.

The arrangement of the standards and criteria into the three functions of Clinical, Support and Corporate identifies the fundamental responsibilities of the key provider groups within a health service.

• The Clinical Function sets out the standards that are predominantly associated with clinical care. Achievement of these standards is largely the responsibility of clinicians.

• The Support Function contains standards and criteria in which quality improvement requires clinical and corporate staff to work together, sometimes with assistance from internal ‘support staff’ or external consultants.

• The Corporate Function identifies those standards and criteria for which the governors of the organisation are predominately responsible.

The arrangement of the EQuIP5 functions provides a basic model for understanding corporate and clinical governance. Corporate governance1 is understood to be the system by which organisations are directed and controlled. Clinical governance2 involves an understanding and acceptance that the governing body has a responsibility for the quality of care delivered by a service and that this accountability is shared equally with the clinicians providing this care.

The Clinical and Support Functions (see figure on page 30) reflect clinical governance; the Support and Corporate Functions reflect corporate governance.

1 Committee on the Financial Aspects of Corporate Governance, and Gee and Co Ltd. Financial aspects of corporate governance. London UK; Committee on the Financial Aspects of Corporate Governance; 1992.

2 Australian Council on Healthcare Standards. News in brief: Clinical governance defined. ACHS News, 2004; 12(Spring): 4.

October 2010  29

Function 1 – Clinical has six standards:

1.1 Continuity of care

1.2 Access

1.3 Appropriateness

1.4 Effectiveness

1.5 Safety

1.6 Consumer focus

Function 2 – support has five standards:

2.1 Quality improvement and risk management

2.2 Human resources management

2.3 Information management

2.4 Population health

2.5 Research

Function 3 – Corporate has two standards:

3.1 Leadership and management

3.2 Safe practice and environment

The table on the following pages identifies at a glance the three functions, the 13 standards (colour highlighted) and each of the 47 criteria.

4.2 Key changes in EQuIP5

New criteria and elements have been introduced to EQuIP5 to:

• incorporate the most recent evidence on providing and improving health services

• fill gaps in earlier editions of the standards, which have been identified through feedback from surveyors and members, growing awareness, formal investigations and inquiries, new evidence and expanding knowledge of quality systems

• increase the focus on the clinical care that is provided by health services, respond to consumer feedback on healthcare service provision and expand consumer participation in service evaluation and development.

Specific changes include:

The achievement of an Outstanding Achievement (OA) rating level in any EQuIP5 criterion will be determined by the ACHS survey team. Organisations are not required to self assess to achieve OA rating levels.

The evaluation rating level (MA) is now termed Marked Achievement to better reflect the level of achievement required to implement quality improvement activity and assessment of performance outcomes.

An additional non–mandatory criterion on consumer / patient nutrition has been introduced to the Safety standard. Criterion 1.5.7 addresses the fundamental aspects of patient nutrition, nutritional screening and prevention of malnutrition.

Some criteria have been separated, combined or broadened:

• Separation of criteria to report and respond to incidents, 2.1.3, and complaints, 2.1.4

• Separation of criteria to specify key requirements for health records management, 2.3.1, and corporate records management, 2.3.2

• The collection, use and storage of data combined into criterion 2.3.3

• The broadening of Corporate elements, 3.1.2 and 3.2.3, to focus governance responsibility for ethical decision making and to provide greater scope for organisations to demonstrate proactive environment management.

For further information on key changes in the criteria and elements from EQuIP 4 to EQuIP5, please refer to the ACHS website.

30  The ACHS EQuIP5 Guide  Book 1  Accreditation, Standards and Guidelines  Clinical Function

1. CLInICAL

1.1 Consumers / patients are provided with high quality care throughout the care delivery process.

1.1.1 Assessment ensures current and ongoing needs of the consumer / patient are identified.

1.1.2 Care is planned and delivered in collaboration with the consumer / patient and when relevant, the carer, to achieve the best possible outcomes.

1.1.3 Consumers / patients are informed of the consent process, and they understand and provide consent for their health care.

1.1.4 Outcomes of clinical care are evaluated by healthcare providers and where appropriate are communicated to the consumer / patient and carer.

1.1.5 Processes for clinical handover, transfer of care and discharge address the needs of the consumer / patient for ongoing care.

1.1.6 Systems for ongoing care of the consumer / patient are coordinated and effective.

1.1.7 The care of dying and deceased consumers / patients is managed with dignity and comfort and family and carers are supported.

1.1.8 The health record ensures comprehensive and accurate information is collaboratively gathered, recorded and used in care delivery.

1.2 Consumers / patients / communities have access to health services and care appropriate to their needs.

1.2.1 The community has information on health services appropriate to its needs.

1.2.2 Access and admission / entry to the system of care is prioritised according to healthcare needs.

1.3 Appropriate care and services are provided to consumers / patients.

1.3.1 Health care and services are appropriate and delivered in the most appropriate setting.

1.4 The organisation provides care and services that achieve effective outcomes.

1.4.1 Care and services are planned, developed and delivered based on the best available evidence and in the most effective way.

1.5 The organisation provides safe care and services.

1.5.1 Medications are managed to ensure safe and effective consumer / patient outcomes.

1.5.2 The infection control system supports safe practice and ensures a safe environment for consumers / patients and healthcare workers.

1.5.3 The incidence and impact of breaks in skin integrity, pressure ulcers and other non-surgical wounds are minimised through wound prevention and management programs.

1.5.4 The incidence of falls and fall injuries is minimised through a falls management program.

1.5.5 The system to manage sample collection, blood, blood components / blood products and patient blood management ensures safe and appropriate practice.

1.5.6 The organisation ensures that the correct consumer / patient receives the correct procedure on the correct site.

1.5.7 The organisation ensures that the nutritional needs of consumers / patients are met.

1.6 The governing body is committed to consumer participation.

1.6.1 Consumers / patients, carers and the community participate in the planning, delivery and evaluation of the health service.

1.6.2 Consumers / patients are informed of their rights and responsibilities.

1.6.3 The organisation meets the needs of consumers / patients and carers with diverse needs and from diverse backgrounds.

4.2.1 EQuIP5 functions, standards, criteria

Key:

Standards

Mandatory Criteria

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October 2010  31

2. SUPPORT

2.1 Thegoverningbodyleadstheorganisationinitscommitmenttoimprovingperformanceandensurestheeffectivemanagementofcorporateandclinicalrisks.

2.1.1 Theorganisation’scontinuousqualityimprovementsystemdemonstratesitscommitmenttoimprovingtheoutcomesofcareandservicedelivery.

2.1.2Theintegratedorganisation-wideriskmanagementframeworkensuresthatcorporateandclinicalrisksareidentified,minimisedandmanaged.

2.1.3Healthcareincidentsaremanagedtoensureimprovementstothesystemsofcare.

2.1.4Healthcarecomplaintsandfeedbackaremanagedtoensureimprovementstothesystemsofcare.

2.2 Humanresourcesmanagementsupportsqualityhealthcare,acompetentworkforceandasatisfyingworkingenvironmentforstaff.

2.2.1Workforceplanningsupportstheorganisation’scurrentandfutureabilitytoaddressneeds.

2.2.2Therecruitment,selectionandappointmentsystemensuresthattheskillmixandcompetenceofstaff,andmixofvolunteers,meetstheneedsoftheorganisation.

2.2.3Thecontinuingemploymentandperformancedevelopmentsystemensuresthecompetenceofstaffandvolunteers.

2.2.4Thelearninganddevelopmentsystemensurestheskillandcompetenceofstaffandvolunteers.

2.2.5Employeesupportsystemsandworkplacerelationsassisttheorganisationtoachieveitsgoals.

2.3 Informationmanagementsystemsenabletheorganisation’sgoalstobemet.

2.3.1Healthrecordsmanagementsystemssupportthecollectionofinformationandmeettheconsumer/patientandorganisation’sneeds.

2.3.2Corporaterecordsmanagementsystemssupportthecollectionofinformationandmeettheorganisation’sneeds.

2.3.3Dataandinformationarecollected,storedandusedforstrategic,operationalandserviceimprovementpurposes.

2.3.4Theorganisationhasanintegratedapproachtotheplanning,useandmanagementofinformationandcommunicationtechnology(I&CT).

2.4 Theorganisationpromotesthehealthofthepopulation.

2.4.1Betterhealthandwellbeingispromotedbytheorganisationforconsumers/patients,staff,carersandthewidercommunity.

2.5 Theorganisationencouragesandadequatelygovernstheconductofhealthandmedicalresearchtoimprovethesafetyandqualityofhealthcare.

2.5.1Theorganisation’sresearchprogramdevelopsthebodyofknowledge,protectsstaffandconsumers/patientsandhasprocessestoappropriatelymanagetheorganisationalriskassociatedwithresearch.

3. CORPORATE

3.1 Thegoverningbodyleadstheorganisation’sstrategicdirectiontoensuretheprovisionofquality,safeservices.

3.1.1 Theorganisationprovidesquality,safehealthcareandservicesthroughstrategicandoperationalplanninganddevelopment.

3.1.2Governanceisassistedbyformalstructuresanddelegationpracticeswithintheorganisation.

3.1.3Processesforcredentiallinganddefiningthescopeofclinicalpracticesupportsafe,qualityhealthcare.

3.1.4Externalserviceprovidersaremanagedtomaximisequality,safehealthcareandservicedelivery.

3.1.5Documentedcorporateandclinicalpoliciesandproceduresassisttheorganisationtoprovidequality,safehealthcare.

3.2 Theorganisationmaintainsasafeenvironmentforemployees,consumers/patientsandvisitors.

3.2.1Safetymanagementsystemsensuresafetyandwellbeingofconsumers/patients,staff,visitorsandcontractors.

3.2.2Buildings,signage,plant,medicaldevices,equipment,supplies,utilitiesandconsumablesaremanagedsafelyandusedefficientlyandeffectively.

3.2.3Wasteandenvironmentalmanagementsupportssafepracticeandasafeandsustainableenvironment.

3.2.4Emergencyanddisastermanagementsupportssafepracticeandasafeenvironment.

3.2.5Securitymanagementsupportssafepracticeandasafeenvironment.

32  The ACHS EQuIP5 Guide  Book 1  Accreditation, Standards and Guidelines  Clinical Function

Criterion Little Achievement LA

Awareness

some Achievement sA

ImplementationLA plus the following

Marked Achievement MA evaluationSA plus the following

excellent Achievement eAexcellenceMA plus the following

outstanding Achievement oALeadershipEA plus the following

Criterion 1.1.1

Assessment ensures current and ongoing needs of the consumer / patient are identified.

this is a mandatory criterion

a) Guidelines are made available to assist staff to assess physical, spiritual, cultural, psychological and social needs, including the identification of ‘at-risk’ consumers / patients.

b) Guidelines are available on the specific needs of self identified Aboriginal and Torres Strait Islander consumers / patients.

c) There is policy / guidelines to assess a consumer / patient’s need for health promotion.

d) Referral systems to other relevant service providers exist.

a) Assessment guidelines based on current professional standards and evidence-based practice are implemented.

b) Assessments are conducted in a timely manner.

c) The needs of ‘at-risk’ consumers / patients are identified and managed.

d) A support person / carer is involved in the assessment system where appropriate.

e) Information is provided to the consumer / patient on their health status.

f) Planning for discharge / transfer of care commences at assessment, is multidisciplinary where appropriate, and coordinated.

a) The assessment process is evaluated and improved as required.

b) Processes for assessing and managing ‘at-risk’ consumers / patients are evaluated and improved as required.

c) Planning for discharge / transfer of care is evaluated to ensure it:

(i) consistently occurs

(ii) is multidisciplinary where appropriate

(iii) meets consumer / patient and carer needs.

d) Referral systems are evaluated and improved, as required.

a) Assessment and discharge / transfer of care planning practices are compared with internal and external systems and improvements are made to ensure better practice.

and/or

b) The organisation undertakes research on assessment and discharge / transfer of care practices and improvements are made to ensure better practice.

a) The organisation demonstrates it is a leader in consumer / patient assessment and separation planning.

4.3 The criteria

4.3.1 Structure of the criteria (an example)The figure below provides an example of the structure of a criterion. EQuIP has a unique format that codes elements according to the maturity of quality improvement processes within the area of interest. Through its left to right progression, this layout enables the reader to easily visualise the steps required to improve performance and reach a higher level of achievement.

Criterion structure example – Clinical criterion 1.1.1

Function 1 – Clinical

standard 1.1 Consumers / patients are provided with high quality care throughout the care delivery process.

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October 2010  33

Criterion Little Achievement LA

Awareness

some Achievement sA

ImplementationLA plus the following

Marked Achievement MA evaluationSA plus the following

excellent Achievement eAexcellenceMA plus the following

outstanding Achievement oALeadershipEA plus the following

Criterion 1.1.1

Assessment ensures current and ongoing needs of the consumer / patient are identified.

this is a mandatory criterion

a) Guidelines are made available to assist staff to assess physical, spiritual, cultural, psychological and social needs, including the identification of ‘at-risk’ consumers / patients.

b) Guidelines are available on the specific needs of self identified Aboriginal and Torres Strait Islander consumers / patients.

c) There is policy / guidelines to assess a consumer / patient’s need for health promotion.

d) Referral systems to other relevant service providers exist.

a) Assessment guidelines based on current professional standards and evidence-based practice are implemented.

b) Assessments are conducted in a timely manner.

c) The needs of ‘at-risk’ consumers / patients are identified and managed.

d) A support person / carer is involved in the assessment system where appropriate.

e) Information is provided to the consumer / patient on their health status.

f) Planning for discharge / transfer of care commences at assessment, is multidisciplinary where appropriate, and coordinated.

a) The assessment process is evaluated and improved as required.

b) Processes for assessing and managing ‘at-risk’ consumers / patients are evaluated and improved as required.

c) Planning for discharge / transfer of care is evaluated to ensure it:

(i) consistently occurs

(ii) is multidisciplinary where appropriate

(iii) meets consumer / patient and carer needs.

d) Referral systems are evaluated and improved, as required.

a) Assessment and discharge / transfer of care planning practices are compared with internal and external systems and improvements are made to ensure better practice.

and/or

b) The organisation undertakes research on assessment and discharge / transfer of care practices and improvements are made to ensure better practice.

a) The organisation demonstrates it is a leader in consumer / patient assessment and separation planning.

34  The ACHS EQuIP5 Guide  Book 1  Accreditation, Standards and Guidelines  Clinical Function

4.3.2 Mandatory criteriaMandatory criteria are those where a rating of Marked Achievement (MA) or higher is required to gain or maintain ACHS accreditation. A mandatory criterion is one where it is considered that without evaluation, the quality of care or the safety of people within the organisation could be at risk.

The ACHS Board determined that the following question be used to decide mandatory status for EQuIP5 criteria: Is this ACHS criterion so important that failure to achieve an MA rating should result in non-accreditation?

The rules for selection were that the criterion is fundamental:

• to consumer rights, and/or

• as a core component of safe, quality care, and/or

• to staff, visitor and consumer safety

... and the criterion could not be adequately covered by an overarching mandatory criterion such as care delivery, quality improvement, and/or risk management.

There are 15 mandatory criteria in EQuIP5.

The figure on pages 30–31 highlights the mandatory criteria in each of the three functions. The mandatory criteria are identified throughout EQuIP5 by italicised text.

4.3.3 Not applicable (NA) criteria / elementsThere are a few criteria and elements that may not be applicable to some organisations. Criteria may be described as not applicable when the topic of the criterion would never occur or would never have the potential to occur in the organisation.

An organisation will need to formally discuss and agree with its Customer Services Manager any criteria and elements that are not applicable to the organisation prior to an onsite survey being undertaken. All EQuIP criteria will be considered applicable to all organisations, except where it has been formally agreed that they are not applicable. It is accepted that in some organisations there may be some criteria which are only partially relevant, but in these cases the criteria will still be applicable for ACHS onsite survey purposes. The table below shows some examples where a particular criterion may not be applicable:

number Criterionexamples where the criterion may be nA

1.1.6 Ongoing care day procedure centres, advisory services

1.1.7 Care of dying day procedure centres, advisory services

1.5.3 Skin integrity advisory services

1.5.5 Blood and blood components

services that never administer blood or blood products or take pre-transfusion blood samples

2.5.1 Research program

organisations that never undertake or participate in research of any kind

4.4 Further information

4.4.1 Aboriginal and Torres Strait Islander people

Although there is inclusion of specific elements addressing the self identification of Aboriginal and Torres Strait Islander consumers / patients within some EQuIP5 criteria, organisations should consider this demographic throughout all of the standards and criteria of EQuIP.

A consumer / patient’s cultural and genetic background may have diagnostic significance and so should be part of routine medical history taking. Research has demonstrated that Aboriginal and Torres Strait Islander people may not receive equivalent care to that provided for people of other racial backgrounds in similar circumstances1, a situation which should be proactively managed by healthcare providers. Provision of guidelines should assist staff to understand, identify and manage any Aboriginal and Torres Strait Islander consumers / patients.

seCtIon 4How to use this EQuIP Guide

1 Cunningham J. Diagnostic and therapeutic procedures among Australian hospital patients identified as indigenous. Med J Aust 2002; 176(2): 58-62.

October 2010  35

Disparities in reported life expectancy exist between aboriginal and non-aboriginal peoples in Australia, USA, Canada and New Zealand, four comparable developed countries with indigenous and non-indigenous residents. Of these four countries, the highest disparity has been reported in Australia between the general population and for Aboriginal and Torres Strait Islander peoples.1 The life expectancy of Aboriginal and/or Torres Strait Islander people is some 10 to 17 years less than other Australians, with levels of disease roughly three times that of non-indigenous people.

People who self identify as Aboriginal or Torres Strait Islander may be eligible for specific government-funded health services, such as the health check items and specific immunisation programs that have been targeted to address the needs of this community.

The Australian Government has implemented a range of health initiatives specifically tailored to the needs of Aboriginal and Torres Strait Islander people. Organisations will find information at: http://www.health.gov.au/tackling-chronic-disease

The National Aboriginal and Torres Strait Islander Community Services Information Plan includes a set of principles regarding personal information management developed by Aboriginal and Torres Strait Islander representatives to assist community service organisations.2

Organisations should ensure their policy and procedures address how staff approach the question of self identification and provide responses to ensure Aboriginal and Torres Strait Islander consumers / patients are aware of why this information is being collected. Consumers / patients should be reassured that:

• the information will not affect their access to services

• this information is collected on all consumers / patients

• it is important information for ensuring appropriate services are provided

• the information will remain confidential.

In organisations where Aboriginal and Torres Strait Islander consumers / patients are seen rarely, it is important that this priority group is not overlooked; for the small number of consumers / patients who do self identify, staff should have access to appropriate guidelines and other information when needed.

Further, organisations will benefit from providing Cultural Safety Training (CST) to improve the quality of service delivered by healthcare providers to Aboriginal and Torres Strait Islander people, as well as the experience of service for Aboriginal and Torres Strait Islander people. Information is available at Healthinfonet: http://www.healthinfonet.ecu.edu.au/health-resources/courses-training?fid=262, as well as many other sites on the internet.

4.4.2 Policies, procedures, protocols, guidelines and by-laws

The purpose of a policy is to provide a clear, documented statement of the expectations of tasks and concepts that is consistent with organisational objectives. In English usage, policies are ‘made’ and ‘implemented’ in the same way that decisions are made and implemented. Yet it is possible to have policies that are not, or cannot be, implemented, so that conceptually, actions that implement policies need not necessarily be specified within the policy. In the context of EQuIP5, the term ‘policy’ refers to a written statement(s) which acts as a guideline and reflects the position and values of the organisation on a given subject. All procedures and protocols should be linked to a policy statement.

Although a policy is like a decision, it is not just a ‘one-off’ independent decision. A policy is a set of coherent decisions with a common long-term purpose(s). In instances where policy is developed by another body, such as an area health service or corporate office, organisations may have guidelines, procedures or a document that bears some other name, to address the implementation of the policy.

1 Cunningham J. Diagnostic and therapeutic procedures among Australian hospital patients identified as indigenous. Med J Aust 2002; 176(2): 58-62.

2 Aboriginal and Torres Strait Islander Health and Welfare Information Unit. National Aboriginal and Torres Strait Islander community services information plan. Canberra ACT; Australian Institute of Health and Welfare (AIHW) and Australian Bureau of Statistics (ABS); 2002.

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Organisations should be aware that they are not expected to have a separate policy for every element that mentions a policy. A range of issues may be addressed under a single policy, and when this is the case, organisations should inform the surveyors of this. Because the items included within a named policy may vary between jurisdictions, it would be wise to note details (such as page numbers, chapters or clauses) and provide this information to surveyors, so that evidence can quickly be validated if required.

Procedures are the specific methods employed to implement and carry out policies in day-to-day activities of the organisation.

Together, policies and procedures ensure that a point of view held by the governing body of an organisation is translated into steps that result in an outcome compatible with that view.

A guideline is any document that aims to streamline particular processes according to a set routine. By definition, following a guideline is never mandatory. (Protocol would be a better term for a mandatory procedure.) Guidelines are an essential part of the larger process of governance.

It is important to differentiate clinical guidelines, which outline decisions and criteria regarding diagnosis, management, and treatment in specific areas of health care. Clinical guidelines are usually based on a review of evidence by experts who reach a consensus on practical approaches to diagnosis, management or treatment. Their aim is to standardise medical care, to raise the quality of care and to reduce several kinds of risk.

Guidelines may be issued by and used by any organisation (government, public or private) to make the actions of its employees or departments more predictable, and presumably of higher quality.

By-law can refer to a law of local or limited application, passed under the authority of a higher law specifying what may be regulated by the by-law, or it can refer to the internal rules of a company or organisation.

In a healthcare setting, by-laws are usually intended to guide the conduct of visiting accredited medical, dental and allied health practitioners. The by-laws document generally sets out those organisational policies, procedures and guidelines that are applicable to visiting health practitioners.

During onsite surveys, surveyors will verify the organisation’s Pre-Survey Assessment against the standards by reviewing the evidence presented to them. Some of this evidence will draw upon the organisation’s policies, guidelines, procedures and/or by-laws. If an organisation provides access to the intranet so that the surveyors can view these documents, it is important that the evidence lists include navigation paths to assist surveyors to locate relevant information easily. Organisations should also ensure that the level of access under any issued passwords is sufficient for full access, without the surveyors having to seek assistance from organisational staff.

4.4.3 Jurisdictions Throughout EQuIP5, reference is made to jurisdictions in the context of guidelines, legislation, regulations, requirements, priorities, common law, policy and/or standards. In the context of EQuIP5, jurisdiction means whatever governing body oversees the development, implementation and/or compliance with a particular item. Within specific contexts a jurisdiction could be the relevant Department of Health, either State, Territory or Commonwealth, or a College or other professional representative group that has developed specific standards, such as the College of Anaesthetists (ANZCA), the National Pathology Accreditation Advisory Council (NPAAC), or authorities involved in blood management (NBA, RCBS, ANZSBT, HSANZ, etc.).

Organisations should be aware of the different legislation, guidelines, regulations, requirements, priorities, common law, policy and/or standards that are relevant to their operation. These will be influenced by the organisation’s location, ownership structures (public or private), services provided, staff profile, building structures and many other factors.

4.4.4 Performance measuresIn the context of EQuIP5, the term ‘performance measures’ differentiates between indicators from the ACHS Clinical Indicator Program, and the suggested performance measures that are listed after each criterion.

Performance measures are most fundamentally data that can be used for evaluation. Performance monitoring is only a part of evaluation. Performance measures inform the evaluation process and may help to identify or flag further issues or questions for investigation.

October 2010  37

To assist healthcare organisations to measure and evaluate their performance, some examples of performance measures are included in the EQuIP5 guide and are listed at the end of each criterion. The measures suggested are not the only ones available.

Not all of the measures will be suitable for all types of organisations. Organisations may wish to modify the suggested measures to meet their own needs. We have included measures that may be useful to a range of health services including day procedure centres, large hospitals, small hospitals, mental health facilities and community centres, and that can be adapted to different services and situations.

The suggested measures are designed to help organisations develop their unique and reliable indicators by:

• more clearly defining terms in the context of their own operations

• specifying numbers, volumes and timing for the calculations

• determining the frequency of calculation of a measure and its evaluation.

Performance monitoring over time provides an indication of rising or falling performance against a repeatable measure. Organisations should continue to collect any pre-existing performance measures that are meeting quality improvement needs; there is no expectation that an organisation must collect any of the suggested performance measures.

An organisation may choose to benchmark particular measures with other similar organisations or with other units / departments within their organisation. The ACHS will not collect these suggested performance measures and does not provide any national aggregate rate or benchmarking rates for the measures listed within the EQuIP guide.

4.4.5 Clinical indicatorsThe use of clinical indicators (CIs) by healthcare organisations continues to be an important component of EQuIP. The collection of specific ACHS Clinical Indicators is not mandatory and organisations may choose to develop their own indicators or use other indicators. Indicators assist healthcare organisations to identify clinical areas that may benefit from a review of their processes and activities, with the goal of improving the quality of care.

A clinical indicator is defined simply as a measure of the clinical management and/or outcome of care. A well-designed indicator should ‘screen’, ‘flag’ or ‘draw attention’ to a specific clinical issue. Usually rate-based, indicators identify the rate of occurrence of an event. Indicators do not provide definitive answers; they are designed to indicate potential problems that should be addressed, usually demonstrated by statistical outliers or variations within data results. The indicators are used to assess, compare and determine the potential to improve care.1 Indicators are, therefore, tools that assist an organisation to assess whether a standard of consumer / patient care is being met.

Members of the ACHS Clinical Indicator Program can submit clinical indicator data to the ACHS on a six monthly basis. Organisations are sent the national aggregate data following this submission. Using PIRT Online (the CI data submission tool), organisations can produce Comparative Reports from the national data set and for their peer group. Each report provides information to identify statistically significant differences between the individual organisation, all organisations and peer groups. The reports also identify potential gains to be made if an organisation’s rate was improved to that of the average and provides information on peer as well as Australian and New Zealand participation.

The ACHS clinical indicator program does not incur any additional charge for member organisations of EQuIP.

Further information about the specific clinical indicator sets and the Comparative Report service are available for EQuIP members from the ACHS website http://www.achs.org.au, or by contacting the ACHS Performance and Outcomes Service. Email: pos@achs.org.au

Utilisation of clinical indicator data for external and internal benchmarking assists healthcare organisations to identify areas in which there is the potential to improve the quality of care being delivered. Whilst the collection of specific ACHS clinical indicators is not mandatory, their use for evaluation of performance and any subsequent changes can be used as evidence for supporting an organisation to attain an MA Marked Achievement award.

1 Howley PP and Gibberd R. Using hierarchical models to analyse clinical indicators: a comparison of the gamma-Poisson and beta-binomial models. Int J Qual Health Care 2003; 15(4): 319-329.

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seCtIon 4How to use this EQuIP Guide

The table below contains ACHS clinical indicators relevant for the listed criteria. Criteria not listed are those for which no clinical indicators are suggested

Criterion Indicator set Version* ACHs Clinical Indicators

1.1.1 Anaesthesia 5 1.1, 3.1, 3.3, 3.4, 3.6, 5.1, 5.2, 6.1

Day Surgery 4 1.2, 1.3

Emergency Medicine 5 1.1, 1.2, 1.3, 1.4, 1.5, 2.1, 4.1, 4.2, 6.2, 7.1, 7.2, 7.3, 7.4, 8.1, 8.2

Gynaecology 6 5.1, 5.2, 5.3, 7.1, 7.2

Hospital in the Home 4 2.1, 2.2, 2.3, 2.4

Hospital-Wide 11 1.1, 2.1, 2.2, 3.1, 4.1, 4.2, 5.2, 5.3, 7.1, 9.1

Intensive Care 4 2.1, 3.1, 6.1, 6.2

Internal Medicine 5 2.1, 3.1, 3.3, 4.1, 4.2, 4.3, 5.2, 5.3, 5.4, 7.1

Medication Safety 3 5.1, 6.1

Mental Health Community Based 2 1.4

Mental Health Inpatient 6 1.1, 2.1, 4.2, 5.4, 5.5, 5.8, 6.1, 6.2, 6.3, 6.4, 6.5, 6.6, 7.1, 10.1

Obstetric 7 9.1, 10.1

Ophthalmology 4 1.1, 1.2, 2.1, 2.2, 3.1, 3.2, 3.4, 4.1, 4.2, 4.5

Oral Health 2 1.2, 4.2, 4.3, 5.1, 5.2, 5.3, 5.4, 5.5, 5.6, 5.7, 5.8, 5.9

Paediatric 4 5.1

Radiology 4 2.1, 2.2, 2.3, 2.4

Rehabilitation Medicine 4 1.1, 2.1, 5.1, 6.1

Surgical 3 1.2, 2.5, 3.1, 6.1, 6.2, 8.1, 8.2, 9.1

1.1.2 As every indicator can be utilised to evaluate care planning and delivery, all are relevant to this criterion

1.1.3 Anaesthesia 5 1.2, 6.3

Dermatology 2 2.8

Hospital-Wide 11 7.2

1.1.4 As every indicator can be utilised to evaluate and improve care, all are relevant to this criterion

1.1.5 Emergency Medicine 5 6.1, 6.2

Medication Safety 3 5.3

Mental Health Inpatient 6 9.1, 9.2

Radiation Oncology 3 2.5

Rehabilitation Medicine 4 4.1

* ACHS aims to review each set of indicators every three years. Changes are incorporated into a new version of the indicator set. It is important that EQuIP members, who are using indicator data to validate performance against EQuIP5 criteria, check the ACHS website for updates to their indicator sets and consider any changes in the context of EQuIP requirements for evidence.

October 2010  39

Criterion Indicator set Version* ACHs Clinical Indicators

1.1.6 Anaesthesia 5 1.1

Emergency Medicine 5 4.1, 4.2, 6.1, 6.2, 8.1, 8.2

Internal Medicine 5 1.4, 3.6, 5.1

Mental Health Community Based 2 2.2

Radiation Oncology 3 2.5

Rehabilitation Medicine 4 4.1, 6.1

1.1.8 Anaesthesia 5 1.1, 1.2, 2.2, 5.1, 5.2, 6.3

Dermatology 2 2.6, 2.7, 2.8, 2.9, 2.10, 2.11

Emergency Medicine 5 6.1, 6.2, 7.1, 7.2, 7.3, 7.4, 8.1, 8.2

Hospital-Wide 11 1.2, 1.3, 7.2

Intensive Care 4 5.1, 5.2, 6.1, 6.2

Internal Medicine 5 3.1, 3.2, 3.3, 3.4, 3.5, 3.6, 3.8, 4.1, 4.2, 4.3, 5.2, 5.3, 5.4, 6.3, 8.1

Mental Health Community Based 2 2.1

Mental Health Inpatient 6 1.2, 1.3, 2.1, 9.1, 9.2, 10.1

Oral Health 2 3.1, 3.2

Paediatric 4 1.1, 1.2, 3.1, 3.2

Radiation Oncology 3 1.2, 1.3, 2.5

Radiology 4 2.1

Rehabilitation Medicine 4 1.1, 2.1, 3.1, 4.1, 5.1

1.2.1 Mental Health Community Based 2 1.1, 1.2, 1.3

1.2.2 Dermatology 2 3.2, 3.3, 3.4, 3.6, 3.7, 3.8, 3.9, 3.10, 3.11

Emergency Medicine 5 1.1, 1.2, 1.3, 1.4, 1.5, 3.1, 3.2, 3.3, 4.1, 4.2, 8.1, 8.2

Intensive Care 4 1.1, 1.2, 1.3, 1.4, 1.5

Mental Health Community Based 2 1.1, 1.2, 1.3

Paediatric 4 4.1, 4.2, 4.3, 4.4, 4.5

Radiation Oncology 3 1.1, 1.3, 2.1, 2.2

1.3.1 As the use and reviewing of clinical indicators is evidence of clinical audit, an important component facilitating the delivery of appropriate care, all indicators are relevant to this criterion

* ACHS aims to review each set of indicators every three years. Changes are incorporated into a new version of the indicator set. It is important that EQuIP members, who are using indicator data to validate performance against EQuIP5 criteria, check the ACHS website for updates to their indicator sets and consider any changes in the context of EQuIP requirements for evidence.

40  The ACHS EQuIP5 Guide  Book 1  Accreditation, Standards and Guidelines  Clinical Function

Criterion Indicator set Version* ACHs Clinical Indicators

1.4.1 As the use of clinical indicators can be an inherent component in the use of evidence based care and the evaluation and improvement of key care processes, all are relevant to this criterion

1.5.1 Hospital-Wide 11 1.1, 1.2, 1.3

Medication Safety 3 2.1, 3.1, 4.1, 5.3, 5.5, 6.1

1.5.2 Emergency Medicine 5 5.1

Infection Control 3 All 49 indicators: 1.1–1.18, 2.1–2.14, 3.1–3.5, 4.1–4.6, 5.1–5.4, 6.1–6.2

Intensive Care 4 4.1, 4.2

Obstetric 7 5.1

Surgical 3 6.1

1.5.3 Hospital-Wide 11 4.1, 4.2

1.5.4 Hospital-Wide 11 5.1, 5.2, 5.3, 5.4

1.5.5 Hospital-Wide 11 7.1, 7.2, 7.3

Internal Medicine 5 6.1

2.1.1 Obstetric 6 11.1

2.1.2 Obstetric 6 11.1

2.1.3 Gastrointestinal Endoscopy 8 1.1, 1.2, 1.3, 1.4, 2.1, 2.2, 2.3, 3.1

Gynaecology 6 2.1, 3.1, 3.2, 3.3, 5.1, 5.2, 5.3

Hospital-Wide 11 1.1, 5.2, 5.3, 5.4, 7.1

Infection Control 3 6.1, 6.2

Medication Safety 3 1.1, 2.1, 3.1, 4.1

Mental Health Inpatient 6 4.2, 5.5, 5.8, 6.1, 6.2, 6.3, 6.4, 6.5, 6.6

Obstetric 6 11.1

Radiology 4 2.2, 2.4

Surgical 3 7.1, 8.1, 8.2, 9.1

2.5.1 Radiation Oncology 4 1.3

* ACHS aims to review each set of indicators every three years. Changes are incorporated into a new version of the indicator set. It is important that EQuIP members, who are using indicator data to validate performance against EQuIP5 criteria, check the ACHS website for updates to their indicator sets and consider any changes in the context of EQuIP requirements for evidence.

seCtIon 4How to use this EQuIP Guide

October 2010  41

4.4.6 National E-Health Transition Authority (NEHTA)

NEHTA was established by the Australian, State and Territory governments in 2005, to develop better ways of electronically collecting and securely exchanging health information. NEHTA’s strategic priorities and initiatives are to orchestrate the uptake of e-health systems of national significance, and to enable the progression and accelerate the adoption of e-health by delivering urgently needed integration infrastructure and standards for health information.

NEHTA is promoting a number of capabilities for national adoption, including identifiers for individuals, providers and organisations, authentication, secure messaging, clinical terminologies, supply chain, pathology requests and reports, diagnostic imaging requests and reports, medication management, referrals and discharge summaries.

Some of NEHTA’s capabilities will be relevant at all levels of EQuIP as they are finalised; other deliverables will apply more to the EA and OA ratings.

Some EQuIP5 criteria and elements were developed in consultation with NEHTA. ACHS will continue to liaise with NEHTA during the term of this edition of EQuIP and will deliver EQuIP updates as new initiatives come to fruition.

4.4.7 National Safety and Quality Health Service Standards (Australian Commission on Safety and Quality in Health Care)

The Australian Commission on Safety and Quality in Health Care (the Commission) was established by the Australian, State and Territory Governments in January 2006, to develop a national strategic framework and associated work program that will guide its efforts in improving safety and quality across the healthcare system in Australia.

Following the initial review of National Safety and Quality Accreditation Standards in 2007, an alternative model of accreditation was developed by the Commission. This model proposes substantial reforms of the accreditation system, having the potential to initiate far-reaching change.

Consultation is continuing with those groups directly affected by the proposed alternative model of accreditation and the Commission is focusing on the development of a set of National Safety and Quality Health Service (NSQHS) Standards.

The NSQHS Standards address the following areas:

• Governance for Safety and Quality in Health Service Organisations

• Healthcare Associated Infection

• Medication Safety

• Patient Identification and Procedure Matching

• Clinical Handover

• Partnering for Consumer Engagement

• Blood and Blood Product Safety

• Prevention and Management of Pressure Ulcers

• Recognising and Responding to Clinical Deterioration in Acute Health Care

• Preventing Falls and Harm from Falls.

The draft NSQHS Standards are due for release in 2011 and implementation will follow. The Commission has commenced piloting of the draft NSQHS Standards. The Standards provide an explicit statement of the expected level of safety and quality of care to be provided to consumers / patients by health services, and provide a means for assessing an organisation’s performance. The draft NSQHS Standards were developed in collaboration with experts, the Commission’s Accreditation Implementation Reference Group and standing committees, jurisdictions and key stakeholders.

ACHS will continue to liaise with the Commission during the term of this edition of EQuIP and will deliver EQuIP updates as new information about the NSQHS Standards becomes available.

42  The ACHS EQuIP5 Guide  Book 1  Accreditation, Standards and Guidelines  Clinical Function

October 2010  43

1.1 Continuity of Care Standard

The standard is: Consumers / patients are provided with high quality care throughout the care delivery process.

The intent of the Continuity of Care standard is to ensure that organisations provide high quality care and a caring environment to the consumer / patient at all times. They should do this:

• from the time that the consumer / patient enters the healthcare organisation or service

• through to when the consumer / patient is discharged or transferred to another organisation / service; and

• during any ongoing care they provide after discharge.

The specific needs of Aboriginal and Torres Strait Islander people should be considered throughout the criteria of standard 1.1.

The Australian Pharmaceutical Advisory Council (APAC)1 guiding principles should be read in conjunction with all Continuity of Care criteria.

The Age-friendly principles and practices should be read in conjunction with all Continuity of Care criteria and referred to when treating older people.2

There are eight criteria in this standard. They are:

1.1.1 Assessment ensures current and ongoing needs of the consumer / patient are identified.

1.1.2 Care is planned and delivered in collaboration with the consumer / patient and when relevant, the carer, to achieve the best possible outcomes.

1.1.3 Consumers / patients are informed of the consent process, and they understand and provide consent for their health care.

1.1.4 Outcomes of clinical care are evaluated by healthcare providers and where appropriate are communicated to the consumer / patient and carer.

1.1.5 Processes for clinical handover, transfer of care and discharge address the needs of the consumer / patient for ongoing care.

1.1.6 Systems for ongoing care of the consumer / patient are coordinated and effective.

1.1.7 The care of dying and deceased consumers / patients is managed with dignity and comfort and family and carers are supported.

1.1.8 The health record ensures comprehensive and accurate information is collaboratively gathered, recorded and used in care delivery.

seCtIon 5Standards, criteria, elements and guidelines

1. Australian Pharmaceutical Advisory Council (APAC). Guiding principles to achieve continuity in medication management. Canberra ACT; Australian Department of Health and Ageing. Accessed from http://www.sport.gov.au/internet/main/publishing.nsf/Content/nmp-guiding on 20 September 2010.

2. Australian Health Ministers’ Advisory Council (AHMAC). Age-friendly principles and practices: Managing older people in the health service environment. Canberra ACT; Department of Health and Ageing; 2005.

seCtIon 5Standards, criteria, elements and guidelinesstandard 1.1: Consumers / patients are provided with high quality care throughout the care delivery process

44  The ACHS EQuIP5 Guide  Book 1  Accreditation, Standards and Guidelines  Clinical Function

Criterion LA – Awareness sA – ImplementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 1.1.1

Assessment ensures current and ongoing needs of the consumer / patient are identified.

this is a mandatory criterion

a) Guidelines are made available to assist staff to assess physical, spiritual, cultural, psychological and social needs, including the identification of ‘at risk’ consumers / patients.

b) Guidelines are available on the specific needs of self identified Aboriginal and Torres Strait Islander consumers / patients.

c) There is policy / guidelines to assess a consumer / patient’s need for health promotion.

d) Referral systems to other relevant service providers exist.

a) Assessment guidelines based on current professional standards and evidence-based practice are implemented.

b) Assessments are conducted in a timely manner.

c) The needs of ‘at risk’ consumers / patients are identified and managed.

d) A support person / carer is involved in the assessment system where appropriate.

e) Information is provided to the consumer / patient on their health status.

f) Planning for discharge / transfer of care commences at assessment, is multidisciplinary where appropriate, and coordinated.

a) The assessment process is evaluated and improved as required.

b) Processes for assessing and managing ‘at risk’ consumers / patients are evaluated and improved as required.

c) Planning for discharge / transfer of care is evaluated to ensure it:

(i) consistently occurs

(ii) is multidisciplinary where appropriate

(iii) meets consumer / patient and carer needs.

d) Referral systems are evaluated and improved, as required.

a) Assessment and discharge / transfer of care planning practices are compared with internal and external systems and improvements are made to ensure better practice.

and/or

b) The organisation undertakes research on assessment and discharge / transfer of care practices and improvements are made to ensure better practice.

a) The organisation demonstrates it is a leader in consumer / patient assessment and separation planning.

IntentThe intent of this criterion is to ensure that the assessment system meets the needs of the consumer / patient, the carer when appropriate, and the organisation. As a first step in care planning and delivery, the assessment phase should promote a consultative, collaborative approach that actively involves the consumer / patient and carer. Quality assessment processes for admission of a new consumer / patient, or assessment as part of ongoing care, will ensure that care is planned and delivered in an holistic, coordinated, efficient manner and that the consumer / patient and carer understand what is occurring.

In the context of this criterion, discharge means to transfer care of a consumer / patient beyond the organisation, and includes discharge to another healthcare organisation.

Relationships of 1.1.1 with other criteriaThe organisation’s delivery of high quality care (Standard 1.1) begins for each consumer / patient with the process of assessment. This will determine access to the system and/or admission according to need (Criterion 1.2.2), and will impact upon the planning and delivery of care (Criterion 1.1.2). The notes taken during assessment will form part of a comprehensive and accurate health record (Criterion 1.1.8) and will facilitate handover of care (Criterion 1.1.5). Effective assessment requires the active involvement of the consumer / patient and, when appropriate, his or her carer(s) (Criterion 1.6.1). It will also ensure that consumers / patients with diverse needs and from diverse backgrounds (Criterion 1.6.3) are provided with the appropriate support and services.

October 2010  45

Assessment processesAssessment is the process by which the current and ongoing needs of the consumer / patient are identified and documented.

An episode of care begins with assessment and requires contact between clinical staff and the consumer / patient. An ineffective or incomplete assessment will increase the risk of errors that may affect health outcomes, and/or consumer / patient satisfaction with the service.

In addition to reflecting consumer / patient needs, guidelines for the assessment process should be specific to the needs of the organisation, or even department, and so may vary significantly between organisations.1, 2 Assessment guidelines may also be developed specifically for the needs of a professional group, such as the guidelines developed by medical colleges.

Holistic assessment should identify the physical, spiritual, cultural, psychological and social needs of the consumer / patient.

Where relevant, assessment notes should include:

• planning for discharge: the return to home poses particular challenges for consumers / patients who live alone, who have children, or who support family members with a disability, mental illness or terminal condition

• access to care: consumers / patients isolated through a rural location or transport issues may struggle to meet some appointment schedules

• cultural and religious beliefs: may impact decision making in areas such as blood transfusion and pain management

• fertility preferences: important for planning before initiating many chemotoxic therapies

• dietary restrictions and preferences.

In addition, assessment processes should identify any risks to the consumer / patient’s ongoing health and wellbeing. Guidelines for assessing consumer / patient need for promotion of better health and wellbeing in the long term should also be available. Policies and procedures should address organisational expectations and requirements, and how these should be achieved by clinical staff.

Criterion LA – Awareness sA – ImplementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 1.1.1

Assessment ensures current and ongoing needs of the consumer / patient are identified.

this is a mandatory criterion

a) Guidelines are made available to assist staff to assess physical, spiritual, cultural, psychological and social needs, including the identification of ‘at risk’ consumers / patients.

b) Guidelines are available on the specific needs of self identified Aboriginal and Torres Strait Islander consumers / patients.

c) There is policy / guidelines to assess a consumer / patient’s need for health promotion.

d) Referral systems to other relevant service providers exist.

a) Assessment guidelines based on current professional standards and evidence-based practice are implemented.

b) Assessments are conducted in a timely manner.

c) The needs of ‘at risk’ consumers / patients are identified and managed.

d) A support person / carer is involved in the assessment system where appropriate.

e) Information is provided to the consumer / patient on their health status.

f) Planning for discharge / transfer of care commences at assessment, is multidisciplinary where appropriate, and coordinated.

a) The assessment process is evaluated and improved as required.

b) Processes for assessing and managing ‘at risk’ consumers / patients are evaluated and improved as required.

c) Planning for discharge / transfer of care is evaluated to ensure it:

(i) consistently occurs

(ii) is multidisciplinary where appropriate

(iii) meets consumer / patient and carer needs.

d) Referral systems are evaluated and improved, as required.

a) Assessment and discharge / transfer of care planning practices are compared with internal and external systems and improvements are made to ensure better practice.

and/or

b) The organisation undertakes research on assessment and discharge / transfer of care practices and improvements are made to ensure better practice.

a) The organisation demonstrates it is a leader in consumer / patient assessment and separation planning.

seCtIon 5Standards, criteria, elements and guidelinesstandard 1.1: Consumers / patients are provided with high quality care throughout the care delivery process

46  The ACHS EQuIP5 Guide  Book 1  Accreditation, Standards and Guidelines  Clinical Function

Criterion 1.1.1

Assessment ensures current and ongoing needs of the consumer / patient are identified. (continued)

Assessment should be multidisciplinary, with more than a single professional background contributing to the review of the consumer / patient. This may be as simple as a medical practitioner and a nurse, or may involve consultation with medical specialists, allied health professionals, and even non-medical expertise from areas such as education, community services or security.

Prompt points

¼ What assessment information is recorded in the health record? How is it relevant? Can it be located when needed?

¼ Are there completed assessments in consumer / patient health records? Do they follow a consistent structure / format?

¼ Who undertakes the assessment? Who records information in the assessment report? Are any other partners, such as anaesthetists, dietitians, community services, a GP or carers involved in the assessment? How does the consumer / patient health record demonstrate a multidisciplinary approach to assessment / diagnosis? In a multidisciplinary environment, what measures avoid repeating the same questioning / paperwork?

¼ What measures are used to evaluate the effectiveness of the assessment process? Are audits of health records used? How do health record audits demonstrate compliance with assessment processes? Following evaluation, what actions have been taken to improve compliance?

Assessment of ‘at-risk’ consumers / patients Risks to consumer / patient safety that should be noted during assessment will vary between organisations and clinical settings.

Expanded assessment processes may be used to assess specific risks.3 Examples include (but are not limited to):

• aged care assessment

• falls risk assessment4

• mental health assessment5

• pressure ulcer / skin integrity risk assessment6

• nutritional risk assessment7

• manual handling / task risk assessment8

• pain assessment9

• anaesthetic risk assessment10

• VTE risk assessment.11

Prompt points

¼ What features of this organisation and consumer / patient pool determine how ‘at-risk’ consumers / patients are defined? How are these consumers / patients identified? What changes are made to better manage these identified risks?

¼ How are records of expanded assessments, such as falls risk or anaesthesia risk assessments, integrated with the health record?

Timely assessmentThe timeliness of completion of assessments may vary based on the needs of the consumer / patient, the clinical staff and the organisation. However, policy should direct what is considered satisfactory timing, which should aim to ensure that information is available when needed. Reassessment should occur at regular intervals, and following any change in the health status of the consumer / patient. Failure to undertake a risk assessment in a timely manner, particularly where other staff assume it has been done, can have serious safety implications.

October 2010  47

Prompt points

¼ How does the organisation ensure that assessments are conducted in as timely a manner as possible? What is done to prevent a lag between assessments and the completion of health records?

¼ How is the timeliness of assessments monitored by the organisation or its departments?

Consumer / patient involvement in assessmentDuring ongoing care, a consumer / patient and carer who are familiar with the outcome of the assessment and further plans for care will be equipped to participate in care coordination with other healthcare providers and to coordinate communication within the consumer / patient’s family.

Where appropriate, members of the consumer / patient’s family should be included in discussions during an episode of care and during recovery and/or ongoing care. As early as possible in the assessment process, and ideally with agreement from the consumer / patient, at least one carer / family member should be involved in care planning with healthcare providers.

Prompt points

¼ What formal information is provided to consumers / patients as part of the assessment process? An example might be a ‘preparing for surgery’ brochure.

¼ How is information about the outcome of an assessment relayed to consumers / patients? How is their understanding of this communication checked? Are carers / other care providers included in these discussions?

Planning for discharge / transfer of care During assessment, the consumer / patient’s social situation, health status and living arrangements up until admission should be recorded, and taken into account when planning for post-procedural care and discharge. At the entry and assessment stage of the episode of care, it may be appropriate to initiate a referral to internal or external services, particularly where the availability of places is limited.

Day surgeries may have only a limited role in ongoing care provision, however where potential risks and challenges have been identified by a thorough assessment process, these should be followed up with the referring clinician to ensure consumer / patient needs are met.

Prompt points

¼ What system is used for case management, particularly where it may involve multiple services (within and/or beyond the organisation)?

¼ What information collected and recorded during assessment is relevant to existing discharge processes? How is this information integrated with additional information accumulated during the ongoing care cycle?

¼ What processes facilitate communication during the transfer of care to ensure that information gained at assessment is followed up?

¼ How and when has the discharge / transfer of care system been evaluated? What were the findings? As a result of investigations, have any changes to the assessment process been made or planned?

seCtIon 5Standards, criteria, elements and guidelinesstandard 1.1: Consumers / patients are provided with high quality care throughout the care delivery process

48  The ACHS EQuIP5 Guide  Book 1  Accreditation, Standards and Guidelines  Clinical Function

Criterion 1.1.1

Assessment ensures current and ongoing needs of the consumer / patient are identified. (continued)

Referral systems A referral system requires:

• strong relationships with a variety of referral partners, preferably reflected in clear, agreed referral protocols

• access to up-to-date service directories of referral options that meet a range of consumer / patient needs (including accessibility, opening hours, cost, etc.)

• clear policy and procedures for associated functions, which include:

– holistic identification of consumer / patient need(s)

– assessment of risks faced by the consumer / patient and/or staff

– documentation, or integration with consumer / patient management system software applications

– selection of suitable referral option(s) in partnership with the consumer / patient and/or carer

– checking suitability of referral option(s), for example, area of expertise, services offered, accessibility, eligibility criteria, priority for service and waiting times

– sharing of relevant health information with explicit, informed consumer / patient consent

– documenting the consumer / patient consent to share identified health information with a specified referral option

– minimising duplication of effort or actions that require the consumer / patient to re-tell his/her ‘story’

– sending / transmitting information according to privacy requirements

– timely acknowledgement of receipt of referral, preferably within an agreed timeframe

– clear and universally applied eligibility criteria

– prioritisation according to clinical need, preferably according to priority of access policy and agreed criteria

– timely response to referral, or application of demand management measures such as referring on if necessary

– advising referrer of referral outcome, preferably within an agreed timeframe.

Prompt points

¼ Is there a system of referral through the department / organisation – if so, does it contribute to consistency, legibility, detail and/or timeliness of information transfer?

¼ Does it include a centrally updated listing of relevant service providers and their contact details that will facilitate appropriately directed referral communications?

¼ How effective is the process? How satisfied are clinicians with the process? Has there been any feedback from organisations receiving referrals from your facility?

Self identified Aboriginal and Torres Strait Islander peopleAboriginal and Torres Strait Islander status cannot be determined by physical appearance alone. “Are you of Aboriginal or Torres Strait Islander origin?” is an accepted question developed by the Australian Bureau of Statistics and has been adopted as the national standard for collecting Aboriginal and Torres Strait Islander origin in administrative data collections.12

Identification is not the final step; improving processes, cultural accountability and awareness of community are also necessary. In addition, organisations should be aware of other questions that should be asked, for example, in maternity units, the father’s descent should be noted in addition to the mother’s.

Organisations should inform consumers / patients why they are asking the question to ensure people can be comfortable to self identify. For example, organisations should provide advice about ‘Closing the Gap’ and improving health care13, and collect information on Aboriginal and Torres Strait Islander origin routinely as part of registration / admission (e.g. name, address, sex, date of birth, next of kin).

October 2010  49

The collection and verification of the information should form part of normal work practices. In addition, organisations should consider adopting a system that flags the health record of an identified Aboriginal and Torres Strait Islander person more clearly than a ticked entry on the admission form.

Prompt points

¼ What guidelines / other resources are available to the organisation’s staff to assist them to understand and meet the specific needs of any Aboriginal and Torres Strait Islander people who may require service?

¼ How are Aboriginal and Torres Strait Islander consumer / patient records identified? Is the standard question “Are you of Aboriginal or Torres Strait Islander origin?” part of normal work practices?

¼ How does the organisation’s staff learn about cultural boundaries? How is orientation used?

¼ Is identification of Aboriginal and Torres Strait Islander consumers / patients used for clinical treatment? If so, how?

Evidence commonly presented

Consider whether the following will help to address criterion 1.1.1

¼ Admission process / procedure (clinician and/or consumer / patient satisfaction)

¼ Pre-admission assessment records for elective procedures

¼ Care and assessment plans

¼ Health record – consumer / patient details / history, referral documents, clinical notes (potentially demonstrating multidisciplinary input) – audits of completeness

¼ Discharge policy / discharge planning procedure

¼ Wards’ discharge board(s) / discharge planning teams / referral systems

¼ Transition care programs

¼ Triage systems / guidelines / performance tracking

¼ Notes from multidisciplinary meetings (case conferences) to discuss management for consumers / patients with complex care needs

¼ Medication reconciliation processes

¼ Additional forms for recording expanded assessments

¼ Information brochures for consumers / patients, for example regarding admission or preparation for surgery

¼ Guidelines that specifically cover Aboriginal and Torres Strait Islander issues in the context of the organisation’s clinical interests and consumer / patient pool

¼ Consistent reporting systems, such as SBAR (Situation, Background, Assessment, Recommendation)

¼ Tagging of consumers / patients or their health records to highlight risk, such as for allergies or high risk of falls

¼ Audit of records, for example the health record or referral documentation, or tracking of clinical indicators to measure performance

¼ Feedback from consumers / patients and/or referral physicians and organisations sought, for example, by satisfaction survey

seCtIon 5Standards, criteria, elements and guidelinesstandard 1.1: Consumers / patients are provided with high quality care throughout the care delivery process

50  The ACHS EQuIP5 Guide  Book 1  Accreditation, Standards and Guidelines  Clinical Function

Criterion 1.1.1

Assessment ensures current and ongoing needs of the consumer / patient are identified. (continued)

Performance measurementThis criterion states that: “Assessment ensures current and ongoing needs of the consumer / patient are identified”. The organisation should be able to demonstrate that it has processes for health assessment that are relevant to its operations, respond to the risks of its consumer / patient pool and meet the needs of the consumer / patient, as well as fulfilling the requirements of its referral partners.

Some common suggested performance measures are as follows:

Number of health records containing evidence of multidisciplinary assessment

Total number of health records audited

Number of consumers / patients admitted who had a completed and documented assessment within 24 hours of admission

Total number of consumers / patients admitted

Number of consumers / patients booked into an elective surgery facility whose procedure was cancelled after their arrival at the facility

Total number of consumers / patients who were booked into the facility for elective surgery

Comment: consider reasons for cancellation, e.g. pre-existing medical condition, consumer / patient on inappropriate medication, etc.

Number of consumers / patients admitted with a certain diagnosis where a key diagnostic test was required and performed

Total number of consumers / patients admitted with a certain diagnosis

Comment: diagnostic tests could include CT scans, blood tests, etc.

Number of consumers / patients who received pre-admission assessment

Total number of consumers / patients flagged for pre-admission assessment

Number of long-term consumers / patients who have regular reassessments

Total number of long-term consumers / patients

Comment: ‘long-term consumers / patients’ and ‘regular reassessment’ to be defined by the organisation as per policy

October 2010  51

References1. Australian Department of Health and Ageing (DoHA) and

Australasian College for Emergency Medicine (ACEM). Approved private emergency department program. Canberra ACT; DoHA; 2001.

2. Royal College of Pathologists of Australasia (RCPA). Pre-operative assessment. RCPA Manual. Sydney NSW; RCPA. Accessed from http://www.rcpamanual.edu.au/ on 15 December 2009.

3. Carroll V, Antonio G and North Coast Area Health Service. Early detection through first rate patient assessment. ARCHI e-library 2008. Accessed from http://www.archi.net.au/e-library/demand/access/early-detection on 18 December 2008.

4. Peninsula Health Falls Prevention Service and Victorian Department of Human Services (DHS). Falls risk assessment tool (FRAT). Melbourne VIC; DHS; 1999.

5. NSW Health. Suicide risk assessment and management protocols. Sydney; NSW Health. Accessed from http://www.health.nsw.gov.au/pubs/2004/general_hosp_ward.html on 5 January 2010.

6. SA Department of Health. Pressure ulcer prevention and management. In: McErlean B. Adelaide; SA Department of Health. Accessed from http://www.safetyandquality.sa.gov.au/Default.aspx?PageContentID=17&tabid=76 on 5 January 2010.

7. Australian Resource Centre for Healthcare Innovations (ARCHI). The Mini Nutrition Assessment Tool: A step in the right direction. Health Administration item 0031. Accessed from http://www.archi.net.au/documents/e-library/health_administration/health_awards/risks/0031-nutrition.pdf on 5 January 2009.

8. NSW Health & Community Services Industry Reference Group, NSW Nurses Association and Workcover NSW. Manual handling for nurses: Program B(1) Patient risk assessment. Gosford NSW; Workcover NSW. Accessed from http://www.smartmove.nsw.gov.au/ContentFiles/WorkCoverManualHandling/Documents/manual_handling_training_package_nurses_section_b1_4798.pdf on 5 January 2010.

9. National Palliative Care Program, Australian Department of Health and Ageing (DoHA). CareSearch: Pain assessment tools. Canberra ACT; DoHA. Accessed from http://www.caresearch.com.au/caresearch/ClinicalPractice/Physical/Pain/AssessmentTools/tabid/748/Default.aspx on 5 January 2010.

10. Qaseem A, Snow V, Fitterman N et al. Risk assessment for and strategies to reduce perioperative pulmonary complications for patients undergoing noncardiothoracic surgery: A guideline from the American College of Physicians. Ann Intern Med 2006; 144(8): 575-580.

11. National Institute of Clinical Studies (NICS). Stop the clot: Integrating VTE prevention guideline recommendations into routine hospital care. Second edn. Melbourne; National Health and Medical Research Council; 2008.

12. Aboriginal and Torres Strait Islander Health and Welfare Information Unit. National Aboriginal and Torres Strait Islander Community Services information plan. Canberra ACT; Australian Institute of Health and Welfare (AIHW) and Australian Bureau of Statistics (ABS); 2002.

13. Chong A, Renhard R, Wilson G et al. Aboriginal and Torres Strait Islander patients: quality improvement toolkit for hospital staff. Melbourne VIC; The Lowitja Institute; 2010.

seCtIon 5Standards, criteria, elements and guidelinesstandard 1.1: Consumers / patients are provided with high quality care throughout the care delivery process

52  The ACHS EQuIP5 Guide  Book 1  Accreditation, Standards and Guidelines  Clinical Function

Criterion LA – Awareness sA – ImplementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 1.1.2

Care is planned and delivered in collaboration with the consumer / patient and when relevant, the carer, to achieve the best possible outcomes.

this is a mandatory criterion

a) Evidence-based guidelines on care planning and delivery are available.

b) Care is provided in response to consumer / patient needs in a timely manner and in accordance with policy and procedures.

c) Care planning reflects jurisdictional priorities for self identified Aboriginal and Torres Strait Islander consumers / patients.

a) Care planning and delivery are based on the assessment of consumer / patient needs, in collaboration with the consumer / patient and when appropriate their carer.

b) Consumers / patients are informed of factors impacting on their health and a plan for promoting their individual wellbeing is discussed.

c) Care planning decisions, actions and changes are documented in the consumer / patient health record.

d) Care is coordinated, planned and delivered by skilled and trained individuals within a multidisciplinary team with an identified team leader.

e) Consumers / patients and when appropriate, carers are provided with information that allows them to understand their care and care delivery options and any variations to their care.

f) A system exists for the effective identification and management of a deteriorating consumer / patient.

a) Policy and procedures for care delivery are evaluated.

b) The care planning and delivery processes are evaluated and improved as required.

c) Multidisciplinary team processes for care delivery are evaluated and improved as required.

d) The system for the effective identification and management of a deteriorating patient is evaluated and improved as required.

a) Care planning and delivery practices, together with data on variances, are compared with internal and external systems and improvements are made to ensure better practice.

and/or

b) Multidisciplinary team work is compared with other health services and/or industries and improvements are made to ensure better practice.

and/or

c) The organisation undertakes research relevant to care planning and the delivery of care, and acts on results.

a) The organisation demonstrates it is a leader in care planning and delivery practices.

October 2010  53

Criterion LA – Awareness sA – ImplementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 1.1.2

Care is planned and delivered in collaboration with the consumer / patient and when relevant, the carer, to achieve the best possible outcomes.

this is a mandatory criterion

a) Evidence-based guidelines on care planning and delivery are available.

b) Care is provided in response to consumer / patient needs in a timely manner and in accordance with policy and procedures.

c) Care planning reflects jurisdictional priorities for self identified Aboriginal and Torres Strait Islander consumers / patients.

a) Care planning and delivery are based on the assessment of consumer / patient needs, in collaboration with the consumer / patient and when appropriate their carer.

b) Consumers / patients are informed of factors impacting on their health and a plan for promoting their individual wellbeing is discussed.

c) Care planning decisions, actions and changes are documented in the consumer / patient health record.

d) Care is coordinated, planned and delivered by skilled and trained individuals within a multidisciplinary team with an identified team leader.

e) Consumers / patients and when appropriate, carers are provided with information that allows them to understand their care and care delivery options and any variations to their care.

f) A system exists for the effective identification and management of a deteriorating consumer / patient.

a) Policy and procedures for care delivery are evaluated and improved as required.

b) The care planning and delivery processes are evaluated and improved as required.

c) Multidisciplinary team processes for care delivery are evaluated and improved as required.

d) The system for the effective identification and management of a deteriorating patient is evaluated and improved as required.

a) Care planning and delivery practices, together with data on variances, are compared with internal and external systems and improvements are made to ensure better practice.

and/or

b) Multidisciplinary team work is compared with other health services and/or industries and improvements are made to ensure better practice.

and/or

c) The organisation undertakes research relevant to care planning and the delivery of care, and acts on results.

a) The organisation demonstrates it is a leader in care planning and delivery practices.

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54  The ACHS EQuIP5 Guide  Book 1  Accreditation, Standards and Guidelines  Clinical Function

Criterion 1.1.2

Care is planned and delivered in collaboration with the consumer / patient and when relevant, the carer, to achieve the best possible outcomes. (continued)

IntentThe intent of this criterion is to ensure that care planning and delivery are responsive to consumer / patient needs and that there is a consultative, collaborative approach to the provision of health care that will actively involve the consumer / patient and his or her carer.

Relationships of 1.1.2 with other criteriaCare planning and care delivery are an integral part of the consumer / patient journey (Standard 1.1). Care planning should consider the processes of access and admission (Criterion 1.2.2), how the most effective care can be delivered (Criterion 1.4.1), the various aspects of ongoing care (Criterion 1.1.6), and how the most appropriate care can be delivered in the most appropriate setting (Criterion 1.3.1). All decisions made should be recorded in the health record (Criterion 1.1.8). The outcomes of the care planned and delivered should be evaluated (Criterion 1.1.4).

Consumers / patients should participate in their own care planning (Criterion 1.6.1), which is one of their healthcare rights (Criterion 1.6.2). Planning should encompass the diverse needs and diverse backgrounds of consumers / patients (Criterion 1.6.3), and how these may impact upon the delivery of care. Effective care planning and delivery are facets of the organisation’s integrated risk management framework (Criterion 2.1.2), and failures in this area may lead to incidents (Criterion 2.1.3) and complaints (Criterion 2.1.4).

Care planning – the processThe planning, delivery and coordination of care is the core business of all healthcare organisations.

The key considerations in care planning are:

• care is planned and documented according to the assessment of consumer / patient needs

• there is input from the consumer / patient and relevant care providers

• there is consideration that a second opinion may be sought

• care planning and delivery are based on the best available evidence

• care is delivered by competent individuals and competent multidisciplinary teams

• care is coordinated between all members of the team (including carers)

• the needs of high-risk consumers / patients are identified and managed appropriately

• the environment within which care is provided is comfortable, caring and appropriate to consumer / patient needs.

Effective planning, delivery and coordination of care may draw upon:

• guidelines developed by professional colleges and/or associations

• clinical pathways / care plans

• legislative requirements, medico-legal requirements, standards, codes of practice, ethics and frameworks

• the organisation’s policies and procedures

• guidelines for consumers / patients identified as being at high risk, such as standard protocols for cardiac arrest or acute psychotic episodes

• organisational strategies to deal with high-risk activities, which will vary within the health sector and be influenced by the consumer / patient. Examples of known high-risk activities include management of blood transfusions or medication management

• strategies to promptly identify / detect and deal with poor nutritional status, delirium, acute psychotic episodes, falls, depression, deterioration in consumer / patient health condition and cardiac arrest

• systems to identify and manage changes in consumer / patient health status including appropriate referral within the organisation or to community services following discharge. Examples include the management of pressure areas, incontinence, post-surgical complications, deterioration in clinical status, development of iatrogenic complications, transfer to an intensive care unit (ICU) and postnatal care

• evidence-based research and guidelines.

October 2010  55

The care plan or clinical pathway may include:

• goals to be achieved which should reflect the clinical condition of the consumer / patient

• tests and investigations to be conducted

• procedures and interventions to be provided

• multidisciplinary team referrals

• consumer / patient education strategies to be implemented

• timeframes to be met

• delineation of responsibilities

• discharge planning / planning for transfer

• transfer of care.

Care planning and coordination includes ensuring that the outcomes of the care delivered are evaluated. The evaluation could involve review of:

• processes around care coordination and communication within the organisation and with external providers

• internal referral processes

• appropriate mechanisms for escalation of care when a consumer / patient is deteriorating

• clinical handover processes

• the consumer / patient’s understanding of his/her progress

• consumer / patient participation in case-conferencing and carers’ discussion

• review against best practice guidelines.

Prompt points

¼ Are clinical pathways / guidelines used in care planning referenced to evidence-based source(s)? How frequently are these reviewed and updated?

¼ Do organisational policies / programs for care planning recognise and reflect jurisdictional priorities for Aboriginal and Torres Strait Islander peoples? Is this stated in the documents or referenced?

¼ Are medico-legal requirements considered and met by the care planning processes? How is this recorded?

¼ Have policy / processes been developed for classes of consumers / patients or disease states identified as ‘high-risk’ for the organisation?

Consumer / patient needs and involvementExplanation should be provided for consumers / patients and carers so that they understand the diagnosis, prognosis, treatment options and illness prevention strategies. Delivery of the information should be timely, and provided in a suitable way for the individual consumer / patient to understand his or her treatment options in collaboration with their carer(s).

Consumers / patients and, where appropriate, carers should understand that there are multiple choices navigated by their physicians on their behalf when planning their care. Despite the development of a framework for participatory doctor-patient communications, achieving collaborative care planning can be very challenging.1

Where appropriate, carers should be made aware of, and referred to, services and support for carers. Care plans should be documented in the health record.

A framework for shared decision making was outlined by Towle and Godolphon1 to evaluate whether care planning was undertaken as a partnership between consumer / patient and physician.2 The framework includes:

• establishing or reviewing the consumer / patient’s preferences for information (such as amount or format)

• establishing the consumer / patient’s preferences for their role in decision making

• explaining any uncertainty about the ‘best’ course of action to take

• ascertaining and responding to the consumer / patient’s ideas, concerns and expectations

• identifying options available, evidence on their efficacy and their relevance for the consumer / patient’s existing situation

• helping the consumer / patient to reflect on and assess the impact of alternative decisions with regard to his or her lifestyle and values

• advising of any variation in clinical care

• negotiating a decision in partnership

• agreeing on an action plan and making next step arrangements.

Where decisions are complex or will involve family members, consumers / patients may be provided with a ‘take home’ summary to assist them to recall their options and consider them with others.

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56  The ACHS EQuIP5 Guide  Book 1  Accreditation, Standards and Guidelines  Clinical Function

Criterion 1.1.2

Care is planned and delivered in collaboration with the consumer / patient and when relevant, the carer, to achieve the best possible outcomes. (continued)

Organisations should consider the timeliness of their care delivery based on the clinical urgency of the consumer / patient’s condition and their system for scheduling appointments, and should review performance against predetermined measures. A ‘timely manner’ may be viewed differently by consumers / patients and healthcare providers, suggesting the need to also consider consumer / patient response to the delivery of services. Clear policy and procedures should be in place, which facilitate the provision of services in the most timely manner and in response to consumer / patient need.

Organisations should be aware of jurisdictional priorities that aim to address disparities in healthcare provision for Aboriginal and Torres Strait Islander people.3-5 Some health departments have specific offices and programs that focus on Aboriginal and Torres Strait Islander health within their constituencies6,7, and evidence-based knowledge of factors contributing to successful outcomes in minority populations are now better understood.8

Prompt points

¼ What standard information is provided to consumers / patients to help them understand the care delivery process?

¼ How is communication about care processes documented in the consumer / patient health record?

¼ What records are used to document discussions with consumers / patients about promoting better health? Are offers of education / support programs to promote better chronic disease management recorded in the health record? How are recommendations to receptive consumers / patients followed up?

¼ Are consumer / patient health records up-to-date and complete during care delivery? How is compliance with health record policies assessed?

¼ Where a mix of electronic and printed materials is used, how are the documents cross-linked so that the consumer / patient journey through assessment, diagnosis, care planning and delivery to discharge (where appropriate) can be traced?

¼ What waiting times are considered ‘appropriate’ for the services provided by the organisation, for example, emergency care, elective surgery, chronic disease self management support? How are consumer / patient and organisational needs considered when timeliness is defined? What organisational actions facilitate the timely provision of care?

¼ How is timely delivery of care assessed on an organisational basis? Are consumer / patient perceptions of timeliness also evaluated?

Environment for delivery of careThe environment in which care is provided will vary depending upon the healthcare organisation, consumer / patient needs and presenting circumstances. Care begins in the waiting rooms / admission area and extends to consulting rooms, surgical preparation areas, wards, and specialty function areas such as gymnasia used in rehabilitation or sound studios in audiology. All these environments will impact on the consumer / patient; all areas should be perceived as comfortable, caring and clean.

The quest for feedback from consumers / patients with regard to the environment should ideally extend beyond an absence of complaints. Follow-up phone calls provide an opportunity to seek feedback on the perceived quality of care and the environment. Satisfaction surveys and focus groups can help to determine consumer / patient perceptions through either general or specific questioning.9

Prompt points

¼ Does the organisation record complaints and compliments regarding the environment in which care is provided? Have any actions been undertaken in response to complaints about the healthcare environment?

¼ Does the organisation review consumer / patient satisfaction including whether consumers / patients perceived the care delivery environment as comfortable, caring and clean?

October 2010  57

Deterioration in consumer / patient statusAll healthcare organisations should develop policy and a system for identifying, reporting and managing deteriorating consumers / patients. The vast majority of consumers / patients show signs of deterioration for up to eight hours prior to an arrest.10

Recognition and management of the deteriorating consumer / patient is a priority focus area for the Australian Commission on Safety and Quality in Health Care (the Commission).11

The Commission has developed a consensus statement12 that summarises the essential clinical processes (measurement and documentation, escalation protocols, rapid response systems, structured communication processes) and organisational prerequisites (support within the organisation, education, evaluation and technological solutions) for recognising and responding to clinical deterioration.11

The system used by an organisation to facilitate identification and management of a deteriorating consumer / patient may include11:

• specialist response teams (such as Rapid Response Teams or Medical Emergency Teams) or a nominated department, person or service

• review of observation charts and their use

• guidelines on appropriate responses based on clinical signs

• protocols that are accessible, supported by training and are effective across all shifts

• continuous evaluation of the effectiveness of the system and organisational adjustment according to those indicators. Evidence-based indicators include the number of urgent calls / 1000 admissions, and potentially preventable deaths and cardiac arrests.

The Commission has also developed a national approach to improve the recognition of and response to deteriorating consumers / patients.12 This includes:

• a nationally agreed consensus statement that describes essential elements for prompt and reliable recognition of, and response to, clinical deterioration in acute care facilities, including agreed practices and the need to have systems in place to address all elements

• an implementation guide to support the consensus statement and provide information about how the elements within it can be put into practice for all consumers / patients across all acute settings

• evidence-based adult general observation charts that incorporate features to support the identification of consumers / patients who are deteriorating, and prompt action to properly manage these consumers / patients.

Prompt points

¼ How is a consumer / patient’s health status assessed and monitored during care delivery?

¼ Does the presentation of information in the consumer / patient health record make it easy to detect a deteriorating consumer / patient?

¼ If there are long waiting periods for a service, such as in emergency departments, are consumers / patients monitored for a change in health status, for example, the triage category reclassified?

Multidisciplinary teamsEffective multidisciplinary teamwork requires the clear delineation of responsibilities of all team members, to ensure comprehensive management without duplication of services, unnecessary services or over-servicing. There should be an identified team leader, who is the person responsible for coordinating the care of the consumer / patient.

Complex, chronic health conditions such as cardiovascular disease, diabetes, asthma and arthritis may lend themselves to multidisciplinary care models that require specialist services (often hospital-based) to work with general practice, allied health and community care services. There are many challenges associated with these multi-service, ongoing care models13, in which the health service may play a variety of roles. Involvement by the health service in these teams may be influenced by the administrative structure and the leadership. Attitudinal or cultural factors may also influence care planning and the delivery of care14 within an organisation, for example services for teenagers or indigenous communities.

Evidence for these elements demonstrating a team approach might be organisational policy / guidelines relating to case responsibility within multidisciplinary teams, care plans15, case team notes or coordinated, integrated input collected into the consumer / patient health record.

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58  The ACHS EQuIP5 Guide  Book 1  Accreditation, Standards and Guidelines  Clinical Function

Criterion 1.1.2

Care is planned and delivered in collaboration with the consumer / patient and when relevant, the carer, to achieve the best possible outcomes. (continued)

Prompt points

¼ Is there evidence of multidisciplinary care in the health record? How is prime responsibility (the team leader) for consumer / patient care assigned and demonstrated within the health record?

¼ When are case conferences used to coordinate care? How are they managed?

¼ Are the members of multidisciplinary teams chosen by the team leader or is this determined by organisational policy / procedures?

Evidence commonly presented

Consider whether the following will help to address criterion 1.1.2

¼ Clinical pathways / care plans (with references or original source)

¼ Policies or guidelines that are used in care planning – easily accessible format

¼ Policies / procedures on record keeping to facilitate care planning

¼ Health records demonstrating multidisciplinary input with responsible clinician identified consistently

¼ Case conference notes

¼ Evaluation of communication delivery or of its comprehension by consumers / patients

¼ Evaluation of consumer / patient satisfaction including satisfaction with the environment in which care was received

¼ Existence of a policy / guideline specifically on management of deteriorating consumers / patients

Performance measurementThis criterion states that: “Care is planned and delivered in collaboration with the consumer / patient and when relevant, the carer, to achieve the best possible outcomes”. The process of care planning and its collaborative aspects should be documented throughout the care journey of the consumer / patient, and evident in health outcomes and consumer / patient satisfaction.

Some common suggested performance measures are as follows:

Number of consumers / patients satisfied with decision making about / involvement in their care

Total number of consumers / patients surveyed

Number of consumers / patients satisfied with their care goals being achieved

Total number of consumers / patients surveyed

October 2010  59

Number of consumers / patients who have signed off on their care pathway

Total number of consumers / patients who have a care pathway

Comment: a care pathway, some times called a care map or plan, is a consumer / patient management tool that organises, sequences and times the major consumer / patient care activities and interventions of the entire multidisciplinary team for consumers / patients with a particular diagnosis, or undergoing a particular procedure.16

Number of variances identified in a pathway in relation to care planning

Total number of possible variances in the pathway

Comment: a variance is defined as “a deviation from the expected consumer / patient or family goals, outcomes and staff interventions outlined in the clinical pathway that potentially affects the expected outcome of the consumer / patient”. Consider the reasons for the variance.

Number of unplanned readmissions to the organisation / service within X days

Total number of separations

Comment: the organisation to define ‘X’

Number of care goals / program goals achieved within the designated timeframe

Total number of care goals / program goals

Number of consumers / patient fulfilling deterioration criteria who did not receive advanced resuscitation

Total number of consumers / patients fulfilling deterioration criteria

Comment: the organisation to define deterioration criteria; advanced resuscitation could be implemented by a Medical Emergency Team in a larger organisation, or by a GP in a smaller one

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Criterion 1.1.2

Care is planned and delivered in collaboration with the consumer / patient and when relevant, the carer, to achieve the best possible outcomes. (continued)

References1. Towle A, Godolphin W, Grams G and Lamarre A. Putting

informed and shared decision making into practice. Health Expectations 2006; 9(4): 321-323.

2. Bird S. Discussing benefits and risks with patients. Aust Fam Physician 2004; 33(4): 266-267.

3. Victorian Department of Health and Victorian Aboriginal Community Controlled Health Organisation. Aboriginal health promotion and chronic care partnership program guidelines. Melbourne; Vic Dept of Health; 2005.

4. Australian Health Ministers’ Advisory Council (AHMAC) Standing Committee on Aboriginal and Torres Strait Islander Health. Cultural respect framework for Aboriginal and Torres Strait Islander health, 2004–2009. Adelaide SA; AHMAC; 2004.

5. Australian Department of Health and Ageing (DoHA). Reconciliation action plan. Canberra ACT; DoHA; 2007.

6. WA Department of Health. Office of Aboriginal Health. Perth WA: Government of WA. Accessed from http://www.aboriginal.health.wa.gov.au/home/ on 7 January 2009.

7. Chong A, Renhard R, Wilson G, et al. Aboriginal and Torres Strait Islander patients: quality improvement toolkit for hospital staff. Melbourne VIC; The Lowitja Institute; 2010.

8. Flores G. Devising, implementing, and evaluating interventions to eliminate health care disparities in minority children. Pediatrics 2009; 124(Suppl3): S214-S223.

9. Wolff AM and Taylor SA. Enhancing patient care: A practical guide to improving quality and safety in hospitals. Sydney NSW; MJA books; 2009.

10. Schein R, Hazday N, Pena M et al. Clinical antecedents to in-hospital cardiopulmonary arrest. Chest Surg Clin N Am 1990; 98(6): 1388-1392.

11. Australian Commission on Safety and Quality in Health Care (ACSQHC). Windows into safety and quality in health care 2009. Sydney NSW; ACSQHC; 2009.

12. Australian Commission on Safety and Quality in Health Care (ACSQHC). National Consensus Statement: essential elements for recognising and responding to clinical deterioration. Sydney NSW; ACSQHC; 2010.

13. May J, Cooper R, Magin P and Critchley A. Integrated models or mayhem? Lessons learnt from three integrated primary health care entities in regional New South Wales. Aust Health Rev 2008; 32(4): 595-604.

14. Nagel T and Thompson C. Motivational care planning: Self management in indigenous mental health. Aust Fam Physician 2008; 37(12): 996-1001.

15. Zwar NA, Hermiz O, Comino EJ, et al. Do multidisciplinary care plans result in better care for patients with type 2 diabetes? Aust Fam Physician 2007; 36(1/2): 85-89.

16. Abdelhak M, Grostick S, Hanken MA and Jacobs E. Health information: Management of a strategic resource. Second edn. Philadelphia USA; Saunders; 2001.

October 2010  61

seCtIon 5Standards, criteria, elements and guidelinesstandard 1.1: Consumers / patients are provided with high quality care throughout the care delivery process

62  The ACHS EQuIP5 Guide  Book 1  Accreditation, Standards and Guidelines  Clinical Function

Criterion LA – Awareness sA – ImplementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 1.1.3

Consumers / patients are informed of the consent process, and they understand and provide consent for their health care.

this is a mandatory criterion

a) There is policy / guidelines for consent that is consistent with jurisdictional legislative requirements.

b) Healthcare providers are advised of the consent policy / guidelines.

c) Consumers / patients are provided with information on recommended investigations, treatment or procedures, and costs prior to providing consent for that health care.

a) Consent is obtained for investigations, treatment or procedures and costs in accordance with the organisation’s policy / guidelines.

b) There is a process to manage consent where it is unable to be given at the appropriate time.

c) There is a process to obtain consent for personal information to be communicated to healthcare workers outside the service, to carers or to other relevant persons when required.

a) The consent process is evaluated and improved as required.

b) Compliance with the consent process is evaluated and strategies for improvement are implemented as required.

a) Documents and practices for consent are compared with internal and external systems and improvements are made to ensure better practice.

a) The organisation demonstrates it is a leader in its systems for obtaining consent.

IntentThe intent of this criterion is to ensure that the process of obtaining consent is managed appropriately.

In this document, the term ‘consent’ covers a number of different legal requirements:

• The consumer / patient and/or carer should be informed in broad terms of the nature of any invasive procedure which is to be performed. This consent protects the consumer / patient and also operates as a defence to legal action.

• The consumer / patient and/or carer should be informed of material risks inherent in the procedure or treatment. This is part of the duty of care owed to the consumer / patient by the appointed clinician who provides treatment.

• Consent for collection of health information, and to any use of that information and/or disclosure by the organisation to third parties, is required under Commonwealth and applicable State / Territory privacy laws.

• The consumer / patient and/or carer must be provided with adequate information to allow informed financial consent.

Relationships of 1.1.3 with other criteriaThe need for the organisation to obtain informed consent from the consumer / patient to treatment is a vital aspect of the planning and delivery of care (Criterion 1.1.2). Consent is also necessary in advance planning for end-of-life care (Criterion 1.1.7), including decisions about organ donation. The consumer / patient has a right to understand his or her treatment options, and to give or withhold informed consent (Criterion 1.6.2), and to have access to support services such as interpreters when required (Criterion 1.6.3). The consent process is an aspect of the organisation’s integrated risk management framework (Criterion 2.1.2), and failure to manage consent processes correctly may lead to complaints (Criterion 2.1.4).

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Criterion LA – Awareness sA – ImplementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 1.1.3

Consumers / patients are informed of the consent process, and they understand and provide consent for their health care.

this is a mandatory criterion

a) There is policy / guidelines for consent that is consistent with jurisdictional legislative requirements.

b) Healthcare providers are advised of the consent policy / guidelines.

c) Consumers / patients are provided with information on recommended investigations, treatment or procedures, and costs prior to providing consent for that health care.

a) Consent is obtained for investigations, treatment or procedures and costs in accordance with the organisation’s policy / guidelines.

b) There is a process to manage consent where it is unable to be given at the appropriate time.

c) There is a process to obtain consent for personal information to be communicated to healthcare workers outside the service, to carers or to other relevant persons when required.

a) The consent process is evaluated and improved as required.

b) Compliance with the consent process is evaluated and strategies for improvement are implemented as required.

a) Documents and practices for consent are compared with internal and external systems and improvements are made to ensure better practice.

a) The organisation demonstrates it is a leader in its systems for obtaining consent.

Consent is defined and providers are advisedConsent is a significant aspect of the assessment of consumer / patient needs both from a clinical and a non-clinical perspective. Organisations should be aware of all legislative requirements and any relevant guidelines, and regularly review existing practices. Consent can include financial, procedural, ethics and/or research consent.

The requirements for gaining consent should be defined in the organisation’s policy; this will influence how the procedural details are addressed.1 The consent policy should reflect jurisdictional legislation and address the following:

• the organisation’s responsibilities in regard to gaining consent

• the procedures, care, treatment and investigation options and costs that require written, verbal or implied consent

• the process used to obtain consent, including the ways that information may be provided to the consumer / patient (verbally, brochures, using interpreters)

• how consent is to be documented in the consumer / patient’s health record

• when a surrogate decision maker, rather than the consumer / patient, may give consent

• the use of interpreters / interpreter services when the consumer / patient is not proficient in the primary language of the organisation’s representatives

• situations where procedures, care and treatment normally requiring consent may be given without consent.

Healthcare providers may be advised of the policy through the orientation process, minutes of Medical Advisory Committee (MAC) meetings, other group meetings and the organisation’s newsletters. In private hospitals, the obligations of visiting medical staff to provide consent documentation will be covered in the facility’s by-laws.

Orientation programs for new clinicians should include the consent process. An understanding of the consent policy by healthcare providers cannot be assumed. Legislation varies between Australian jurisdictions, and healthcare organisations differ in the philosophical principles on which their care principles are based. Despite the World Health Organization’s international protocol on consent2, overseas-trained clinicians may have trained or worked under very different policies.

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Criterion 1.1.3

Consumers / patients are informed of the consent process, and they understand and provide consent for their health care. (continued)

Prompt points

¼ Does the organisation have a consent policy? Does it state the procedures / circumstances to which the policy applies? How does the organisational policy address potentially controversial situations?

¼ Is consent covered in orientation or other training for clinical staff? How is the organisation’s consent policy made readily accessible to staff?

Informed consent is obtainedA completed consent process should include a discussion of the following issues3:

• the nature of the proposed care, treatment, services, medications, interventions, investigations or procedures

• possible benefits, risks, complications and side effects

• the probability of achieving care and treatment goals

• reasonable alternatives to the proposed care and treatment, and the relevant risks, complications and side effects of alternate treatments including the possible results of receiving no treatment or care

• any limitations on the confidentiality of information gained from or about the consumer / patient.

Discussions / outcomes should be documented in the consumer / patient’s health record in any situation where this information is not included on the printed consent form.

Consent should be obtained and documented in accordance with the organisation’s policy. The relationship between a healthcare organisation and a medical practitioner will impact upon the organisation’s responsibilities in the consent process. In the private sector, there are cascading levels of consent; for example, the treating clinician will usually obtain

consent for recommended investigations, treatment or procedures and their costs within their own rooms prior to providing that health care. In these cases, there should be a copy of the documented, signed consent obtained by the treating clinician, or an ‘acknowledgement of the consent’, in the consumer / patient health record.

Private hospitals are not required to provide specific costs for surgeons, anaesthetists and such, but should inform consumers / patients that these costs will be in addition to the hospital costs. Private consumers / patients should be directed to inquire directly to the clinician’s rooms for cost estimates.

Organisations should have specific policies and/or procedures to address circumstances where procedural consent has not been provided, and relevant medical practitioners should be advised of these.

Organisations should make every effort to ensure understanding by the consumer / patient.2 The following approaches may be useful:

• use diagrams and models to illuminate verbal descriptions

• respond to questions from the consumer / patient and his or her family

• recognise that some consumers / patients may need time for decision making in partnership with family members, carers and/or community or religious consultants / elders

• employ a professional interpreter rather than relying on family members in situations where English is not the consumer / patient’s first language and there are doubts about proficiency1; consent obtained without the use of an interpreter may not be legally binding

• ask consumers / patients to repeat back what they have been told to gauge their understanding.4

In organ donation, consent issues can be particularly challenging and hospitals undertaking organ transplants must have policy in place. There is a need for more organ donation to save the lives of individuals needing a transplant. At the time that decisions regarding the organs of dying consumers / patients must be made, the consumer / patient will be unable to participate in the process. Healthy people are therefore asked to provide an advance directive by including their names on the Australian Organ Donor Registry coordinated by Medicare and by notifying their family of their wishes.5

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Organisations should use trained staff who have been designated to seek consent for organ donation and there should be an agreed approach to the management of the ethical conflict between grief counselling, promoting understanding and efforts to gain approval for organ harvesting.6 A predefined process and nominated personnel responsible for determining brain death will help to reduce procedural confusion as death approaches.

Prompt points

¼ Are audits7 undertaken to check that consent is being obtained in accordance to the organisation’s policy?

¼ Are consent levels considered satisfactory? What actions have been taken to maintain or improve consent levels or to reduce risks associated with consent?

¼ What processes are used to manage consent where English language proficiency is uncertain?

¼ What processes are used to manage requests for organ donation (where this may apply)?

¼ Where a procedure is explained to consumers / patients at the organisation, what information is provided to assist them to understand the risks and benefits of the procedure?

¼ What procedure is used to provide accurate financial estimates to consumers / patients? Does the organisation take action to ensure that consumers / patients understand the cost implications?

¼ How is compliance with the consent process evaluated?

When consent cannot be obtainedValid informed consent is premised on the disclosure of appropriate information to a competent consumer / patient who is permitted to make a voluntary choice. When consumers / patients lack the competence to make a decision about treatment, substitute decision makers must be sought. The determination of whether consumers / patients are ‘competent’ is important for maintaining the autonomy of individuals who are capable of making informed decisions, while protecting those with cognitive impairment.8

Some settings, such as intensive care units, include a significant proportion of consumers / patients who may not be competent. Assessing competence can be challenging, particularly differentiating impairment from incapacity.8 Legal standards for decision making capacity for consent to treatment vary somewhat across jurisdictions, but generally for adults over 18 years an assessment of competence should involve three aspects1:

1. Does the person understand?

2. Does the person believe what they are being told?

3. Can the person make a judgment based on this information?

Specific situations where consent conditions do not apply should be covered by policy according to jurisdictional requirements and organisational / professional ethics. Subjects likely to be covered include1:

• emergency situations

• advance care directives

• treatments authorised by statute or court order.

Organisations may also have policy to cover circumstances where the transfer of paperwork has not occurred and it is in the consumer / patient’s assumed best interests to proceed.9,10

Prompt points

¼ Under what circumstances are consumers / patients deemed incompetent in the organisation? Is there policy / guidelines for managing situations where consent may not have been obtained from a consumer / patient?

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Criterion 1.1.3

Consumers / patients are informed of the consent process, and they understand and provide consent for their health care. (continued)

Consent to communicate personal informationThe National Privacy Principles aim to ensure that personal information collected for the legitimate activities of a healthcare organisation is used only for purposes related to the reason for which the data were originally collected.

This requires that consent be sought, except in some specifically stated circumstances, before information is transferred to other organisations or people.11

Prompt points

¼ Under what circumstances does the organisation seek a signed consent for the transfer of information? How is any risk associated with information provision broached with consumers / patients?

Evidence commonly presented

Consider whether the following will help to address criterion 1.1.3

¼ Organisational consent policy

¼ Health records containing consent forms or notes on discussions about consent

¼ Training and information resources for healthcare professionals on consent

¼ Estimates of procedure costs with signed consent

¼ Complaints management in situations related to consent

¼ Health records audit to assess levels of consent and quality of process

¼ Review of consent forms and communication documents for ease of understanding

Performance measurementThis criterion states that: “Consumers / patients are informed of the consent process, and they understand and provide consent for their health care”. The organisation should be able to demonstrate that it has policies and procedures in place to comply with the jurisdictional requirements governing the gaining of informed consent, and also that it is able to manage those situations where variations to the standard procedure are necessary.

Some common suggested performance measures are as follows:

Number of consent forms that have been signed by consumers / patients prior to their admission for elective surgery

Total number of consumers / patients admitted for elective surgery

Number of consent forms signed by an appropriate medical practitioner / health professional and the consumer / patient

Total number of consent forms reviewed

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Number of consumers / patients who were given verbal or written information about risks associated with a treatment / procedure, which was then documented in their health record

Total number of consumers / patients undergoing a treatment / procedure

Number of consumers / patients giving financial consent to a treatment / procedure

Total number of consumers / patients undergoing the treatment / procedure

Number of culturally and linguistically diverse (CALD) consumers / patients accessing the interpreter service to gain assistance with giving informed consent

Total number of consumers / patients identified as CALD

References1. ACT Health. Procedure: Consent to treatment.

Canberra; ACT Health; 2008.

2. World Health Organization. Best practice protocols: Clinical procedures safety. Geneva CH; WHO; 2007.

3. National Health & Medical Research Council (NHMRC). Communicating with patients: Advice for medical practitioners. Canberra ACT; Commonwealth of Australia; 2004.

4. Wu HW, Nishimi RY, Page-Lopez CM and Kizer KW. Learning from early adopters: Improving patient safety through informed consent in limited english proficiency/low-literacy populations. Washington DC USA; National Quality Forum; 2005.

5. Medicare Australia. Australian organ donor register. Australian Government. Accessed from http://www.medicareaustralia.gov.au/public/services/aodr/index.jsp on 14 January 2010.

6. Truog RD. Consent for organ donation — balancing conflicting ethical obligations. N Engl J Med 2008; 358(12): 1209-1212.

7. Siddins MT, Klinken EM and Vocale LR. Adequacy of consent documentation in a specialty surgical unit: time for community debate? Med J Aust 2009; 191(5): 259-262.

8. Appelbaum PS. Assessment of patients’ competence to consent to treatment. N Engl J Med 2007; 357(18): 1834-1840.

9. WA Department of Health. Consent to treatment policy for the Western Australian health system. Perth; WA Health; 2009.

10. WA Department of Health. Form F: Authorisation to proceed with surgery on a patient without a valid consent form. Perth; WA Health; 2010.

11. Office of the Federal Privacy Commissioner. National privacy principles. Information sheet. Canberra ACT; Office of the Privacy Commissioner; 2008.

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Criterion LA – Awareness sA – ImplementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 1.1.4

Outcomes of clinical care are evaluated by healthcare providers and where appropriate are communicated to the consumer / patient and carer.

this is a mandatory criterion

a) Healthcare providers are aware of the organisation’s systems for the evaluation of clinical care.

b) Policy / guidelines exist for providing feedback about clinical care to consumers / carers.

c) Consumers / patients and when appropriate carers are enabled to provide feedback on the care provided.

a) Formal processes are implemented across the organisation for the review of clinical care.

b) Prior to discharge, healthcare providers discuss the outcomes of care with the consumer / patient and when appropriate the carer, and this is documented.

a) Clinical audit is supported across the organisation and reviewed by the relevant clinician groups to evaluate and improve health care.

b) Individual and group consumer / patient care and outcomes data (including ‘at risk’ patients) are evaluated and improved as required.

c) Data collected from the feedback of consumers / patients are used by the organisation in the evaluation of clinical care.

d) Consumers / patients and when appropriate, carers participate in the evaluation of care.

a) Performance measures for process and outcome data are used across the organisation and compared with internal and external systems and improvements are made to ensure better practice.

and/or

b) The organisation contributes to national databases and comparative reports from the databases are regularly reviewed and improvements are made to ensure better practice.

a) The organisation demonstrates it is a leader in the evaluation of care as demonstrated by its processes and consumer / patient outcomes.

IntentThe intent of this criterion is to ensure that organisations evaluate the outcomes of the care and services that they provide. Care should be evaluated on a case-by-case basis, as well as organisation-wide.

Outcomes of care evaluation must be communicated to key clinical staff in senior nursing, medical and allied health roles, to ensure that appropriate responses are identified and implemented in order to improve the quality of care provided.

Relationships of 1.1.4 with other criteriaOrganisations must evaluate the clinical care that they provide to ensure the delivery of high quality health care to the consumer / patient, and with the goal of continuous improvement of services (Standard 1.1). Evaluation should consider the effectiveness (Criterion 1.4.1), appropriateness (Criterion 1.3.1), safety and quality (Standard 1.5) of care. The organisation must have processes in place to review and revise policy and processes on the basis of care evaluation, and to ensure that recommended changes are implemented (Criterion 3.1.5).

Consumers / patients, their families and/or carers have the right to participate actively in the planning, delivery and evaluation of care (Criterion 1.6.1) and to comment on any aspect of the care provided (Criterion 1.6.2). Feedback and complaints from consumers / patients (Criterion 2.1.4) may provide insight into areas of care requiring improvement. Evaluation is an aspect of the organisation’s integrated risk management framework (Criterion 2.1.2). Failure to evaluate and improve clinical care may lead to incidents, including adverse events, which under the principles of open disclosure should be discussed with the consumer / patient (Criterion 2.1.3).

Feedback on clinical careOrganisational feedback to consumers / patients may be provided in two different contexts:

• feedback to an individual consumer / patient and their family / carer(s) about the care that the consumer / patient personally received at an organisation

• more general feedback on the overall performance of the organisation in relation to its clinical care.

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Criterion LA – Awareness sA – ImplementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 1.1.4

Outcomes of clinical care are evaluated by healthcare providers and where appropriate are communicated to the consumer / patient and carer.

this is a mandatory criterion

a) Healthcare providers are aware of the organisation’s systems for the evaluation of clinical care.

b) Policy / guidelines exist for providing feedback about clinical care to consumers / carers.

c) Consumers / patients and when appropriate carers are enabled to provide feedback on the care provided.

a) Formal processes are implemented across the organisation for the review of clinical care.

b) Prior to discharge, healthcare providers discuss the outcomes of care with the consumer / patient and when appropriate the carer, and this is documented.

a) Clinical audit is supported across the organisation and reviewed by the relevant clinician groups to evaluate and improve health care.

b) Individual and group consumer / patient care and outcomes data (including ‘at risk’ patients) are evaluated and improved as required.

c) Data collected from the feedback of consumers / patients are used by the organisation in the evaluation of clinical care.

d) Consumers / patients and when appropriate, carers participate in the evaluation of care.

a) Performance measures for process and outcome data are used across the organisation and compared with internal and external systems and improvements are made to ensure better practice.

and/or

b) The organisation contributes to national databases and comparative reports from the databases are regularly reviewed and improvements are made to ensure better practice.

a) The organisation demonstrates it is a leader in the evaluation of care as demonstrated by its processes and consumer / patient outcomes.

It is likely that organisations will have distinct policy / guidelines to cover these separate situations.

Some State / Territory health departments and private hospital groups track performance using indicators. Organisations will hold a position on whether this information is reported to the consumers on their committees and to the general public; this position will be reflected in policy and/or guidelines.

Increasingly, there are moves to provide consumers with concrete figures to enable performance comparisons; this happens to some extent for various measures in overseas countries. There are equally strong questions about the value of providing information that can be ranked into ‘league tables’ which may be open to interpretation without due context.

Objectives being pursued through the Australian Commission on Safety and Quality in Health Care may mean that a broad range of healthcare providers across Australia will provide regular data for benchmarking on carefully selected performance indicators.1

Organisations may choose to release performance information to the public through various avenues including their public relations departments or their websites; the information selected for public disclosure is generally the ‘good news’ or the ‘positive angle’.

Prompt points

¼ Is there policy or guidelines on communicating clinical care outcomes to consumers / patients? What guidance, if any, does the organisation’s policy on feedback provide to clinicians?

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Criterion 1.1.4

Outcomes of clinical care are evaluated by healthcare providers and where appropriate are communicated to the consumer / patient and carer. (continued)

Feedback is given to consumers / patients before discharge / transfer of careThe importance of consumers / patients understanding their health status, any resultant limitations, obligations or changes, and then committing to proactively managing their health following discharge or transfer of care cannot be over-estimated.

In cases where the original care plan required variation during the course of treatment, a discussion of the circumstances that led to the change should be included as part of the care dialogue. A structured discussion of a consumer / patient’s care outcomes and expectations of their ongoing recovery and/or care needs may help the individual to better manage recovery, and to recognise and respond to any adverse events post-discharge.2

Prompt points

¼ Is there a record of what information about outcomes of care has been discussed with the consumer / patient (in the health record, discharge summary, care plans, case management reviews)?

¼ Does discharge planning at the organisation permit / encourage a discussion regarding the outcomes of clinical care?

¼ How variable is the manner in which outcomes of care are discussed with consumers / patients? What impact does the individual personality of the consumer / patient and/or clinician play in discussions about outcomes of care?

Consumers / patients can provide feedback on their careConsumers / patients may not be able to assess the technical aspects of the clinical choices made by their healthcare providers, but they do expect that their treatment or procedure should lead to an improvement in their health and wellbeing. Similarly, most consumers / patients can assess whether they had input into the decisions made on their behalf, and whether their care planning was respectful of and responsive to their individual preferences, needs and values.3 Obviously, Australian health care cannot meet everyone’s ideals, however the options available and their respective costs and benefits should be made available to consumers / patients and explained, to enable them to be considered on their merits.

Considering the views of consumers / patients in a systematic and thoughtful manner is the first step to incorporating this perspective into clinical practice.4 Organisations may differ in how they facilitate consumer / patient participation. They should consider opportunities for consumers / patients to discuss their discharge and ongoing care before leaving the facility, and there is scope for retrospective care evaluation on an individual basis to be formalised as part of this discharge discussion. An alternative is to seek feedback during any follow-up contact after discharge5, although organisations should be mindful that too great a delay may result in less effective feedback.

Mechanisms that can invite and enable feedback include:

• a post-discharge email or phone call

• an email address that specifically includes the word ‘feedback’, and is promoted in the organisation’s brochures and website

• the addition of a question or reminder during discharge planning.

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Prompt points

¼ Based on single cases or episodes of care, can the organisation demonstrate that the service made a difference to the consumer / patient’s health status? Were the care goals met? Were consumer / patient-oriented goals met? Did the consumer / patient understand and participate in his or her care?

¼ What systems are in place to encourage, enable, record, monitor and respond to consumer / patient feedback?

¼ How does the organisation manage the communication of information to consumers / patients following an adverse event?

Review of clinical careIndividual care evaluation, including review of the care processes provided, should take place to determine whether the best possible outcomes were achieved for a consumer / patient. Subsequently, the aggregate results for many consumers / patients should be evaluated, possibly refining the information by grouping consumers / patients according to their demographic parameters (for example, gender, age, ethnicity), disease state and/or procedures.

As an example, not only should the care process and outcome for a single consumer / patient having a coronary artery bypass operation be reviewed, but also the care and outcomes for all consumers / patients undergoing the same procedure in a given period of time, such as the previous six months. Similarly, a consumer / patient with a history of non-compliance with medication may be provided with additional support, while at an organisational level, a health record audit of all consumers / patients over the previous six months with a similar history is undertaken to determine whether there are any common features in these cases that might be used to improve care.

Evaluation practices should also consider how the findings and recommendations arising from previous reviews have been followed up.

‘At-risk’ consumers / patients form a special group. These consumers / patients have been recognised early in their care as having a higher likelihood of an adverse outcome, based on their identified risk factors. Consumers / patients may be ‘at-risk’ of blood clots (VTE), falls, allergic reactions, malnutrition or other adverse events. Evaluation could consider whether

the incidence of adverse outcomes among the ‘at-risk’ group was reduced to levels similar to those for consumers / patients without this risk factor.

Some important considerations for healthcare providers include6:

• whether the care plan worked

• whether healthcare providers made a difference in the health status of the consumer / patient

• what the organisation measures to determine whether the care made a difference

• the reliability of data collected from clinical pathways

• whether the care goals were met

• where appropriate, whether requirements for seamless integrated care provision were met.

Organisations can use formalised data collection and tracking processes to monitor their performance. A range of indicators are tracked by health departments and other organisations. ACHS offers its members a clinical indicator data collation and analysis service through its Performance and Outcomes Service. Before committing to collection of any indicator, its usefulness to the organisation should be considered:

• Does the indicator measure an important aspect of clinical practice?

• Will the data collected on this indicator assist in improving clinical care?

• Will the information be useful and meaningful to clinicians in demonstrating how the service is performing and ways that it may be improved?

• Will the data be accessible to clinicians to allow for monitoring of the indicator?

• Are existing resources sufficient for ongoing monitoring of the indicator?

For integrity to be maintained by those submitting data for grouped analysis, it is important that the goal be to respond to issues identified, rather than to penalise those whose performance is not meeting goals.7

Once consistency in the collection and review process is achieved, data can be monitored over time to track changes in performance. Changes in organisational data may result from many factors independent of staff performance; all potential contributing factors should be considered as part of the review process.

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Performance measurementThis criterion states that: “Outcomes of clinical care are evaluated by healthcare providers and where appropriate are communicated to the consumer / patient”. The organisation should be able to demonstrate that it has policy and procedures in place to evaluate clinical care, and that improvements are made as necessary; and that processes for facilitating consumer feedback, and for communicating with the consumer / patient in the event of an adverse event, are in place.

Some common suggested performance measures are as follows:

Note: Clinical indicators may be used as supporting evidence for this criterion. Please refer to the Clinical Indicator Summary Guide on the ACHS website, http://www.achs.org.au

Number of formal follow-ups / investigations of clinical indicator outlier cases identified through the ACHS clinical indicator reports

Total number of outliers identified through ACHS clinical indicator reports

Number of formal review processes devoted to the review of aggregated medical / surgical cases

Total number of formal review processes

Comment: examples of formal review processes are peer review meetings, mortality and morbidity meetings, departmental meetings, etc.

Criterion 1.1.4

Outcomes of clinical care are evaluated by healthcare providers and where appropriate are communicated to the consumer / patient and carer. (continued)

Prompt points

¼ What processes are used to evaluate clinical care in the organisation?

¼ How are data reconciled across the continuum of care?

¼ Describe how a review of care led to a change in consumer / patient management with the objective of reducing an identified risk?

¼ Can the organisation track its performance against specific measures over time? What precautions are taken to protect the integrity of these measures?

Evidence commonly presented

Consider whether the following will help to address criterion 1.1.4

¼ Processes for consumer / patient / carer feedback

¼ Policy / guidelines on care evaluation

¼ Evaluation of care plans and delivery

¼ Clinical outcome reviews

¼ Clinical indicators or other performance indicators, ideally tracked over time and benchmarked against other departments / organisations

¼ Evaluation of instances of adverse events and the circumstances surrounding them

¼ Minutes or notes taken at review committee meetings

¼ Demonstrated changes made in response to a problem identified by consumer / patient complaints or a review of care

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References1. Australian Commission on Safety and Quality in Health Care

(ACSQHC). Windows into safety and quality in health care 2009. Sydney NSW; ACSQHC; 2009.

2. Tsilimingras D and Bates D. Addressing postdischarge adverse events: a neglected area. Joint Comm J Qual & Patient Safety 2008; 34(2): 85-97.

3. Newell S. The consumer voice and experience must underpin and shape safety and quality in health care. Health Issues 2009; 98(Autumn): 10-11.

4. Black N and Jenkinson C. Measuring patients’ experiences and outcomes. Br Med J 2009; 339: b2495.

5. Studer Q. Discharge phone calls deliver quality care, higher patient satisfaction. Hospital News.(5 Jan 2006): Accessed from http://www.studergroup.com/dotCMS/knowledgeAssetDetail?inode=252512 on 1 September 2010

6. Promotion and Prevention Section of Mental Health and Special Programs Branch. Evaluation – a guide to good practice. Canberra ACT; Australian Dept of Health and Ageing; 2001.

7. Deloitte Touche Tohmatsu. NSW Department of Health: Triage benchmarking review. Sydney; NSW Health; 2008.

Number of evaluated programs / services that have been adjusted to meet identified community needs

Total number of evaluated programs / services

Number of adverse events discussed with the consumer / patient and/or his or her family, as per the National Open Disclosure Standard

Total number of adverse events

Number of adverse events subjected to formal case review

Total number of adverse events

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Criterion LA – Awareness sA – ImplementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 1.1.5

Processes for clinical handover, transfer of care and discharge address the needs of the consumer / patient for ongoing care.

this is a mandatory criterion

a) Guidelines for discharge and transfer of care are available.

b) Arrangements with other service providers and, where appropriate, the carer, are made with consumer / patient consent and input, and confirmed prior to discharge or transfer of care.

a) There is an effective, organisation-wide system for discharge / transfer of care which ensures continuity of care and timely notification between referrers and providers.

b) Clinical handover processes are utilised to ensure continuity of care.

c) Results of investigations follow the consumer / patient through the referral system.

d) There is evidence to demonstrate that service providers receive timely notification about consumer / patient discharge to their care.

e) Discharge information is discussed with the consumer / patient and a written discharge summary is provided.

f) Formalised follow-up occurs for ‘at risk’ consumers / patients.

a) The processes for discharge / transfer of care are evaluated, and improved as required.

b) Discharge and referral information for consumers / patients, other service providers and the systems for providing the information are evaluated and improved as required.

a) Performance measures for discharge / transfer of care are used, compared with internal and external systems, and improvements are made to ensure better practice.

and/or

b) Advanced strategies are in place for notification of ongoing care needs to other service providers.

a) The organisation demonstrates it is a leader in discharge / transfer of care systems.

IntentThe intent of this criterion is to ensure that clinical handover is effective and that healthcare organisations have and follow established processes to ensure consumers / patients a smooth and safe transition when an episode of care is completed, or when there is a change in clinical personnel.

Relationships of 1.1.5 with other criteriaEffective processes for handover, transfer of care and discharge are a vital component of the journey of care (Standard 1.1). Planning for discharge should begin when a consumer / patient is admitted (Criterion 1.2.2) and be considered during assessment (Criterion 1.1.1) and care planning (Criterion 1.1.2). Clinical handover / transfer of care is key to effective ongoing care within an organisation (Criterion 1.1.6) as well as following discharge. Discharge information should

feed into a system of ongoing care that will promote smooth recovery or satisfactory management of a chronic condition.

Good discharge planning should ensure that ongoing care and services are appropriate for consumer / patient needs and capabilities, and delivered in the most appropriate setting (Criterion 1.3.1).

Good communication at clinical handover and appropriately detailed discharge information aims to promote consumer / patient safety (Standard 1.5). In particular, there are key relationships to safe and effective medication practices (Criterion 1.5.1), maintenance of skin integrity (Criterion 1.5.3), reducing the likelihood of falls (Criterion 1.5.4) and ensuring that consumers / patients, particularly the frail aged or those who are incapacitated, receive appropriate hydration and nutrition to facilitate their recovery (Criterion 1.5.7).

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Criterion LA – Awareness sA – ImplementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 1.1.5

Processes for clinical handover, transfer of care and discharge address the needs of the consumer / patient for ongoing care.

this is a mandatory criterion

a) Guidelines for discharge and transfer of care are available.

b) Arrangements with other service providers and, where appropriate, the carer, are made with consumer / patient consent and input, and confirmed prior to discharge or transfer of care.

a) There is an effective, organisation-wide system for discharge / transfer of care which ensures continuity of care and timely notification between referrers and providers.

b) Clinical handover processes are utilised to ensure continuity of care.

c) Results of investigations follow the consumer / patient through the referral system.

d) There is evidence to demonstrate that service providers receive timely notification about consumer / patient discharge to their care.

e) Discharge information is discussed with the consumer / patient and a written discharge summary is provided.

f) Formalised follow-up occurs for ‘at risk’ consumers / patients.

a) The processes for discharge / transfer of care are evaluated, and improved as required.

b) Discharge and referral information for consumers / patients, other service providers and the systems for providing the information are evaluated and improved as required.

a) Performance measures for discharge / transfer of care are used, compared with internal and external systems, and improvements are made to ensure better practice.

and/or

b) Advanced strategies are in place for notification of ongoing care needs to other service providers.

a) The organisation demonstrates it is a leader in discharge / transfer of care systems.

Involving consumers / patients in discharge planning can present challenges, but will help to avoid misunderstandings that might lead to re-admission, as well as ensuring that organisations meet their responsibilities to those with diverse needs and from diverse backgrounds (Criterion 1.6.3).

Processes for clinical handover, transfer of care and discharge Good handover and communication with ongoing providers and carers are at the heart of an effective healthcare system and stand alongside consumer / patient clinical documentation, letters of referral and transfer and discharge documentation. Together, these make up the links in the chain of continuity of consumer / patient care.1

Organisations should ensure there is policy / guidelines that address the requirements for clinical handover, transfer of care and discharge, as well as a system for implementing the policy / guidelines and a method for evaluating whether these processes are effective.

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Criterion 1.1.5

Processes for clinical handover, transfer of care and discharge address the needs of the consumer / patient for ongoing care. (continued)

Clinical handover refers to the transfer of professional responsibility and accountability for some or all aspects of care for a consumer / patient, or group of consumers / patients, to another person or professional group on a temporary or permanent basis.1, 2 Effective clinical handover results in the safe transfer of care of consumers / patients. Organisations seeking further information could refer to the Australian Medical Association’s Safe handover: Safe patients. Guidance on clinical handover for clinicians and managers, available from the AMA website1, and the resources available on the website of the Australian Commission on Safety and Quality in Health Care.3

Common handover scenarios include1:

• nursing ‘change of shift’ report

• Junior Medical Officer (JMO) handover to afterhours medical cover

• transfer of care between hospital teams and from hospital to community teams

• transfer of care to general practitioner (GP)

• transfer of care between facilities

• handover in specific clinical situations, for example management of the deteriorating patient

• communication with consumer / patient and family / carer.

Handover occurs2:

• from one provider or team of providers to another

• at points of consumer / patient transition across settings

• between services or levels of care

• due to the need to organise clinical work into manageable shifts

... and includes handover of consumer / patient information and material risks.

Community settings may approach clinical handover in a different manner from acute settings. Whatever process is used, it is important that it is documented, that staff are aware of the procedure and that compliance with the handover process is evaluated.

Policy / guidelines should include4:

• the handover situations to which it applies

• persons who should be involved in the communication, and appropriate responses where face-to-face briefings are not possible

• care information

– diagnoses and current condition of the consumer / patient

– recent changes in condition or treatment

– anticipated changes in condition or treatment

– suggestions on what to watch for in the next interval of care

• print or electronic information that should be available to the incoming carer / clinician.

Discharge refers to the release of a consumer / patient from care5 or movement of a consumer / patient from one setting of care to another.6

The key issues to be considered in the discharge or transfer of a consumer / patient are that:

• the discharge or transfer has been appropriately planned with the consumer / patient and/or their carer and the multidisciplinary team

• it is actioned in a smooth and timely fashion

• all necessary information about past, present and future care is communicated clearly to the consumer / patient and/or to ongoing care providers

• the consumer / patient and carer understand what is to happen and why.

There is an expectation that a discharge summary will be provided to:

• the consumer / patient

• the healthcare provider to whom the consumer / patient is discharged

• the referring healthcare provider

• the health record.

In some cases, such as in rural / remote areas, the treating healthcare provider within the organisation may be the same as the healthcare provider caring for the consumer / patient following discharge from the organisation. On condition that the health record is accessible to the healthcare provider in both the organisation and following discharge, the copy of the discharge summary in the health record is sufficient to satisfy the requirement for the discharging healthcare provider to receive a copy. The purpose of the discharge summary is to ensure that the consumer / patient, the referring healthcare provider and any

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other relevant healthcare providers are aware of, and understand, ongoing plans and their responsibilities in ongoing management of the consumer / patient.

The National E-Health Transition Authority’s (NEHTA’s) Continuity of Care Program is a national initiative to support the development of emerging e-health infrastructure that is currently taking shape across Australia. This program is implementing a series of Discharge Summary and Referral specifications to improve continuity of consumer / patient care. Information on the development of e-discharge summaries, including examples of templates, is available at www.nehta.gov.au

Prompt points

¼ What policy / guidelines / processes does the organisation use to manage discharge? Internal transfer of care, e.g. between departments / healthcare facilities? Handovers at shift changes?

¼ Are the same processes used organisation-wide? If not, where, why and how have specific adaptations to the processes been made?

¼ What standardised processes are used to ensure continuity of care at clinical handover? Are these processes followed throughout the organisation? How effective have these processes proven to be?

¼ Are there any situations where face-to-face clinical handover cannot occur? If so, what happens under these circumstances? What documentation, forms or records, support or replace a face-to-face transfer of care?

¼ Have the incident monitoring system or complaints processes identified any problems resulting from communication failures at clinical handover? If so, what efforts have been made to reduce the problems?

Test results follow the consumer / patientRequests for investigations and the movement of blood or other tissues or images between health professionals should be standardised, but allow clinicians to consciously limit details according to their professional view of what is relevant to procedure. The process should ensure that staff receiving the consumer / patient know that he or she has arrived and should provide an opportunity to properly identify the consumer / patient and the test(s) to be done. The inclusion of special precautions for specific consumers / patients, such as isolation, fall risk or suicide risk, may be useful when sending a consumer / patient for diagnostic tests or investigations.4 Because additional questions may arise, it is important that the name of the referring doctor and a contact number be clearly printed (if written) or entered (if computerised) on the pathology request form, with an alternative contact in case of unavailability if appropriate.7

As consumers / patients move through a multidisciplinary care process, it is important that their diagnostic test results are available. Repeating the same tests within a short time interval has long been identified as a potentially wasteful practice.

Prompt points

¼ What processes ensure that pathology and imaging results are available to all clinicians who may need them for decision making? What are the systems for archiving and retrieval of images?

¼ How does the health record system link consumers / patients, their care plans and ongoing monitoring data with test and image results? Can the information be accessed from the bedside / within the ward / other locations? How are test / imaging results transferred when the consumer / patient moves to another part of the organisation or visits another clinician?

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Criterion 1.1.5

Processes for clinical handover, transfer of care and discharge address the needs of the consumer / patient for ongoing care. (continued)

Consumer / patient participation in discharge planningWell-informed consumers / patients who understand the planning of their care are more capable of managing their condition proactively, and potentially decreasing rehospitalisation.8

The capability of consumers / patients and their carers to participate in discharge planning will be influenced by their health literacy.9 Because this may at times be difficult to assess, discharge planners should be alert for misunderstandings resulting from their communications. Communication in relation to medication management, particularly for products such as warfarin, require that consumers / patients understand the need for ongoing monitoring and adjustment, be alert for adverse events such as abnormal bleeding, and that the clinician(s) responsible for ongoing care is fully informed.10, 11

An example of proactive discharge planning with consumer / patient involvement might include assigning a specific discharge person to work with consumers / patients prior to their discharge8 to:

• arrange follow-up appointments

• confirm medication reconciliation

• conduct consumer / patient education with an individualised instruction booklet

• conduct post-discharge follow-up to ensure there have been no problems in relation to discharge planning

• provide education materials to the primary care provider.

Prompt points

¼ What processes are in place for discharge / transfer of consumers / patients? Is there a system of review of discharge summaries sent to GPs (and specialists) for quality and content? Are clinical staff trained in the use of the software where discharge summaries are done electronically?

¼ Is there a system that provides opportunities to identify impending discharges / transfers for the same or following day?

¼ Does the discharge / transfer process enable enough time for discussion of ongoing care with the relative / carer?

¼ Are discharge summaries ready at the time of transfer / discharge of the consumer / patient?

¼ Is there a system in place to identify when e-discharge summaries do not reach the destination?

Referral organisations notifiedIn the context of discharge planning, the timeliness of information received by a referring physician about a discharged consumer / patient will be reflected in the satisfaction of referring physicians and an absence of complaints / feedback from consumers / patients who have been discharged from care.

Consumer / patient transfer to primary care providers requires a transfer of information that may include a discharge care plan to accompany the discharge summary. The inclusion of this information enhances the capacity of a GP / specialist to provide high quality continuing care following any admission.1

Important items of information to be included in the discharge summary are12:

• treatment whilst in hospital

• a list of diagnoses

• follow-up treatment

• management and outcomes

• list of medications at discharge

• dates of admission and discharge.

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Prompt points

¼ What information is provided by clinicians / organisations / primary care providers to which / whom consumers / patients are transferred? What feedback is received from recipients regarding the usefulness of this information / timeliness of its arrival?

¼ Is there evidence in the consumer / patient satisfaction process that appropriate discharge information is provided to community carers?

Follow-up The timing and mode of follow-up should be established for the service provided, assessed risks to consumers / patients and needs of the consumer / patient population. The most common form of follow-up has been a post-discharge phone call13, 14, but where the consumer / patient population has access to them, modern technologies such as email and SMS may offer alternative methods of sending reminders or seeking further information from consumers / patients.15

Whichever form the follow-up takes, it should be documented in the health record and the consumer / patient should receive a copy of the follow-up plan.

Formalised follow-up of ‘at-risk’ consumers / patients involves a planned process for after the consumer / patient has been discharged or transferred from the treating health facility / clinician. Some forms of follow-up include organising a date for review with a health provider or arranging a community support visit.

The categories of consumers / patients considered ‘at-risk’ will vary between health services. Organisations should form a clear view of how they identify ‘at-risk’ consumers / patients. Examples include consumers / patients:

• judged to be at risk of suicide16

• with chronic diseases17, particularly those with complex monitoring or medication needs, as occurs in asthma, diabetes mellitus, rheumatoid arthritis and acute coronary syndrome

• who are frail aged, debilitated, intoxicated or children

• who experienced an adverse event while admitted.

Prompt points

¼ Which consumers / patients are followed-up post-discharge? What is the method of follow-up? What is the timing of this contact and why has this timing been chosen?

¼ What factors does the organisation use to determine whether consumers / patients might be ‘at-risk’ of difficulties after discharge?

¼ Are risk assessments conducted prior to discharge and does a copy of this go to the referrer?

The communication processThere is growing awareness of the variation in needs between different consumers / patients for healthcare information. Key to judging the effectiveness of any communication is retrospective feedback from the target audience that considers receipt of information, but also whether it was understood and acted upon. The most effective communication will be capable of educating the recipient and influencing behaviour.

The following suggestions can be utilised to communicate health information to consumers / patients18:

• avoid complex language and too much jargon

• avoid busy layouts and small print

• risk communication may be too negative with insufficient information on the benefits of taking the medicine, making it difficult for the consumer / patient to assess risk versus benefit

• the information should supplement a discussion with the prescriber and be consistent with advice given (ideally a brochure / leaflet could be used in the conversation)

• provide sources for further information particularly in relation to specific diseases

• include helpline numbers and website addresses as pointers to further information

• comparative information and information about lifestyle issues can aid consumer / patient decision making.

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Performance measurementThis criterion states that: “Processes for clinical handover, transfer of care and discharge address the needs of the consumer / patient for ongoing care”. The organisation should be able to demonstrate policy and procedures for the transfer of care, responsibility and information pertaining to the consumer / patient, both within the organisation itself, and also to external service providers and family members / carers.

Some common suggested performance measures are as follows:

Number of consumers / patients who cannot be discharged due to no suitable accommodation being available

Total number of consumers / patients scheduled for discharge on a particular day

Comment: this could be due to internal reasons or social reasons

Criterion 1.1.5

Processes for clinical handover, transfer of care and discharge address the needs of the consumer / patient for ongoing care. (continued)

Prompt points

¼ Does the organisation check that consumers / patients and carers have received appropriate information relating to their condition on discharge / transfer? Is the consumer / patient’s understanding of that information ever reviewed?

¼ Has the organisation checked with the relevant clinicians to whom it most frequently refers consumers / patients to determine that their needs for timely information about referred consumers / patients are met?

¼ Have discharge education leaflets for consumers / patients been evaluated with regard to their content and/or communication effectiveness?

¼ Has the quality of information entered on clinical handover documentation been audited?

Evidence commonly presented

Consider whether the following will help to address criterion 1.1.5

¼ Completed discharge plans

¼ Policies / guidelines / processes on clinical handover, transfer of care and discharge

¼ Records system that facilitates clinician access to consumer / patient imaging and pathology test results

¼ Review of quality and content of discharge summaries by senior staff

¼ Home care, aged care or community services liaison systems and information

¼ Staff training in systems / processes for clinical handover, transfer of care and discharge including the use of software / templates

¼ Records of inquiries, complaints, and other feedback post-discharge, ideally monitored and evaluated over time

¼ Reviews of process adherence, communication efficacy, and consumer / patient satisfaction associated with discharge, transfer of care and/or clinical handover

¼ Feedback from GPs as to the usefulness of discharge summaries

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Number of consumers / patients who cannot be discharged on the expected discharge date

Total number of consumers / patients scheduled for discharge on a particular date

Comment: the organisation may choose to collect the different reasons for failure to discharge, e.g. clinical, anaesthetic, social

Number of consumers / patients whose criteria for discharge have been fully met by the planned date of discharge

Total number of consumers / patients scheduled for discharge within a given time period

Comment: consider a documented discharge plan

Number of consumers / patients who received a discharge summary / letter at the time of discharge

Total number of consumers / patients discharged

Number of consumers / patients who have a final discharge summary recorded in the health record within X days of facility discharge / community care discharge

Total number of consumers / patients discharged

Comment: the organisation to define ‘X’

Number of consumers / patients satisfied with their discharge instructions

Total number of consumers / patients surveyed

Number of phone calls / contacts from discharged consumers / patients querying their discharge instructions

Total number of consumers / patients discharged

Number of unplanned re-entries / intakes into the service

Total number of consumers / patients discharged

Number of transfers from community-based services to residential / inpatient services

Total number of consumers / patients accessing the community-based service

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Criterion 1.1.5

Processes for clinical handover, transfer of care and discharge address the needs of the consumer / patient for ongoing care. (continued)

References1. Australian Medical Association (AMA). Safe handover: safe

patients. Guidance on clinical handover for clinicians and managers. Canberra ACT; AMA; 2006.

2. Australian Commission on Safety and Quality in Health Care (ACSQHC). Windows into safety and quality in health care 2008. Sydney NSW; ACSQHC; 2008.

3. Australian Commission on Safety and Quality in Health Care (ACSQHC). OSSIE guide to clinical handover improvement. Sydney NSW; ACSQHC; 2009.

4. Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Hand-off communications. National Patient Safety Goal 020501. Oak Terrace USA; JCAHO. Accessed from http://www.jointcommission.org/AccreditationPrograms/Hospitals/Standards/09_FAQs/NPSG/Communication/NPSG.02.05.01/hand_off_communications.htm on 25 January 2010.

5. MedlinePlus Medical Dictionary. Medical Dictionary. Merriam-Webster. Accessed from http://www.merriam-webster.com/medlineplus/at%20risk on 12 August 2010.

6. Ma E, Coleman E, Fish R et al. Quantifying posthospital care transitions in older patients. J Am Med Dir Assoc 2004; 5(2): 71-74.

7. Garling P, SC. Final report of the special commission of inquiry: Acute care services in NSW public hospitals. Sydney; NSW Special Commission of Inquiry; 2008.

8. Jack BW, Chetty VK, Anthony D et al. A reengineered hospital discharge program to decrease rehospitalization: a randomized trial. Ann Intern Med 2009; 150(3): 178-187.

9. Nutbeam D. The evolving concept of health literacy. Soc Sci Med 2008; 67(12): 2072-2078.

10. Makeham MAB, Saltman DC and Kidd MR. Lessons from the TAPS study. Warfarin: a major cause of threats to patient safety. Aust Fam Physician 2008; 37(10): 817-818.

11. Lowthian JA, Diug BO, Evans SM et al. Who is responsible for the care of patients treated with warfarin therapy? Med J Aust 2009; 190(12): 674-677.

12. Alderton M and Callen J. Are general practitioners satisfied with electronic discharge summaries? Health Inf Manag J 2007; 36(1): 7-12.

13. Queensland Health Quality and Safety Program. 2006/07 Patient satisfaction: Maternal post-birth survey. Brisbane; Qld Health. Accessed from http://www.health.qld.gov.au/quality/pat_sat_survey/patsat2007.asp on 27 January 2010.

14. Hordacre A-L, Pirone C and Taylor A. Poster: the SA patient evaluation of hospital services (PEHS). Adelaide; SA Department of Health, Population Research and Outcomes Studies Unit; 2009.

15. South Eastern Sydney Illawarra Area Health Service. Impact of an electronic SMS appointment reminder system on waiting times at a large publicly funded sexual health centre. Sydney NSW; Australian Resource Centre for Healthcare Innovations (ARCHI). Accessed from http://www.archi.net.au/e-library/performance/flow/sms-reminder on 27 January 2010.

16. Australian Department of Health and Ageing. LIFE: A framework for prevention of suicide in Australia. Canberra; Dept of Health and Ageing; 2008.

17. Victorian Department of Human Services (DHS). HARP chronic disease management guidelines. Melbourne VIC; DHS; 2004.

18. Committee on Safety of Medicines Working Group on Patient Information. Always read the leaflet. Getting the best information with every medicine. London UK; Medicines and Healthcare Products Regulatory Agency; 2005.

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Criterion LA – Awareness sA – ImplementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 1.1.6

Systems for ongoing care of the consumer / patient are coordinated and effective.

a) There are formal processes for coordinating ongoing care by multiple service providers in a timely manner.

a) Care coordination and/or case management is available for appropriate consumers / patients and their carer.

b) There are systems for screening, prioritisation and readmission of consumers / patients with chronic conditions.

c) Strategies are developed to reduce acute presentations and avoidable admissions of consumers / patients with chronic conditions.

a) The ongoing care process is evaluated and improvements are made to ensure better practice.

b) Education provided for consumers / patients requiring ongoing care and where appropriate their carer, is evaluated, and improvements are made to ensure better practice.

a) Performance measures for ongoing care are used, compared with internal and external systems, and improvements are made to ensure better practice.

and/or

b) The screening, prioritisation and readmission process for consumers / patients with chronic conditions is compared with other service providers and improvements are made to ensure better practice.

and/or

c) The education provided for consumers / patients requiring ongoing care and their carer, is compared with other service providers’ and improvements are made to ensure better practice.

and/or

d) The organisation undertakes research into the management of chronic conditions and publishes its results in peer reviewed journals.

a) The organisation demonstrates it is a leader in systems for ongoing care.

IntentOngoing care refers to the active and supportive management of care for people with chronic or complex conditions as well as the process that follows an admission to a healthcare organisation. The intent of this criterion is to ensure that all healthcare organisations and individuals involved in the ongoing care of consumers / patients actively contribute to a seamless continuum of care for the consumer / patient and fulfil their responsibilities for their part of this process.

Relationships of 1.1.6 with other criteriaSystems for coordinated ongoing care are a major aspect of the management of the consumer / patient’s care journey (Standard 1.1), and should be integrated with the organisation’s procedures for access and admission (Criterion 1.2.2), assessment (Criterion 1.1.1), collaborative care planning (Criterion 1.1.2), clinical handover, transfer of care and discharge (Criterion 1.1.5) and care of the dying (Criterion 1.1.7).

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Criterion LA – Awareness sA – ImplementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 1.1.6

Systems for ongoing care of the consumer / patient are coordinated and effective.

a) There are formal processes for coordinating ongoing care by multiple service providers in a timely manner.

a) Care coordination and/or case management is available for appropriate consumers / patients and their carer.

b) There are systems for screening, prioritisation and readmission of consumers / patients with chronic conditions.

c) Strategies are developed to reduce acute presentations and avoidable admissions of consumers / patients with chronic conditions.

a) The ongoing care process is evaluated and improvements are made to ensure better practice.

b) Education provided for consumers / patients requiring ongoing care and where appropriate their carer, is evaluated, and improvements are made to ensure better practice.

a) Performance measures for ongoing care are used, compared with internal and external systems, and improvements are made to ensure better practice.

and/or

b) The screening, prioritisation and readmission process for consumers / patients with chronic conditions is compared with other service providers and improvements are made to ensure better practice.

and/or

c) The education provided for consumers / patients requiring ongoing care and their carer, is compared with other service providers’ and improvements are made to ensure better practice.

and/or

d) The organisation undertakes research into the management of chronic conditions and publishes its results in peer reviewed journals.

a) The organisation demonstrates it is a leader in systems for ongoing care.

The coordination of ongoing care is facilitated by the timely and accurate entry of data into the health record (Criterion 1.1.8) and the management of the health record system (Criterion 3.2.1).

Coordination of ongoing care helps to ensure that the care is both appropriate (Criterion 1.3.1) and effective (1.4.1).

Health promotion activities by the organisation assist consumers / patients to understand their health, address risk factors and better manage chronic conditions (Criterion 2.4.1).

Coordination of ongoing careTo achieve good health outcomes, many consumers / patients need care from more than one healthcare provider. Consumers / patients with chronic or complex conditions in particular require ongoing care, whilst others need some ongoing care and follow-up after an inpatient admission. The goal of care coordination is continuing care that is delivered seamlessly and achieves better health outcomes.

Community health services, mental health services and organisations that provide outreach services may have more involvement in the provision of ongoing care than acute care organisations, but all services can facilitate ongoing care through appropriate referrals and care coordination arrangements, and clear bi-directional communication with general practitioners / specialists.

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Criterion 1.1.6

Systems for ongoing care of the consumer / patient are coordinated and effective. (continued)

Collaborative strategies undertaken in outpatient or home care settings may reduce acute presentations and avoidable admissions.

Effective ongoing care should not be hampered by program or organisational boundaries: organisations should focus on meeting individual consumer / patient needs over and above their own immediate goals.1 Care coordination should enable continuity of care and avoid duplication in service provision.

Effective processes for ongoing care may be evident in:

• clear arrangements for liaison and referral between services and organisations

• roles and responsibilities that reflect a multidisciplinary integrated care approach

• involvement of care providers, the consumer / patient and, where appropriate, their carer in ongoing care planning

• active support to enable the consumer / patient to understand and manage his or her condition

• support services for carers

• maintenance of ambulatory care wherever possible, but with appropriate access to acute care where it cannot be avoided

• integration of record systems to facilitate secure and reliable information exchange

• an understanding of consumer / patient rights that facilitates access by consumers / patients.

Prompt points

¼ How are relationships developed with other service providers? What types of facilities / health professionals does the organisation most commonly liaise with when planning and delivering ongoing care?

¼ What formal arrangements or protocols for ongoing care provision tie the organisation to these ‘partners’ in care provision?

¼ How are clinicians informed about and updated regarding referral options for ongoing care?

¼ Which, if any, consumers / patients receive care coordination / case management support at this organisation?

¼ When was the ongoing care process last reviewed? What were the findings? Assuming there were some changes following the review, how effective have they been?

Screening, prioritising and readmitting patients with chronic conditionsEducation and training initiatives support consumers / patients to manage their disease so as to reduce the risk of acute crises that might require readmission. Education should reflect the appropriate level of care according to consumers / patients’ circumstances, including the capacity to understand and carry out such care, and risk factors.

Organisations should work to develop processes for effective identification and screening of new and returning consumers / patients with chronic conditions. This will help to correctly direct consumers / patients to an appropriate level of care and facilitate prioritisation of cases. Acute facilities might establish fast-track admission and readmission processes that provide access to direct assessment by clinicians skilled in the particular area for some classes of consumers / patients with chronic conditions at times when they are vulnerable to acute deterioration.

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Regardless of whether the chronic disease is their primary reason for presentation at the healthcare organisation, these consumers / patients will require ongoing care of their condition(s), and all assessments and selections of services must take the chronic condition(s) and its management into consideration. Chronic diseases that may impact ongoing care following surgery or after an acute injury include diabetes, arthritis, cardiovascular disease, autoimmune diseases, obesity and asthma.

The potential for frail aged consumers / patients to suffer from delirium should also be a consideration, especially where it may impact or be impacted by the chronic disease. Coordination of ongoing care following surgery or other acute illness should be undertaken with the consumer / patient, and the carer, to ensure decisions are appropriate, manageable and achievable.2

Prompt points

¼ Where demand for services exceeds supply, how does the organisation screen and prioritise consumers / patients requiring ongoing care?

¼ Are there processes in place to manage consumers / patients who regularly return and require readmission due to an ongoing condition?

Education for consumers / patients requiring ongoing careThe overarching goal of chronic disease care is self management; education and coaching are key to achieving effective daily management by consumers / patients.3

Ensuring effective management during recovery from surgery or a serious injury is also likely to require planning and education to facilitate recovery, develop strength, and promote independence.

All organisations have a responsibility to provide education or facilitate its availability for consumers / patients who need it to progress from inpatient to outpatient care.

An organisation may provide consumer / patient education in diverse settings and using different media, such as:

• written information

• a consultation or mentoring session

• a small group training session

• larger seminars

• pre-recorded video segments

• web-based programs including multimedia that might include online live discussions.

Prompt points

¼ What chronic disease self management support programs or strategies are provided by the organisation? Which clinicians are educated and supported in the delivery of such interventions? How is this service publicised and what referral mechanisms are in place?

¼ For whom does the organisation’s chronic disease management support programs or strategies cater? How is the education delivered?

¼ In cases where consumers / patients attend education provided by another supplier, how are referrals made and outcomes followed-up? How is the appropriateness and suitability of referrals measured?

¼ What specific consumer / patient education programs are in place? How does the organisation measure the consumer / patient outcomes and impact of these programs?

¼ Where there are no formal education programs offered by the facility, what action would be taken for a consumer / patient whose understanding of his or her chronic condition and approach to self management could be improved?

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Criterion 1.1.6

Systems for ongoing care of the consumer / patient are coordinated and effective. (continued)

Reducing acute presentations and avoidable admissionsConsumers / patients with chronic conditions and poor continuity of care have more visits to emergency departments and more medical non-elective hospital admission than consumers / patients with regular contact with a healthcare professional.4 Better continuity of care reduces unplanned admissions and emergency department presentations, as well as meeting consumer / patient requirements.4, 5

Following diagnosis and initiation of treatment, the major goal in the management of chronic conditions is to delay or avert complications. Ongoing care may include:

• regular monitoring of the condition by a single practitioner or a multidisciplinary team

• use of pathology tests that can alert deteriorating control or the onset of complications

• educating the consumer / patient to manage his or her condition and recognise signs of deterioration in control

• facilitating supportive networking by consumers / patients / carers managing similar conditions.

Achieving large scale strategic goals that may avoid acute presentations at emergency departments / casualty is likely to require a multifaceted approach. Consider the potential impact of6:

• improving communication and cohesion between services

• identifying ‘at-risk’ consumers / patients and providing additional clinical oversight or self management skills

• proactively managing consumers / patients who fail to report for scheduled appointments to review their care

• providing better continuity of care following an acute presentation

• improving responsiveness to earlier approaches made by consumers / patients, even if their issues were not clearly stated

• improving self management training

• changing workforce capability through changed rosters, recruitment strategies or professional development and training.

Consumers / patients with chronic conditions who have a known risk for acute deterioration may be given alternative means to approach care management. Where diagnosis and risk have been established, fast track pathways can bypass emergency department triage procedures with their focus on determining the diagnosis and prioritising consumers / patients for medical attention.

Strategies to avoid acute presentations, prevent avoidable admissions and any alternative processes used to admit high-risk consumers / patients should be regularly reviewed and improvements made in accordance with the findings of that review.

Prompt points

¼ How does the organisation screen and prioritise the needs of consumers / patients with chronic or complex conditions?

¼ What chronic conditions common in the organisation’s community result in significant numbers of acute presentations or avoidable admissions?

¼ What strategies are in place to reduce acute presentations and avoidable admissions to hospital (for example, self management, better coordination of care or choice of different clinical interventions)?

¼ How is the effectiveness of these strategies measured and what improvements have been made?

Evidence commonly presented

Consider whether the following will help to address criterion 1.1.6

¼ Case management system and evaluation

¼ Arrangements with other providers such as aged care services, disease education services, allied health providers

¼ Surveys of consumer / patient perceptions

¼ Clinicians’ feedback regarding arrangements for ongoing care

¼ Clinicians’ feedback regarding their ability to access data from earlier admissions

¼ Readmission rates and other chronic disease indicators.

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Performance measurementThis criterion states that: “Systems for ongoing care of the consumer / patient are coordinated and effective”. The organisation should be able to demonstrate processes that result in a seamless, integrated episode of care for the consumer / patient within and without the organisation, as well as implement strategies for improving self management of chronic disease by the consumer / patient that help to improve community health and to reduce acute admissions.

Some common suggested performance measures are as follows:

Note: Organisations may choose to look at chronic disease management for particular conditions, e.g. diabetes, or compare performance across different chronic conditions.

Number of consumers / patients with a chronic condition involved in a self management program

Total number of consumers / patients with a chronic condition

Number of consumers / patients with a chronic condition admitted to the organisation who are involved in a self management program

Total number of consumers / patients with a chronic condition involved in a self management program

Number of consumers / patients with a chronic condition who undertake education and/or participate in support activities

Total number of consumers / patients with a chronic condition

Number of consumers / patients flagged for ‘fast track’ admission who are subsequently admitted

Total number of consumers / patients flagged for ‘fast track’ admission

Number of consumers / patients flagged for ‘fast track’ admission who undergo a standard assessment upon presentation

Total number of consumers / patients flagged for ‘fast track’ admission

Number of consumers / patients who follow up on an internal referral to an outpatient service

Total number of consumers / patients given an internal referral to an outpatient service

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Criterion 1.1.6

Systems for ongoing care of the consumer / patient are coordinated and effective. (continued)

Number of consumers / patients receiving care coordination

Total number of consumers / patients eligible for care coordination

Number of clinicians within the organisation satisfied with the timeliness and completeness of information transferred during continuous care episodes

Total number of clinicians surveyed

References1. Victorian Department of Human Services (DHS), Primary

and Community Health Branch. Community health services – creating a healthier Victoria. Melbourne VIC; DHS; 2004.

2. O’Connor B. Wanting to be heard and included: Carers’ experiences of hospitals. Health Issues 2007; 90(Autumn): 15-18.

3. National Health Priority Action Council (NHPAC). National chronic disease strategy. Canberra ACT; Australian Health Ministers’ Advisory Council (AHMAC); 2005.

4. Glazier R, Moineddin R, Agha M et al. The impact of not having a primary care physician among people with chronic conditions. Toronto CAN; Institute for Clinical Evaluative Sciences (ICES); 2008.

5. Jencks S, Williams M and Coleman E. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med 2009; 360(14): 1418-1428.

6. Victorian Department of Human Services, Metropolitan Health and Aged Care Services Division. Improving care – hospital admission risk program (HARP). Melbourne; Victorian Government; 2006.

October 2010  91

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Criterion LA – Awareness sA – ImplementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 1.1.7

The care of dying and deceased consumers / patients is managed with dignity and comfort and family and carers are supported.

a) Policy and procedures for the management of consumer / patient end-of-life care are consistent with jurisdictional legislation, common law and policy.

b) The organisation has access to palliative care and/or to pain management services.

c) There is policy / guidelines for supporting staff, consumers / patients and carers involved in organ and tissue donation.

a) Policy and procedures are implemented throughout the organisation.

b) Relevant staff are educated about the policy and procedures for end-of-life care of a consumer / patient.

c) When clinically indicated, consumers / patients are referred to palliative care, pain management services and/or other support services.

d) A support system is used to assist staff, relatives, carers and patients affected by a death.

a) Processes surrounding dying and death are evaluated and improved as required.

b) Clinical review committees, including morbidity / mortality and case review, evaluate the appropriate referral of end-of-life patients to palliative care and/or to pain management services, and improvements are made as required.

a) Staff are provided with advanced training for end-of-life management of consumers / patients.

and/or

b) End-of-life care and mortality management processes are compared with internal and external systems and improvements are made to ensure better practice.

a) The organisation demonstrates that it is a leader in end-of-life care.

IntentThe intent of this criterion is to ensure that healthcare organisations place a high priority on the care and management of consumers / patients at the end of life, and provide appropriate support services for families / carers.

note:

This criterion will apply to healthcare organisations in varying degrees; however, some organisations will address requirements within another criterion. While a death in facilities such as a day hospital or community health service may occur unexpectedly and be considered a sentinel event, occasionally a consumer / patient will die in such facilities and policy and procedures covering this rare and tragic event are needed. All organisations should also be aware of local end-of-life care options and be able to refer inquiries regarding eventually fatal conditions and end-of-life care to appropriate sources.

Relationships of 1.1.7 with other criteriaThis criterion covers a distinct phase of the consumer / patient care journey (Standard 1.1). In some cases, a transition occurs from striving to combat a disease course according to an original care plan (Criterion 1.1.2) to managing the passage to death with end-of-life or palliative care, although in many cases the two care pathways are delivered in alignment. Such a transition may occur along with a transfer of care (Criterion 1.1.5), such as to home, a hostel or other palliative care facility, where there will also be a transfer of responsibility.

Because death and dying occur within the context of cultural beliefs and traditions, and spiritual and religious values, organisations must provide for consumers / patients with diverse needs and from diverse backgrounds (Criterion 1.6.3).

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Criterion LA – Awareness sA – ImplementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 1.1.7

The care of dying and deceased consumers / patients is managed with dignity and comfort and family and carers are supported.

a) Policy and procedures for the management of consumer / patient end-of-life care are consistent with jurisdictional legislation, common law and policy.

b) The organisation has access to palliative care and/or to pain management services.

c) There is policy / guidelines for supporting staff, consumers / patients and carers involved in organ and tissue donation.

a) Policy and procedures are implemented throughout the organisation.

b) Relevant staff are educated about the policy and procedures for end-of-life care of a consumer / patient.

c) When clinically indicated, consumers / patients are referred to palliative care, pain management services and/or other support services.

d) A support system is used to assist staff, relatives, carers and patients affected by a death.

a) Processes surrounding dying and death are evaluated and improved as required.

b) Clinical review committees, including morbidity / mortality and case review, evaluate the appropriate referral of end-of-life patients to palliative care and/or to pain management services, and improvements are made as required.

a) Staff are provided with advanced training for end-of-life management of consumers / patients.

and/or

b) End-of-life care and mortality management processes are compared with internal and external systems and improvements are made to ensure better practice.

a) The organisation demonstrates that it is a leader in end-of-life care.

End-of-life care Supporting and managing the inevitable processes of dying and death is commonplace in health care. The frequency and nature of this varies widely, both according to the organisation type and the stage of the dying process at which the consumer / patient comes into contact with the organisation.

The end of life is considered that part of life where a person is living with, and impaired by, an eventually fatal condition, even if the prognosis is ambiguous or unknown. An eventually fatal condition is a progressive condition that has no cure and can be reasonably expected to cause the death of a person within a foreseeable future, i.e. a person has an eventually fatal condition if their death in the foreseeable future would not be a surprise. This definition is inclusive of malignant and non-malignant illness and ageing.1 This period can be very brief but may also be quite extended and organisation policy and procedures should incorporate flexibility in responsiveness to this variability. Moreover, sudden or unexpected death can occur in any location without warning, and policy and procedures to manage such an event should be in place in all organisations.

Needs-based end-of-life care is a quality management approach that evaluates the individual holistic needs of the consumer / patient and his or her family / carer, and coordinates appropriate care. It recognises the

interdependent physical, social, emotional, cultural and spiritual aspects of care and includes the combination of broad health and community services that care for a person at the end of their life.1 The goal of end-of-life care is to maximise quality of life through appropriate needs-based care for each person, with a focus on symptom control and comfort rather than cure. Use of a term such as ‘comfort care’ to describe end-of-life care is recommended2, as comfort is a familiar and unambiguous concept in everyday experience.

The end-of-life care pathway should address timely symptom control, support for carers and families, and needs-based referral to specialist palliative care providers, and encompass both likely deterioration as well as the potential for active treatment, i.e. plan for death while remaining hopeful. Palliative care should be integrated with disease-modifying therapy as part of routine care.

Dying consumers / patients are cared for in many settings, including the home, community, hospice facilities, aged care facilities, hospital wards and intensive care units. Sometimes the process will involve moving in and out of facility-based care depending on needs at different stages of the journey. No matter what the setting(s), systems should be in place to support the consistent implementation of end-of-life policies organisation-wide.

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Criterion 1.1.7

The care of dying and deceased consumers / patients is managed with dignity and comfort and family and carers are supported. (continued)

Components of systems for end-of-life care include:

• decision making guidelines

• advance care planning

• recognition of cultural, spiritual and religious factors

• access to cultural, spiritual and religious resources

• referral to chaplaincy, spiritual or pastoral care

• care of the dying

• referrals to palliative care, pain management and/or other services

• conflict resolution3

• legal requirements

• management of recognised risks

• mortality management.

End-of-life care should be delivered according to the Standards for Providing Quality Palliative Care for all Australians4, which address nationally agreed areas to ensure optimal care for those at end of life. These standards are available from Palliative Care Australia at: http://www.palliativecare.org.au/

Legislated obligations vary between jurisdictions and depend on the detail of the law. Healthcare organisations should be familiar with, and ensure that policies and procedures reflect relevant legislation pertaining to:

• consumers / patients’ decision-making capacity and matters relating to these decisions, such as advance care directives

• legal guardianship / responsible person issues regarding children or young people

• substitute decision making and applicability of guardianship / health attorney / Enduring or Medical Power of Attorney / Public Advocate role for consumers / patients who lack decision-making ability

• treatment limitation decisions and the withholding or withdrawal of life-sustaining treatment

• assisted suicide and euthanasia

• brain death and agreements for organ / tissue transplant

• death certification and reporting to the coroner

• reporting of deaths to organ and tissue donation agencies and/or tissue and eye banks to facilitate eye and tissue donation

• responsibility for transfer of a deceased person with no next-of-kin, or where finances are insufficient for a funeral.

Advance care planning is a process of preparing for likely scenarios near the end of life. It includes an assessment of, and dialogue about, a consumer / patient’s understanding of his or her medical history and condition, values, preferences and personal and family / familial resources. Advance care planning supports consumers / patients in communicating their wishes about their end of life. Where possible, organisations should encourage the use of advance care plans.4

An advance care directive is a document that contains instructions that consent to, or refuse, specified medical treatments and that articulate care and lifestyle preferences in anticipating future events or scenarios. It becomes effective in situations where the consumer / patient is no longer able to make decisions. For this reason, advance care directives are sometimes referred to as living wills.5 As an advance care directive has legal status, it is governed by legislative arrangements in each jurisdiction.

All people, regardless of religion, faith or cultural background, may have pastoral and spiritual care needs. In regards to end-of-life care, the organisation should therefore:

• acknowledge the importance of faith and spirituality

• have policy and procedures in place regarding spiritual and pastoral care

• promote and provide access to a range of accredited practitioners in pastoral and spiritual care to meet consumer / patient, family / carers, and staff needs

• provide staff education by a practitioner qualified in pastoral and spiritual care on:

– faith practices, spirituality and spiritual care

– culturally appropriate spiritual care needs in relation to the organisation’s particular culturally and linguistically diverse (CALD) communities

– staff provision of spiritual care regardless of their discipline

– the use of a spiritual care screening tool3, as appropriate

• ensure that spiritual or pastoral care is delivered according to relevant standards.6

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Mortality management refers to care of the family and the deceased after death. Mortality management should include:

• management of the deceased in regard to notification, infection control, property, etc.

• management of the death certification process4

• referral to the coroner when and where appropriate

• consideration of relevant cultural, religious and spiritual issues for the deceased person and his or her family / familial group, particularly if a post-mortem examination is involved

• interaction with the police when appropriate

• consent for post-mortem as appropriate, with particular consideration of cultural, religious and spiritual issues and appropriateness

• consent for organ and tissue donation as appropriate

• interaction with other agencies such as funeral directors

• emphasis on documentation of decisions both before and after death.

To ensure that all consumers / patients with eventually fatal conditions, as well as those who die unexpectedly, and family, carers and friends have access to appropriate and integrated end-of-life care, relevant policies and procedures must be embedded throughout, consistently applied and monitored across the organisation.

Prompt points

¼ What end-of-life policy and procedures are in place?

¼ What are the relevant legislation or common law obligations and does policy reflect this?

¼ How does the organisation’s philosophy, values, culture, structure and environment contribute to the provision of competent and compassionate end-of-life care?

¼ How is advance care planning and decision making undertaken? How are such decisions documented?

¼ How is faith support and spiritual or pastoral care delivered?

¼ How does the organisation measure implementation across the organisation?

¼ What reflective practices are in place and how do they contribute to continuous improvement of end-of-life care?

Access and appropriate referral The end-of-life needs of many are provided along a continuum of care. Quality care at the end of life is provided by a range of carers, professional and otherwise – from community or family members with primary or generalist care providers, to specialist palliative care providers, based on the individual’s needs and choices.1 Care needs can be appropriately met by primary care (generalist, and other specialist and support care) providers, with specialist palliative care providers contributing direct or indirect care, or consultation advice, as required. This approach recognises that consumers / patients with more complex needs may require periodic or ongoing direct care from specialist palliative care providers and that care delivery needs to be as individual and flexible as the end-of-life journey.1

Pain management, psychosocial support, carer support and home care services also address the needs of consumers / patients with a wide range of eventually fatal conditions, or those of their families. It is crucial that the organisation has strong referral relationships with such services, either within the organisation or in the broader service system, to ensure good continuum of care as the consumer / patient journeys along the end-of-life pathway.

Prompt points

¼ What pain management, palliative care, grief support and other services does the organisation provide, or have good referral relationships with?

¼ What protocols are in place to guide clinicians regarding assessment and referral for such services?

¼ How does the organisation measure and evaluate the appropriateness and timing of referrals to specialist palliative care, pain management, chaplaincy, psychological and other support services?

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Criterion 1.1.7

The care of dying and deceased consumers / patients is managed with dignity and comfort and family and carers are supported. (continued)

Staff educationMany staff participate in the care of dying or deceased consumers / patients, including clinicians, technicians, chaplains, ward assistants, porters, mortuary attendants and other relevant staff. Volunteers can also play a role. The organisation should provide education and support to ensure that staff and volunteers are appropriately qualified for the level of service offered, and also demonstrate ongoing participation in continuing professional development.4

Education should be tailored to the specific groups, and cover areas such as:

• the philosophy, values, culture, structure and environment for the provision of competent and compassionate end-of-life care4

• relevant policies and procedures, including for organ donation

• communication skills

• symptom control and effective pain management

• use of technology in end-of-life care

• skills to competently begin and guide discussions around end of life and facilitate consumers / patients’ decision making

• advance care planning

• navigating ethical issues such as ongoing use of technology to sustain life and tissue or organ donation

• organ and tissue retrieval following death

• mortality management

• addressing spiritual care needs.

Additionally, in healthcare organisations where organ or tissue donation and retrieval may occur, organisations are responsible for the appointment, training and retention of suitably experienced staff to fulfil the governance role of the organ and tissue donation Designated Officer. The Designated Officer has responsibility for reviewing the entire process and ensuring that it occurs in accordance with organisational policy / protocol, relevant professional bodies’ standards and the law.

Prompt points

¼ What orientation and education is in place for various staff and volunteer groups regarding end-of-life care?

¼ How does the organisation ensure that all relevant staff receive appropriate education and participate in ongoing professional development?

¼ How are relevant volunteers educated regarding their role in end-of-life care?

¼ How are clinicians encouraged and supported to initiate, discuss and document end-of-life care issues and decision making with consumers / patients?

¼ What organ and tissue donation education program is in place?

Organ and tissue donationLegal requirements for many aspects of organ and tissue donation vary between jurisdictions. As a result, legislation and regulation of Australia’s organ donation and transplantation sector, covering a broad range of activities and procedures including consent for organ donation, differs across the country. Clinicians are required to act within the legislation of the jurisdiction in which they practise.7

Organisational policy should cover areas such as2, 7:

• roles, authority, appointment processes and ongoing education of Designated Officer, Donor Coordinator and other staff

• staff education and support

• process of recognising the possibility of organ and/or tissue donation

• identification of potential donors using the Clinical Trigger Tool and GIVE Protocol2, or similar

• recognition of prior expressions by potential donors on donor registries or otherwise

• discussing option of organ and/or tissue donation with families

• liaison with donor coordinators

• confidentiality

• determination and certification of brain death according to relevant jurisdictional legislation

October 2010  97

• donation after cardiac death

• medical management of the potential donor

• retrieval surgery

• donor family support

• ethical and professional standards

• staff support

• donor / recipient correspondence

• donor family follow-up.

In circumstances where a consumer / patient wishes to donate their whole body or specific organs for scientific research or teaching purposes, arrangements can be made with various organ and tissue donation agencies or body bequest programs that exist across the jurisdictions. In respect of living donor transplantation, national protocols have been developed by the Transplantation Society of Australia and New Zealand and more recently for the Australian Paired Kidney exchange (AKX) program by the Australian Organ and Tissue Donation and Transplantation Authority. Organisations are directed to the Donatelife™ website at http://www.donatelife.gov.au for these and other resources.

Prompt points

¼ What policy is in place regarding organ and/or tissue donation?

¼ Is the organisation eligible to implement the Clinical Trigger Tool and GIVE Protocol? Is it being utilised effectively?

¼ How are the Designated Officer, Donor Coordinator, and hospital-based medical and nursing DonateLife™ positions allocated and supported?

¼ How are organ and/or tissue donor activities evaluated?

Bereavement supportThe process of dying can involve a wide range of losses that includes, but is not limited to, bereavement.

Comprehensive spiritual care during end of life and bereavement can moderate the impact of psychosocial stress on physical and mental health.8

This care may include:

• assessment of religious and/or spiritual needs

• identification of formal and informal support systems

• bereavement support strategies, such as:

– access to social work, spiritual or pastoral care support

– bereavement information packs that includes Palliative Care Australia resources

– in the case of the death of a child, the use of memento books, photos, clothing, blankets, etc., and facilitating preferred contact with the deceased

– bereavement follow-up program including memorial services.

Staff in all roles can be affected by death and should be encouraged to access bereavement support as necessary. In addition to universal bereavement experiences, healthcare staff can also experience a wide range of feelings, such as:

• seeing death as a medical failure

• feeling there is no medical role in dying and undervaluing palliative care skills

• feeling that the role of the clinician ends when care shifts from curative to palliative

• believing there is always more biotechnology to prolong life

• feeling anxiety about one’s own mortality.

Access to debriefing sessions following a death, as well as self care, bereavement counselling and access to cultural, religious and spiritual staff support systems can provide opportunities for experiences such as these to be explored, normalised and put into perspective.

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Criterion 1.1.7

The care of dying and deceased consumers / patients is managed with dignity and comfort and family and carers are supported. (continued)

Prompt points

¼ What bereavement support system is in place?

¼ How are consumers / patients and their families encouraged to access bereavement support?

¼ How is death and dying normalised within the culture of the organisation?

¼ How are staff and volunteers encouraged to access bereavement support?

¼ How is the system evaluated and improved?

Evidence commonly presented

Consider whether the following will help to address criterion 1.1.7:

¼ Documented policies, including

– staff education policies and evidence of education in relevant areas, e.g. end-of-life care, pain management, advance care planning, mortality management, organ and tissue donation, etc.

– when and how end-of-life issues and decision making is raised with consumers / patients, their carers and staff

– decision making and documentation guidelines

– cultural, religious and pastoral / spiritual care guidelines

– organ donation, including profile, triggers, processes and outcomes

¼ Evidence of mechanisms to deal with family / familial issues

¼ Evidence of compliance with legislative requirements

¼ Health record review for advance care plans, documented decisions and their outcomes

¼ Evidence of care provision by, or referral to, specialist palliative care, pain management and other services, including evidence of staff education in end-of-life management

¼ Evidence of access to and uptake of bereavement support systems

¼ Evidence of organ and tissue donations undertaken according to national guidelines.

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Performance measuresThis criterion states that: “The care of dying and deceased consumers / patients is managed with dignity and comfort and family and carers are supported”. The organisation should be able to demonstrate that it has policy and processes in place to facilitate end-of-life care, including support services for consumers / patients and their family / carers, so that this part of the care journey is managed with dignity and comfort.

Some common suggested performance measures are as follows:

Number of staff and volunteers who receive orientation and education regarding end-of-life care

Total number of staff and volunteers

Number of consumers / patients who have an advance care plan

Total number of consumers / patients with an eventually fatal condition

Number of relevant consumer / patient health records with end-of-life decisions documented

Total number of relevant health records reviewed

Number of consumers / patients who have a palliative care plan

Total number of consumers / patients receiving palliative care

Number of relevant consumer / patient health records with a numeric pain score documented on admission

Total number of relevant health records reviewed

Number of relevant consumer / patient health records with a numeric pain score documented every X days

Total number of relevant health records reviewed

Comment: organisation to define ‘X’

Number of referrals to pain management, palliative care, grief support and other related services

Total number of consumers / patients receiving end-of-life care

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Criterion 1.1.7

The care of dying and deceased consumers / patients is managed with dignity and comfort and family and carers are supported. (continued)

Number of staff who were associated with the care of a dying consumer / patient and attended a debriefing session

Total number of staff associated with the care of a dying consumer / patient

Number of deaths that were appropriately referred to the coroner as required by legislation

Total number of deaths

Number of occasions when the Clinical Trigger Tool and GIVE protocol were implemented

Total number of consumers / patients eligible to become organ donors

Number of organ or tissue retrievals and donations undertaken according to national guidelines

Total number of organ or tissue retrievals and donations

Number of relatives / carers satisfied with end-of-life care

Total number of relatives / carers surveyed

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References1. Palliative Care Australia (PCA). Palliative care –

Glossary of terms. Melbourne VIC; PCA; 2008.

2. Australian and New Zealand Intensive Care Society (ANZICS). The ANZICS statement on death and organ donation. Edn 3.1. Melbourne VIC; ANZICS; 2008 (updated 2010).

3. Carey L and Rumbold B. Pastoral care research projects in palliative care settings. Spiritual Care Australia Conference. Melbourne VIC; Australian Health and Welfare Chaplains Association (AHWCA). Accessed from http://www.spiritualcareaustralia.org.au/website/conference10.html on 20 June 2010.

4. Palliative Care Australia (PCA). Standards for providing quality palliative care for all Australians. Canberra ACT; PCA; 2005.

5. NSW Health. Guideline: Using advance care directives. Sydney; NSW Health; 2005.

6. Australian Health and Welfare Chaplains Association (AHWCA). Health care chaplaincy guidelines. Melbourne VIC; AHWCA; 2004.

7. National Health and Medical Research Council (NHMRC). Organ and tissue donation after death, for transplatation: Guidelines for ethical practice for health professionals. Canberra ACT; Australian Government; 2007.

8. McWilliam L. Spiritual interventions in bereavement supports: Theory strategies and a case study. Spiritual Care Australia Conference. Melbourne VIC; Australian Health and Welfare Chaplains Association (AHWCA); 2010.

Further reading Palliative Care Australia. Winter issue theme: Pain management. EoL – Towards quality care at the end of life 2009; 1(1).

Palliative Care Australia. Spring issue theme: Equity. EoL – Towards quality care at the end of life 2009; 1(2).

Palliative Care Australia. Winter issue theme: Health system reform and care at the end of life. EoL – Towards quality care at the end of life 2010; 2(1).

La Trobe University. Respecting patient choices – Advance care planning e-learning course. Bendigo VIC; La Trobe University. Accessed on 6 September 2010.

Palliative Care WA. Consent: Living wills in WA. Perth WA; Palliative Care WA. Accessed from http://www.palliativecarewa.asn.au/consent.php on 6 September 2010.

Central Coast Division of General Practice. Advance Care Planning. Gosford/Wyong; CCDGP. Accessed from http://www.ccdgp.com.au/site/index.cfm?display=23902 on 6 September 2010.

Spiritual Care Australia. Welcome to Spiritual Care Australia. Melbourne VIC. Accessed from http://www.spiritualcareaustralia.org.au/website/home.html on 18 June 2010.

Healthcare Chaplaincy Council of Victoria (HCCVI). Welcome. Melbourne VIC; HCCVI. Accessed from http://www.hccvi.org.au/about.html on 6 September 2010.

ICD-10-AM Pastoral Care Intervention codes:

• 96186-00

• 96187-00

• 96087-00

• 6109-01

• 95550-12

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Criterion LA – Awareness sA – ImplementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 1.1.8

The health record ensures comprehensive and accurate information is collaboratively gathered, recorded and used in care delivery.

this is a mandatory criterion

a) Every consumer / patient has a health record with a unique identifier.

b) Health record documentation policy and procedures are available for staff and meet relevant professional and jurisdictional guidelines.

c) Healthcare providers are aware of the organisation’s systems for healthcare record creation and management.

d) Authorised internal and external healthcare providers have access to information about the consumer / patient in accordance with jurisdictional privacy legislation.

e) Consumers / patients are given advice / written guidelines on how to access their health records.

a) Healthcare providers use the health record to document and communicate all aspects of care delivery in accordance with the organisation’s policy / guidelines.

b) Systems are implemented to monitor the legibility of the health record.

c) Results of reviews and clinical consultations are made available to healthcare providers.

a) Health records are evaluated to ensure they meet medico-legal requirements, professional documentation standards and jurisdictional health department guidelines.

b) Health records are evaluated to ensure that the clinical content supports high quality care and improvements are made as required.

c) Evaluation of legibility of the health record is addressed through the use of audits, and improvements are made as required.

d) Timeliness of inclusion of reports and information from reviews, tests and other clinical investigations into the health record is evaluated and improved, as required.

a) The health record documentation system is compared with internal and external systems and improvements are made to ensure better practice.

and/or

b) Results of monitoring of documentation are trended, and demonstrate that documentation continuously meets all requirements of external standards and guidelines.

a) The organisation demonstrates it is a leader in health record documentation.

IntentThis criterion focuses on the collaborative gathering and recording of information that provides the content of individual health records, and how a consumer / patient’s record facilitates the delivery of care. Complete, accurate health records are fundamental to the provision of safe, high quality care. The intent of this criterion is to ensure that consumer / patient health records are comprehensive and efficiently maintained, and that consumer / patient confidentiality is protected.

Relationships of 1.1.8 with other criteriaThis criterion addresses the gathering and entry of information into the health record, and how that information is used in the delivery of care. This process will be facilitated by records management systems that meet the needs of both the consumer / patient and the organisation (Criterion 2.3.1), and which in turn are supported by the organisation’s processes for data collection and storage (Criterion 2.3.3) via its integrated approach to information and communication technology (Criterion 2.3.4).

The health record should accurately reflect the consumer / patient’s journey through the care delivery process (Standard 1.1), and ensure the provision of safe care and services (Standard 1.5). The entry of data into the health record is a vital aspect of effective and coordinated ongoing care (Criterion 1.1.6) and of the process(es) of clinical handover (Criterion 1.1.5), including the exchange of information between referrers and providers by which continuity of care is maintained (Criterion 1.2.2). Correctly managed health records should allow meaningful evaluation of the outcomes of clinical care (Criterion 1.1.4).

The information in the health record should assist the organisation in meeting its responsibility towards those with diverse needs and from diverse backgrounds (Criterion 1.6.3). The consumer / patient has a right to access his or her own health record, and to expect that privacy and confidentiality will be maintained (Criterion 1.6.2). Failure of the organisation to respect these rights may lead to complaints (Criterion 2.1.4).

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Criterion LA – Awareness sA – ImplementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 1.1.8

The health record ensures comprehensive and accurate information is collaboratively gathered, recorded and used in care delivery.

this is a mandatory criterion

a) Every consumer / patient has a health record with a unique identifier.

b) Health record documentation policy and procedures are available for staff and meet relevant professional and jurisdictional guidelines.

c) Healthcare providers are aware of the organisation’s systems for healthcare record creation and management.

d) Authorised internal and external healthcare providers have access to information about the consumer / patient in accordance with jurisdictional privacy legislation.

e) Consumers / patients are given advice / written guidelines on how to access their health records.

a) Healthcare providers use the health record to document and communicate all aspects of care delivery in accordance with the organisation’s policy / guidelines.

b) Systems are implemented to monitor the legibility of the health record.

c) Results of reviews and clinical consultations are made available to healthcare providers.

a) Health records are evaluated to ensure they meet medico-legal requirements, professional documentation standards and jurisdictional health department guidelines.

b) Health records are evaluated to ensure that the clinical content supports high quality care and improvements are made as required.

c) Evaluation of legibility of the health record is addressed through the use of audits, and improvements are made as required.

d) Timeliness of inclusion of reports and information from reviews, tests and other clinical investigations into the health record is evaluated and improved, as required.

a) The health record documentation system is compared with internal and external systems and improvements are made to ensure better practice.

and/or

b) Results of monitoring of documentation are trended, and demonstrate that documentation continuously meets all requirements of external standards and guidelines.

a) The organisation demonstrates it is a leader in health record documentation.

The role of the health record Having a single health record for every consumer / patient is vital to continuity of care. The health record should outline all identified needs of consumers / patients, and the care / management received.

Regardless of whether a record is electronic or paper-based, the location and if possible the appearance of inserts / data attachments should be consistent and predictable within each record.

At the end of an episode of care, the record should be retained in accordance with legislative requirements; the health record will serve as a historical record and should guide ongoing and future care.1 A discharge summary that outlines the episode of care should be prepared and sent to those organisations / clinicians who will continue the consumer / patient’s care in the community. The health record may be used by coders and statisticians to produce data for calculating the incidence of diseases, adoption of different treatment protocols, and for quality control and planning.2 The information in the record may also be utilised by clinicians, administrators and researchers; access and use should always be managed according to jurisdictional law, policy and the organisation’s processes.

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Criterion 1.1.8

The health record ensures comprehensive and accurate information is collaboratively gathered, recorded and used in care delivery. (continued)

The health record is primarily a medico-legal and communication document, which records those events and decisions required by healthcare providers to manage consumer / patient care both contemporaneously and in time sequence. It may provide evidence in lawsuits, hearings or inquests.2 The health record can protect the legal interests of the organisation and the clinician, or it can become a legal risk.3 The health record is the backbone of evidence for almost every medical professional liability action; it will be used to reconstruct the episode of care.4 It can also be used as evidence in other types of legal proceedings, royal commissions and formal inquiries.

Prompt points

¼ How does the design of the health record facilitate the recording and communicating of key aspects of care delivered within a ward or department? For what structured documents are standardised templates available and used (e.g. discharge summaries, pathology reporting, radiology reporting, specialist referrals)?

¼ Are healthcare providers completing the records to ensure that events and decisions required to manage care are appropriately documented?

Record creation and management A consumer / patient attending a healthcare facility for the first time will require a health record to be created. Various management strategies may be used to ensure consistency and completeness of records and should include:

• training of staff who open / create new records

• computer prompts or reminder cards

• limiting access to ensure only designated staff will open / create new records.

The structure of health records will vary according to the specific needs of different organisations.

Because record keeping is fundamental to the delivery of quality care, new staff should be made aware during orientation of organisational policies and systems relating to records5, and how those records are created. Staff should understand their responsibilities for complete and accurate records and the need for confidentiality of consumer / patient information.6

In private hospitals, the responsibilities of visiting medical officers for health records should be outlined in the organisation’s by-laws. In addition, orientation should provide sufficient information to agency staff about the organisation’s requirements for health records.

Within teaching hospitals, junior medical officers are often key in clinical record keeping. Transient personnel such as junior medical officers and contract / agency staff may spend only brief periods in individual wards and often have demanding workloads.7 For this reason, it is important that their experience is reviewed during orientation to a new department and that they receive some oversight and instruction in the organisation’s requirements for health record creation and management, before they become caught up in the immediate demands of their roles.

Whatever system is used to capture the information, the consumer / patient health record should unite relevant information so that it can be accessed by individual clinicians as needed. Given the recognised challenges of paper-based record systems, transition to an electronic system should be considered by all organisations. Using standard forms and formats for all health records throughout the organisation is a key preliminary step.

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Prompt points

¼ How does the organisation ensure that healthcare providers are aware of the systems for health record creation and management?

¼ What systems and processes ensure that any proposed new forms or documents that will be integrated into the record are consistent with existing forms, and do not unnecessarily duplicate their content?

¼ How does the organisation instruct its clinical and administrative staff in their responsibilities for documentation? How is their learning assessed both immediately and throughout their on-the-job performance? How is the education and its content assessed?

¼ How are the risks associated with record keeping and communication by transient and/or junior clinical staff managed by the organisation?

Unique identifier Health records belonging to a single consumer / patient or single episode of care should be linked by a unique identifier.

The creation of unique identifiers for individual consumers / patients, individual healthcare professionals, and individual organisations is a foundation platform in the development of a national electronic health record system.

Systems established by organisations should ensure that any reports and/or results of investigations from other organisations or departments are integrated into each consumer / patient’s record through links and cross-referencing to avoid misplacement, facilitate understanding by multiple parties, and ensure the retention of, and access to, a complete record.

Prompt points

¼ How are individuals identified within the records system? When an individual first presents, what checks ensure that he or she does not have a pre-existing health record?

¼ Does every consumer / patient have their own health record? Do duplicate records ever creep into the system? What processes are used to detect and correct duplications within the record system?

¼ Does the organisation assign individual consumers / patients or episodes of care with a unique key in its health records system? How is the allocation of these unique key numbers coordinated across the organisation?

Policies and proceduresDespite the availability of many guidelines on the importance of health record documentation, poor documentation continues to be a major factor in medical indemnity claims and adverse events.

Australian standards do not cover the specific content of health records due to the diversity of organisations functioning in the health sector. Organisations should consider the needs of their consumers / patients, healthcare providers and the organisation itself when developing policies in relation to content of the record. All staff should have access to the policy, and the location of the policy should be advised during orientation.

Policy / by-laws and procedures should address the organisation’s requirements for standard forms to be incorporated into the health record as needed, for example, a form that identifies Aboriginal and Torres Strait Islander consumers / patients, or the ‘Anaesthesia Event Report’ form developed by the Australian Society of Anaesthetists. Whatever standard forms are used within an organisation, it is important that all users of the health record know what is to be used, where the forms can be obtained and the information that should be recorded.

There should be regular evaluation of the organisation’s health records, to ensure that they meet all jurisdictional and medico-legal requirements.

Further information about health records can be found in Australian standards8-10 and health department policies and guidelines, and be obtained from various professional colleges, and medical defence organisations.

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Criterion 1.1.8

The health record ensures comprehensive and accurate information is collaboratively gathered, recorded and used in care delivery. (continued)

Prompt points

¼ Are the documentation policies and procedures used by the organisation referenced to legislation, Australian standards and/or professional codes / guidelines? How frequently are they reviewed and updated? When was the last review of health records policy undertaken?

¼ How do clinical and administrative staff members with health record responsibilities access policies or other guidance documents?

Legibility Illegible handwriting impacts on the standard of treatment provided and can lead to errors.7 Alterations to handwritten notes without attribution are illegal and can be confusing. In the event of an adverse outcome, they may also be a cause for suspicion and accusations of ‘cover-up’.

Entries to paper health records should be made in blue or black indelible ink. Entries should be dated and initialled, and always include time of action. They should be made without erasure; where changes are needed, a strikethrough should be used and the changes initialled.8, 11 Handwriting must be legible, not only to the author, but to other users of the record.

Legibility can also be problematic with some communications technologies. Administrators should check incoming faxes and proactively request that poor quality or incomplete faxed materials be re-sent; this is the reason for using clearly typed coversheets that include total page numbers on all faxed documents. In addition, scanned items should be checked for legibility prior to assignment to a consumer / patient health record. When paper-based records are electronically scanned, the resolution must be adequate to ensure legibility of the scanned materials.

Prompt points

¼ What types of audits of health record entries and their legibility are undertaken? Is the review managed by a person with knowledge of clinical care, its conventions and risks? When problems have been identified, how is the information communicated to relevant staff and what actions are undertaken to reduce the associated risks?

¼ If scanning is used in the organisation, does the review include checks on the legibility of print documents scanned into electronic record systems?

Access to records and information by healthcare providers; confidentiality and privacyWherever possible, there should be capability for healthcare providers to access all components of a health record, where there is a clinical need, both during and outside office hours. Similarly, in priority situations, health professionals at other sites should be able to consult a clinician who can source information about a discharged or transferred consumer / patient.7, 12

Access to diagnostic images is an essential part of care delivery. Where digital systems are used, clinical staff should be trained in accessing and retrieving images from current and archival systems to ensure that after-hours care is not compromised.

Release of information for ongoing care is often specified as part of the consent for a procedure, however in some circumstances organisations may request signed consent from the consumer / patient before transferring the record.13

Organisations should have access to privacy legislation, policies and guidelines related to their service. Current information is available from: http://www.privacy.gov.au/health/index.html Information provided includes:

• national privacy legislation

• consumer information “My Health My Privacy My Choice”

• information sheet on the Privacy Act

• guidelines on health privacy

• guidelines on research privacy

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... and http://www.privacy.gov.au/privacy_rights/laws/index.html provides links to:

• privacy legislation in all States / Territories

• international human rights instruments.

There should be a process to incorporate and monitor compliance with legislation and guidelines and this should be evident.

Prompt points

¼ How does the organisation facilitate access to all components of the record in a timely manner? How is record access ensured after hours?

¼ How are healthcare providers who are new to a ward or organisation oriented to ensure that they can access all aspects of an existing consumer / patient’s health record?

¼ How does the organisation and/or its different departments manage the competing demands for access to records and personal privacy / confidentiality?

Consumer access to personal health recordsThe National Privacy Principles state that: “An organisation must set out in a document clearly expressed policies on its management of personal information. The organisation must make the document available to anyone who asks for it”. National Privacy Principle Six (6) describes the rights that consumers / patients have in gaining access to their own health records. The overarching statement is: “If an organisation holds personal information about an individual, it must provide the individual with access to the information on request by the individual”.

The organisation should have processes in place by which the consumer / patient can gain access to his or her own health record, and this information should be proactively provided to the individual prior to or upon admission. This aspect of consumer / patient rights is discussed in more detail within criterion 1.6.2.

Prompt points

¼ How does the organisation ensure that it meets the intent of the National Privacy Principles?

¼ How is this commitment communicated to consumers / patients?

Monitoring health record qualityAudits or other monitoring should be undertaken to ensure that policies relating to health records are actioned. Health record audits can also be used to support total quality management and risk management activities. Health record review teams should be multidisciplinary wherever possible.11 Outcomes of audits and proposed solutions to any identified problems should be fed back to staff.

A health record audit of the standard of documentation can commence with a basic chart audit to determine whether the entries are:

• legible

• in black or blue pen

• corrected as per organisation policy

• dated, timed and signed, with the enterer’s name and professional designation printed in block letters after the entry; a pager number or other contact is also desirable

... and that:

• only approved abbreviations are used

• any student entries are countersigned.

Audits of timeliness of responses to referrals, and evidence that the advice has been documented and noted need to be undertaken and improvements made if necessary. This will require auditing of a variety of referral sources over a period of time and careful examination of records to check for inappropriate delays. ‘Timeliness’ should be interpreted according to the timelines for procedures within the organisation / department and focus upon consumer / patient and clinician need, not administrative convenience.

Where any deficiencies in health record quality or accuracy are identified by audit, an action plan should be developed, and all improvements documented. Wolff and Taylor’s book Enhancing patient care provides a good discussion on the uses and limitations of health record review in the management of adverse events.14

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Criterion 1.1.8

The health record ensures comprehensive and accurate information is collaboratively gathered, recorded and used in care delivery. (continued)

Examples of checklists for monitoring health record quality can be found online and adapted for specific organisational needs: http://www.omic.com/resources/risk_man/forms/medical_office/MedicalRecordAudit.rtf

Prompt points

¼ What systems are used in your organisation to monitor health record quality?

¼ How frequently are formal audits undertaken? How are the results disseminated to the relevant staff?

¼ What checks of the relevance and completeness of the record are included in the review process?

Evidence commonly presented

Consider whether the following will help to address criterion 1.1.8

¼ Content of health records – cross-references to other records or evidence of flags or hyperlinks to indicate another record in another format may help to demonstrate techniques to facilitate professional access

¼ Results of health record audits; any communications to staff or training materials developed to respond to audit findings

¼ Techniques / systems used to ensure a unique identifier on each record and avoid duplication when it is assigned

¼ Policies and procedures, including techniques or additional materials used to respond to specific organisational or department requirements

¼ Standardised forms and templates

¼ Instructional materials, such as lists of approved abbreviations or ‘how to’ guidance to staff

¼ Orientation, training or review programs that ensure new or contract staff adopt correct and consistent systems and processes in unfamiliar clinical settings

¼ Reviews to eliminate any duplication of records for individual consumers / patients

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Performance measurementThis criterion states that: “The health record ensures comprehensive and accurate information is collaboratively gathered, recorded and used in care delivery”. The accuracy of the health record and the timeliness of data entry are fundamental to safe, high quality care. The organisation should be able to demonstrate that its processes ensure accurate and timely entry of data into the health record.

Some common suggested performance measures are as follows:

Number of health records where care plans are not documented

Total number of health records audited

Number of health records where illegible writing resulted in an adverse event

Total number of health records audited

Comment: for instance, the medication dose and time when it was last given to the consumer / patient were noted in the health record in a way that staff who needed to know these details were unable to read them

Number of health records containing illegible faxes / scans / photocopies / images

Total number of health records audited

Number of requests from coders to clinicians to clarify ‘content’ issues

Total number of requests from coders to clinicians

Comment: ‘content issue’ could be primary and secondary diagnosis

Number of health records audited for clinical content that are compliant with organisational policy

Total number of health records audited

Number of health records with all entries dated, signed and designation of person recorded

Total number of health records audited

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Criterion 1.1.8

The health record ensures comprehensive and accurate information is collaboratively gathered, recorded and used in care delivery. (continued)

References1. Medical Practitioners’ Board of Victoria. Medico-

legal guidelines: protecting patients, guiding doctors. Melbourne; Victoria Medical Practitioners’ Board; 2006.

2. NSW Health. Medical records in hospitals and community care centres. Policy Directive PD2005_004. Sydney; NSW Health; 2005.

3. Nurses and Midwives Board of WA. Management of consumer information and documentation guidelines. Perth WA; NMBWA; 2009.

4. McWay DC. Legal aspects of health information management. 2nd edn. New York USA; Thomson Delmar Learning; 2003.

5. Institute for Safe Medication Practices (ISMP). ISMP’s list of error-prone abbreviations. Horsham USA; ISMP; 2007.

6. Government of South Australia and South Australia Health. A guide to maintaining confidentiality in the public health system. Adelaide; SA Health; 2006.

7. Garling P, SC. Final report of the special commission of inquiry: Acute care services in NSW public hospitals. Sydney; NSW Special Commission of Inquiry; 2008.

8. AS 2828:1999 Paper-based health care records.

9. AS ISO 15489.1:2002 Records management: General.

10. AS ISO 15489.2:2002 Records management: Guidelines.

11. Abdelhak M, Grostick S, Hanken MA and Jacobs E. Health information: Management of a strategic resource. Second edn. Philadelphia USA; Saunders; 2001.

12. Australian Medical Association (AMA). Position Statement: access to medical records by doctors who are not treating the patients concerned. Canberra ACT; AMA; 2002.

13. Australian Medical Association (AMA). Transfer of medical records between treating doctors. Canberra; AMA; 1998 (revised 2002).

14. Wolff AM and Taylor SA. Enhancing patient care: A practical guide to improving quality and safety in hospitals. Sydney NSW; MJA books; 2009.

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1.2 Access Standard

The standard is: Consumers / patients / communities have access to health services and care appropriate to their needs.

The intent of the Access standard and criteria is to ensure that communities and consumers / patients have access to necessary health care and services. Health services should ensure that the community has information on available health services and that access is determined by the clinical needs of consumers / patients.

There are two criteria in this standard. They are:

1.2.1 The community has information on health services appropriate to its needs.

1.2.2 Access and admission / entry to the system of care is prioritised according to healthcare needs.

Access is one of the fundamental dimensions of quality in health care.1 There will be different issues about access depending on the service (acute or community) and the sector (public or private). Each organisation should interpret the criteria relevant to their sector and service.

1. Australian Commission on Safety and Quality in Health Care (ACSQHC). Windows into Safety and Quality in Health Care 2008. Sydney NSW; ACSQHC; 2008.

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Criterion LA – Awareness sA – ImplementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 1.2.1

The community has information on health services appropriate to its needs.

a) Information is gathered to define the needs of the community.

b) Information on the organisation’s healthcare services is available to the community.

c) Relevant external service providers are provided with information on the health service and are informed of referral and entry processes.

a) Consumers / patients have information about the specific service they are using.

b) Healthcare providers within the organisation have information on relevant external services.

c) There is collaboration between the organisation, consumers / patients and where required, external service providers.

a) The organisation reviews and evaluates content and processes for dissemination of information on services, and makes improvements as required.

b) Collaboration between the organisation, consumers / patients, carers and external service providers is evaluated, and improvements are made as required.

a) The organisation works with its community and key stakeholders to implement innovative methods for information provision and distribution.

and/or

b) The organisation compares content and processes for dissemination of information on services with external systems and processes, and improvements are made to ensure better practice.

and/or

c) The organisation undertakes research into information systems and processes, and acts on the results.

a) The organisation demonstrates it is a leader in providing information on health services appropriate to the community’s needs.

IntentThe intent of this criterion is to ensure that organisations provide information on their services appropriate to the needs of the community they serve.

Relationships of 1.2.1 with other criteriaHealthcare organisations should provide relevant information for consumers / patients, their carers and members of the general public about the organisation and its services, including clear information for consumers / patients about the treatment and care they may receive. Information should also be provided to health professionals who are involved in ongoing (Criterion 1.1.6) or transfer of care (Criterion 1.1.5), or who may refer consumers / patients to the service (Criterion 1.2.2).

Information content should be provided with consideration for consumers / patients with diverse needs and from diverse backgrounds (Criterion 1.6.3), and in addition to services provided, should address issues such as access to health care and admission processes (Criterion 1.2.2), consent processes (Criterion 1.1.3) and consumer / patient rights and responsibilities (Criterion 1.6.2).

Defining community needsThe community that the organisation serves may be defined in two ways. Public healthcare organisations have a responsibility for providing health services to a general community, usually defined geographically. A private healthcare organisation’s community, however, is those consumers / patients who are referred to the health service, by whatever means, for care. Most private health services do not have a responsibility for satisfying the needs of a geographic community; their community is usually defined by their referrers. Private organisations may be assisted in understanding the diverse needs and backgrounds of their community by contacting their referrers for this information.

Defining its community often poses a challenge for a day procedure centre, whose consumers / patients may be both local to the organisation and referred from much greater distances; or, for some specialised services, even from overseas. The organisation should consider both its geographical area and its referral base when defining its community.

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Criterion LA – Awareness sA – ImplementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 1.2.1

The community has information on health services appropriate to its needs.

a) Information is gathered to define the needs of the community.

b) Information on the organisation’s healthcare services is available to the community.

c) Relevant external service providers are provided with information on the health service and are informed of referral and entry processes.

a) Consumers / patients have information about the specific service they are using.

b) Healthcare providers within the organisation have information on relevant external services.

c) There is collaboration between the organisation, consumers / patients and where required, external service providers.

a) The organisation reviews and evaluates content and processes for dissemination of information on services, and makes improvements as required.

b) Collaboration between the organisation, consumers / patients, carers and external service providers is evaluated, and improvements are made as required.

a) The organisation works with its community and key stakeholders to implement innovative methods for information provision and distribution.

and/or

b) The organisation compares content and processes for dissemination of information on services with external systems and processes, and improvements are made to ensure better practice.

and/or

c) The organisation undertakes research into information systems and processes, and acts on the results.

a) The organisation demonstrates it is a leader in providing information on health services appropriate to the community’s needs.

It is important that an organisation defines its community and/or the usual accessors of its services, in order to understand the cultural influences or specific requirements within that community. Demographic data derived through the census and available from the Australian Bureau of Statistics can assist in understanding a geographic community, and assessing its needs.

Following definition of its ‘community’, an organisation will be better equipped to determine the range of services to be provided, and the information that consumers / patients and the community will need in order to access those services. It will then be able to address any special needs of consumers / patients, for example, making kosher and halal meals available, or providing a designated play area for children.

The community and the role that the organisation has within it are usually defined in the organisation’s strategic and/or operational plans. The organisation’s definition of its community may depend on the type of services it provides. For example, if the organisation is a community centre, its community may be young families within the area. If, however, the organisation is a private hospital that specialises in ophthalmic surgery, then its community will be consumers / patients who are referred to the organisation by (probably) ophthalmic surgeons, as well as the ophthalmic surgeons themselves. Day procedure centres / private organisations should include their referring general practitioners (GP), specialist physicians and surgeons as part of their community.

Prompt points

¼ How has the organisation defined its community? Who did the organisation contact to do this?

¼ How are the needs of the community addressed?

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Criterion 1.2.1

The community has information on health services appropriate to its needs. (continued)

Providing information about healthcare services The Australian Charter of Healthcare Rights, adopted by the Australian Health Ministers in 2008, summarises seven basic rights that consumers / patients are entitled to receive when accessing healthcare services.

These rights cover:

• access

• safety

• respect

• communication

• participation

• privacy

• comment.

The fourth right of consumers / patients accessing the Australian healthcare system is for appropriate communication. Organisations must provide enough information, and in the appropriate formats, to address the right of consumers / patients to be informed about services, treatments, options and costs in a clear and open way.1

Information on health services may be provided in many different formats; the most appropriate formats will depend on the message and for whom it is intended. Information about services may rely on:

• directories or lists of organisational and community-based services

• brochures and handouts

• websites

• news media (including items resulting from press releases) and documentaries

• paid advertising

• signage

• other forms of telecommunication, such as DVDs, online video files, phone text reminders, etc.

The information that organisations are required to provide to their community includes:

• services available within the organisation, such as specialty medical services, emergency services, outpatient services, pharmacy, counselling, rehabilitation and education classes, as well as auxiliary services such as cafes or onsite attached accommodation for out-of-town relatives / carers

• how the organisation will handle health information, irrespective of whether consent is given. This information should be provided at the earliest opportunity and in line with the National Privacy Principles (NPP)2 and privacy legislation of the relevant jurisdiction

• inclusion and/or exclusion criteria for admission to the health service

• collaborative links between the organisation and specific community / advocacy / support groups

• schedule of programs and/or education sessions

• transport and/or parking information.

There are a variety of ways in which the organisation can inform its community about the services that it provides, including presenting education sessions for community groups, holding open days, setting up information booths at shopping centres, and distributing newsletters. The organisation should also take these opportunities to discuss its provision of information, and determine how it could better communicate with the various groups that make up its community.

Consumers / patients being admitted to a specific service should be provided with all necessary information, and in an appropriate format and language. This should not only address the procedure, treatment, test or assessment that the consumer / patient will undergo, but give all necessary details about when and how to access the service, what forms (if any) to fill in before doing so, and what to bring. The organisation should also inform the consumer / patient of his or her rights and responsibilities under the Australian Charter of Healthcare Rights. The organisation’s own responsibilities in this respect, including what information should be provided and in what formats and languages, are addressed in more detail within criteria 1.6.2 and 1.6.3.

In addition to providing information about their own services, organisations should provide consumers / patients with information about related external services and their providers, to ensure that consumers / patients can access these services,

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where appropriate. Usually, the organisation will maintain a service directory, which will supply operational and contact details for relevant external services as required by the consumer / patient.

Prompt points

¼ How is information on the health service provided to the community? In what formats? In what languages? How did the organisation decide upon these languages?

¼ How often is the content and processes for dissemination of information on services evaluated? What recent changes have been made to the content? What recent changes have been made to the system of dissemination?

¼ If no changes have been made, explain the reasons in relation to the results of any evaluation of health service information?

External service providersOrganisations will have relationships with external service providers who refer consumers / patients to the organisation, and who may later resume responsibility for their ongoing care. In order to facilitate these processes, the organisation should provide its referrers with all necessary information about its access and admission processes, the channel(s) by which it should receive referrals, and the means and timeframe within which it in turn will transfer consumer / patient information to the referrer. These issues are addressed in more detail within criterion 1.2.2.

In addition, external service providers within a community may speak to their consumers / patients about services provided by the organisation, initiating independent contact without formal referral. These external healthcare providers should therefore be notified of any changes to hours of operation, access conditions, location of specialty services, contact details and any other relevant information, in order to ensure that the information provided in turn to consumers / patients is accurate and up-to-date.

Collaboration between the organisation itself and external facilities, services and groups has the capability to significantly extend and enhance the range of services available to the consumer / patient, and to more thoroughly and efficiently meet the needs of the community. When an organisation finds itself regularly referring consumers / patients to another provider, it should follow up with the external

provider and discuss the existing relationship, in order to formalise the relationship if necessary, and to identify any joint strategies by which they may better meet consumer / patient needs. Both parties to the collaboration should use their usual channels for dissemination of information to inform their community of the links between them, and the way in which the provision of care is improved by the relationship.

Prompt points

¼ How are consumers / patients and healthcare providers within the organisation informed about external service providers? How does the organisation ensure the information is relevant?

¼ What collaborations exist between the organisation and external service providers in its community? Are these formal or informal?

¼ How does the organisation know whether its collaborations are helping it to meet the needs of its community?

Evidence commonly presented

Consider whether the following will help to address criterion 1.2.1

¼ Information sheets provided for community, including information on:

– public transport routes and timetables – available parking options – locations of community or affiliated

pharmacies ¼ Media releases / advertising / newsletters /

open days / public displays

¼ Results of consumer surveys

¼ Organisational service directory

¼ Evidence of new or extended services provided as a result of consumer feedback

¼ New community groups that are accessing information

¼ Details of other aligned service providers that assist with post-operative care

¼ Contact number for referrers and processes of referral if requested

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Criterion 1.2.1

The community has information on health services appropriate to its needs. (continued)

Performance measurementThis criterion states that: “The community has information on health services appropriate to its needs”. It is the responsibility of the organisation to ensure that its community in general is informed of the services that it provides; that consumers / patients and their carers accessing those services are provided with all information necessary about their health care; and that it actively pursues collaborations with external service providers so as to enhance its range of services.

Some common performance measures are as follows:

Number of consumers / patients accessing services due to education session / open day / public display

Total number of consumers / patients surveyed

Number of consumers / patients satisfied with pre-admission information

Total number of consumers / patients surveyed

Number of staff able to provide information on external services

Total number of staff surveyed

Number of consumers / patients provided with information about external services

Total number of consumers / patients requiring external service provision

Number of referrers satisfied with the organisation’s provision of consumer / patient information

Total number of referrers surveyed

Number of collaborations established with external service providers in the current 12 months

Total number of collaborations with external service providers

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References1. Australian Commission on Safety and Quality in Health

Care (ACSQHC). Australian charter of healthcare rights (for consumers). Sydney NSW; ACSQHC; 2008.

2. Office of the Federal Privacy Commissioner. National privacy principles (extracted from the Privacy Amendment (Private Sector) Act 2000.) Sydney NSW; Australian Government; 2001.

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Criterion LA – Awareness sA – ImplementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 1.2.2

Access and admission / entry to the system of care is prioritised according to healthcare needs.

a) The organisation has documented processes on prioritisation for admission / entry to services.

b) The organisation has clear inclusion and/or exclusion criteria for admission to the service.

a) A system exists for prioritising care according to need.

b) Admission / entry processes meet consumer / patient needs and minimise duplication.

c) There are processes that ensure continuity of care between referrers and providers.

a) The organisation evaluates the effectiveness of its prioritisation guidelines, and these are improved as required.

b) The organisation evaluates the admission / entry processes, and makes improvements as required.

a) The organisation compares admission / entry processes internally and externally, and improvements are made to ensure better practice.

and/or

b) The organisation undertakes research on access systems and processes, and acts on the results.

a) The organisation demonstrates it is a leader in prioritising access according to health care needs.

IntentConsumers / patients will access the health system according to clinical and personal need. The intent of this criterion is to ensure that, firstly, the organisation has processes in place to facilitate consumer / patient access; and secondly, that consumer / patient needs are considered during prioritisation of care and admission of the individual to the organisation.

Processes pertaining to access and admission will vary according to the nature of the organisation, its location and the sector in which it operates. Each organisation should interpret this criterion and the information in this guideline within its own context, while ensuring that it fulfils its duty of care towards its consumers / patients.

Relationships of 1.2.2 with other criteriaInformation on health services and how to access them should be readily available to the community (Criterion 1.2.1). Access to the health system begins the consumer / patient’s journey of care (Standard 1.1). However, before being admitted to a healthcare organisation, the consumer / patient’s needs will be assessed, and subsequent access may be subject to inclusion / exclusion criteria and processes that help to ensure that the consumer / patient receives the appropriate care in the most appropriate setting (Criterion 1.3.1). Following admission, coordinated and effective systems facilitate the ongoing care of the consumer / patient (Criterion 1.1.6), whose needs, both within the facility and following transfer / discharge, will be addressed via the processes for clinical handover (Criterion 1.1.5).

Access to the health system is a fundamental right of the consumer / patient (Criterion 1.6.2). It is the responsibility of the organisation to ensure that it meets the requirements of consumers / patients with diverse needs and from diverse backgrounds, according to the demographic that it serves (Criterion 1.6.3), including facilitating physical access through the provision of appropriate entries and signage (Criterion 3.2.2), so that access to health care is not hindered.

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Criterion LA – Awareness sA – ImplementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 1.2.2

Access and admission / entry to the system of care is prioritised according to healthcare needs.

a) The organisation has documented processes on prioritisation for admission / entry to services.

b) The organisation has clear inclusion and/or exclusion criteria for admission to the service.

a) A system exists for prioritising care according to need.

b) Admission / entry processes meet consumer / patient needs and minimise duplication.

c) There are processes that ensure continuity of care between referrers and providers.

a) The organisation evaluates the effectiveness of its prioritisation guidelines, and these are improved as required.

b) The organisation evaluates the admission / entry processes, and makes improvements as required.

a) The organisation compares admission / entry processes internally and externally, and improvements are made to ensure better practice.

and/or

b) The organisation undertakes research on access systems and processes, and acts on the results.

a) The organisation demonstrates it is a leader in prioritising access according to health care needs.

AccessThe term access refers to the various pathways and processes via which the consumer / patient may enter the health system and obtain required services. It encompasses both the physical process of access (i.e. the location of the organisation, its hours of operation, transport, ramps, signage) as well as means for making contact, and broader concepts such as eligibility criteria and the catchment boundaries for the services provided. Access is the first step in the consumer / patient’s journey of care.

From the perspective of the organisation, consumer / patient access may be planned or unplanned. Planned access is when an appointment or booking has been made, and the consumer / patient attends at a pre-arranged time to receive specific, agreed services; while unplanned access is contact by a consumer / patient other than to make an appointment, or the arrival of a consumer / patient at a healthcare facility without immediate prior contact, whose clinical need must then be determined.

The pathway by which the consumer / patient gains access to the health system will vary according to the nature and urgency of his or her clinical need, and the character and situation of the organisation being accessed.

Ideally, access to a healthcare organisation is a relatively straightforward process. However, the unpredictability of acute care will sometimes result in access block, that is, overcrowding and/or delay in care provision.1 This may be a consequence of high occupancy and non-availability of appropriate beds, excessive demand on equipment or heavy staff workloads. Although the circumstances that result in access block may be beyond the control of the organisation, it is vital that the organisation’s own processes do not contribute to the problem. Research has demonstrated that procedures facilitating the integration of the consumer / patient’s journey, that strive for seamless rather than compartmentalised care and minimise opportunities for breakdowns in communication and delays in clinical handover, assist in streamlining consumer / patient movements through the system, with reduction in the incidence of access block and its associated harmful outcomes.2

Prompt points

¼ How many ways may the consumer / patient access this organisation? Is referral always necessary?

¼ Is access block an issue for this organisation? What means does the organisation employ to reduce or overcome access block?

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Criterion 1.2.2

Access and admission / entry to the system of care is prioritised according to healthcare needs. (continued)

PrioritisationPrioritisation is the process by which the urgency of the consumer / patient’s clinical need is determined.3 It involves a risk assessment and a clinical judgement informed by the equivalent and comparable assessment of the need of others seeking care of the same kind or at the same facility. Prioritisation occurs at different points in the healthcare journey, and may occur multiple times in the journey of a single consumer / patient. The process and its criteria will vary according to the nature of the organisation, but clinical need should always be the overriding consideration.

Triage is a form of prioritisation most commonly associated with emergency situations.4 It is a means of assigning a consumer / patient to a ‘category’ in order to ensure that he or she receives care in a manner commensurate with clinical urgency. Traditionally, Accident & Emergency Departments have used a system of five categories, from resuscitation (i.e. action within seconds) to non-urgent; although alternative approaches, including identifying urgent need before dividing the remaining cases into ‘likely to be admitted’ and ‘likely to be discharged’, have been trialled and found effective.5

In healthcare organisations where self presentation or self referral is the means of access for the consumer / patient, a system of frontline prioritisation, or demand management, is necessary to ensure the most appropriate and timely response. At the same time, in circumstances in which those same organisations employ a formal booking system for their services, or in organisations where a formal appointment system is employed at all times, prioritisation will usually occur before the consumer / patient accesses the facility. The process of referral can itself be an example of prioritisation: the referring clinician will judge the urgency of the clinical need, and select the most appropriate specialist or facility to provide the care required; while the receipt of a valid referral by the organisation allows care planning to begin and streamlines the access process for the consumer / patient.

The nature of the organisation and the sector of the health service in which it functions will determine at which point(s) in the care journey prioritisation will occur. Organisations should have a system or systems of prioritisation in place that, wherever possible, are developed in partnership with key referrers, that are based upon documented processes, and whose aim is to ensure not only that those in greatest need obtain care as soon as practicable, but also that all those accessing the organisation receive appropriate and timely care.

Prompt points

¼ How does the organisation prioritise consumer / patient care? At what point(s) in the care journey does this occur?

¼ What staff members are responsible for prioritising care?

¼ What documentation is available to demonstrate appropriate prioritisation has taken place?

¼ How does the organisation evaluate its prioritisation processes? What changes have been made as the result of such an evaluation?

Inclusion / exclusion criteriaInclusion and exclusion criteria are the conditions that determine eligibility or ineligibility for services provided by a healthcare organisation. They should be formally documented. The public hospital system operates within a philosophy of universal inclusion, meaning that consumers / patients should achieve access regardless of the nature or severity of their healthcare needs or their personal status or circumstances. Financial considerations should not deny access to treatment in a public hospital or other public facility.

The basis for, and implementation of, exclusion criteria will vary according to the nature, sector and location of the organisation. However, when drafting such criteria the needs and the wellbeing of the consumer / patient must at all times be the overriding consideration. It is also imperative that the organisation makes it clear to the consumer / patient that any decision to exclude is not made on a personal basis, but is made to avoid providing inappropriate care, in an inappropriate setting; or that it is due to other external factors, such as funding conditions. In excluding consumers / patients, the organisation has a duty of care to, at a minimum, provide advice as to an alternative point of care, or to re-direct the consumer / patient either back to the referrer or to another appropriate clinician or

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service. In some circumstances, an assisted referral to another organisation or service provider may be required.

Prompt points

¼ Does the organisation have exclusion criteria? On what basis were they implemented?

¼ How does the organisation assist excluded consumers / patients to receive appropriate care?

AdmissionIn the first instance, admission refers to the administrative process by which an individual’s details are entered into the organisation’s systems so that the care journey may begin. However, it is important to recognise that, depending upon the nature and sector of the organisation, admission does not necessarily require the provision of accommodation, or access to a specific facility.

Furthermore, the consumer / patient may not need to attend the facility in order to be admitted; while the organisation’s duty of care towards the consumer / patient may begin before there is any direct contact. In private hospitals, admission generally occurs when the consumer / patient attends at an appointed time. The process may need to incorporate approval from relevant private insurers and/or the confirmation of alternative payment options. Conversely, when a consumer / patient self-presents at an Accident & Emergency Department, access may or may not be followed by admission. Triage will determine the organisation’s course of action, including prioritisation of care and admission where appropriate. However, the organisation’s duty of care commences at the moment of presentation. Organisations should ensure that there is policy that outlines when a consumer / patient is considered to have been admitted to the health service and when the duty of care commences.

Organisations will have procedures in place to facilitate admission, which should include dissemination of information to all necessary parties while respecting the consumer / patient’s right to privacy and confidentiality. It is important that the organisation consider the process of admission from the perspective of the consumer / patient and make improvements as required. Repeated requests for the same information and duplication of forms can make admission unnecessarily frustrating and tiresome.

While organisations should avoid duplication wherever possible, it must be understood, and explained to the consumer / patient, that there are certain circumstances in which repetition of questioning is a deliberate and necessary safety precaution. This includes such aspects of care as consent, consumer / patient identification, and blood and blood component management, which are discussed within Criteria 1.1.3, 1.5.6 and 1.5.5, respectively.

Prompt points

¼ When, in this organisation, is a consumer / patient considered to be ‘admitted’? Must a consumer / patient attend at the organisation to be admitted? Must he or she be admitted to receive a service?

¼ How does the organisation avoid duplication of information collection upon consumer / patient admission?

¼ How is consumer / patient satisfaction with admission processes determined? How often is this done?

Continuity of careIn order to ensure continuity of care, the organisation must have integrated processes that allow the collection, dissemination and transfer of all necessary information between all necessary parties.6 Continuity of care requires that each clinician who sees a consumer / patient in a multidisciplinary environment is aware of what is known about the consumer / patient and of what actions have been taken by others. Continuity of care will help to ensure that:

• diagnostic tests and imaging are not repeated

• significant medical history is not omitted

• there is an accurate history, particularly in regards to allergic reactions and medication complications

• medications or other therapies that failed to produce a desired response are not repeated

• clinicians do not need to rely on recollections of consumers / patients, their families and/or carers, which may be unreliable.

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Criterion 1.2.2

Access and admission / entry to the system of care is prioritised according to healthcare needs. (continued)

Well-managed continuity of care also provides for the transfer of information between the organisation and those outside of the organisation also involved in the provision of care.7 When a consumer / patient is referred, the details provided should be incorporated into the health record, to ensure that it reaches all clinicians involved in the episode of care. This is also the case where an internal referral occurs within a multidisciplinary facility. Similarly, there is a need for the organisation to have processes for the provision of information concerning the care episode to relevant external clinicians.

The organisation should regularly evaluate its approach to continuity of care, and seek feedback from those providing / receiving referrals, in order to gauge their satisfaction with the organisation’s admission processes and transfer of information.

Prompt points

¼ What are the organisation’s actions upon receiving a referral?

¼ How does the organisation ensure the transfer of all relevant information when arranging the transfer of a consumer / patient to another healthcare facility?

¼ How does the organisation ensure the referral is actioned in a timely manner?

Evidence commonly presented

Consider whether the following will help to address criterion 1.2.2

¼ Policies on triage

¼ Policies on prioritisation

¼ Admission policy, including the documented eligibility criteria

¼ Referral information for ineligible consumers / patients in line with criteria

¼ ICU access policy

¼ Theatre lists

¼ Evaluated data from waiting lists

¼ Results of patient satisfaction surveys which have included questions on the admission process

¼ Results of referrer satisfaction surveys on the admission process and the transfer of information

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Performance measurementThis criterion states that: “Access and admission / entry to the system of care is prioritised according to healthcare needs”. While providing access to health care, the organisation must have processes in place to determine the eligibility of consumers / patients, and the conditions under which they might be excluded; and to ensure that the provision of care is prioritised according to clinical need. The organisation should also have systems for facilitating continuity of care via its admission process, and the transfer of information between referrers and providers.

Some common suggested performance measures are as follows:

Number of consumers / patients waiting more than X weeks for urgent surgery

Total number of consumers / patients booked for urgent surgery

Comment: organisation to define ‘X’ and category of surgery

Number of consumers / patients waiting more than X weeks for elective surgery

Total number of consumers / patients booked for elective surgery

Comment: organisation to define ‘X’ and category of surgery

Number of new consumers / patients waiting more than X weeks for service appointment from date of request

Total number of consumers / patients booked for a specific service appointment

Comment: organisation to define ‘X’; service appointments include outpatient services, allied health and medical services.

Number of consumers / patients having procedures cancelled by the hospital on the day of surgery due to unavailability of beds / theatre closure

Total number of consumers / patients booked for a procedure

Comment: it is recommended that the reasons for cancellation be collected

Number of consumers / patients waiting more than X days between initial referral contact and assessment or first service

Total number of consumers / patients admitted to the service

Comment: organisation to define ‘X’

Number of referrers satisfied with the organisation’s processes and timeliness for transfer of information

Total number of referrers surveyed

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Criterion 1.2.2

Access and admission / entry to the system of care is prioritised according to healthcare needs. (continued)

Number of consumers / patients satisfied with the organisation’s admission processes

Total number of consumers / patients surveyed

Number of consumers / patients transferred / referred / advised of options following exclusion

Total number of consumers / patients excluded

References1. Australasian College for Emergency Medicine (ACEM).

Access block and overcrowding in Emergency Departments. Melbourne VIC; ACEM; 2004.

2. Services for Australian Rural and Remote Allied Health (SARRAH). Prioritisation and demand management. Accessed from http://www.sarrahtraining.com.au/ on 31 August 2010.

3. Ben-Tovim DI, Dougherty ML, O’Connell TJ and McGrath KM. Patient journeys: the process of clinical redesign. Med J Aust 2008; 188(6): S14–S17.

4. Australian Department of Health and Ageing (DoHA). The state of our public hospitals: June 2010 report. Canberra ACT; DoHA; 2010.

5. Ben-Tovim DI, Bassham JE, Bennett DM et al. Redesigning care at the Flinders Medical Centre: clinical process redesign using “lean thinking”. Med J Aust 2008; 188(6 suppl): S27–S31.

6. National E-Health Transition Authority (NEHTA). The NEHTA continuity of care program is a national initiative enabling efficient transfer of information between clinicians to improve the transfer of patient care. Continuity of Care Bull 2010; 1: 1–2.

7. Pelletier D, Duffield C and Donoghue J. Documentation and the transfer of clinical information in two aged care settings. Aust J Adv Nurs 2005; 22(4): 40–45.

Further readingClinical Excellence Commission (CEC). Improving patient access to acute care services: A practical toolkit for use in public hospitals. Sydney NSW; CEC. Accessed from http://www.cec.health.nsw.gov.au/pdf/toolkit.pdf on 6 September 2010.

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1.3 Appropriateness Standard

The standard is: Appropriate care and services are provided to consumers / patients.

The intent of the appropriateness standard and criterion is to ensure that consumers / patients receive appropriate and necessary care, interventions and services.

There is one criterion in this standard. This is:

1.3.1 Health care and services are appropriate and delivered in the most appropriate setting.

Appropriateness is doing the right treatment, intervention or service in the right way and effectiveness is the extent to which those treatments, interventions or services achieve the desired outcomes.

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Criterion LA – Awareness sA – ImplementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 1.3.1

Health care and services are appropriate and delivered in the most appropriate setting.

a) Documented processes exist on how the organisation assesses the appropriateness of care.

b) Policy / guidelines exist on how to assess the appropriateness of the setting in which care is provided.

c) Clinical guidelines are used to guide appropriate care delivery.

a) The organisation has a strategy to ensure the appropriate use of interventions and services.

b) Service planning includes an evaluation of the appropriateness of the services to be provided.

c) The organisation collects a suite of key indicators relating to appropriateness of care.

a) The system for assessing the appropriateness of care and services is evaluated by clinicians and management, and improved as required.

b) Healthcare providers, including clinicians and managers and/or consumers, are involved in the evaluation of appropriateness of care.

c) Indicators for appropriateness of care and services are evaluated and improvements are made as required.

a) The system for ensuring appropriateness of care is compared externally and improvements are made to ensure better practice.

and/or

b) The organisation publishes comparative data demonstrating improvements in appropriateness.

and/or

c) The organisation researches the appropriateness of particular interventions and acts on results.

a) The organisation demonstrates it is a leader in providing appropriate care and services in the appropriate setting.

IntentIn health care, appropriateness is about doing what is necessary, and not doing what is not necessary. Appropriate care is reflected in positive care outcomes, and in the extent to which the consumer / patient’s needs and wants are met.

The intent of this criterion is to ensure that consumers / patients receive appropriate and necessary care, interventions and services in the most appropriate setting.

Relationships of 1.3.1 with other criteriaAppropriateness should be evident throughout the journey of care (Standard 1.1). The processes of access and admission and the use of inclusion and exclusion criteria (Criterion 1.2.2) will ensure that care is delivered in the most appropriate setting. Assessment (Criterion 1.1.1) and care planning (Criterion 1.1.2) will determine what is appropriate for the consumer / patient; while the care subsequently given will be not only appropriate, but delivered in the most effective way (Criterion 1.4.1) by clinicians who are credentialled and performing within their defined scope of practice (Criterion 3.1.3). Appropriate care will be reflected in positive health outcomes (Criterion 1.1.4).

Research can help to determine the appropriateness of specific health interventions (Criterion 2.5.1), while quality improvement programs may assist in promoting adherence to best-practice clinical guidelines and broaden the delivery of appropriate care (Criterion 2.1.1).

Ensuring appropriateness of care is an aspect of the organisation’s integrated risk management framework (Criterion 2.1.2). Inappropriate care, or care delivered in inappropriate settings, may lead to incidents (Criterion 2.1.3) and complaints (Criterion 2.1.4).

Appropriateness of careAppropriateness is the degree to which service is consistent with a consumer / patient’s expressed requirements and is provided in accordance with current best practice.1 It refers to the relative weight of the benefits and harms of a medical or surgical intervention. An appropriate procedure is one in which the expected health benefit (e.g. increased life expectancy, relief of pain, reduction in anxiety, improved functional capacity) exceeds the expected negative consequences (e.g. mortality, morbidity, anxiety, pain, time lost from work) by a sufficiently wide margin that the procedure is worth carrying out, exclusive of cost.2

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Criterion LA – Awareness sA – ImplementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 1.3.1

Health care and services are appropriate and delivered in the most appropriate setting.

a) Documented processes exist on how the organisation assesses the appropriateness of care.

b) Policy / guidelines exist on how to assess the appropriateness of the setting in which care is provided.

c) Clinical guidelines are used to guide appropriate care delivery.

a) The organisation has a strategy to ensure the appropriate use of interventions and services.

b) Service planning includes an evaluation of the appropriateness of the services to be provided.

c) The organisation collects a suite of key indicators relating to appropriateness of care.

a) The system for assessing the appropriateness of care and services is evaluated by clinicians and management, and improved as required.

b) Healthcare providers, including clinicians and managers and/or consumers, are involved in the evaluation of appropriateness of care.

c) Indicators for appropriateness of care and services are evaluated and improvements are made as required.

a) The system for ensuring appropriateness of care is compared externally and improvements are made to ensure better practice.

and/or

b) The organisation publishes comparative data demonstrating improvements in appropriateness.

and/or

c) The organisation researches the appropriateness of particular interventions and acts on results.

a) The organisation demonstrates it is a leader in providing appropriate care and services in the appropriate setting.

Inappropriate care can result from either:

• underuse, such as the failure to provide a service which has a benefit that is greater than the risk

• overuse, when a health service is provided even though the risk outweighs the benefit.

The question of appropriateness of care is applicable to all healthcare settings and modes of service delivery.

There are three levels of appropriateness:

• The national level

• The organisation level

• The clinician level.

National level – This level encompasses work that has been done by medical, nursing and allied health professional bodies, jurisdictions, and other industry bodies in relation to appropriateness. For example, the National Health and Medical Research Council (NHMRC) has developed guidelines for the appropriate use of blood transfusions3, with which most health services comply.

Organisation level – This level should be the focus of the appropriateness criterion for both organisations and surveyors when assessing and reviewing appropriateness.

An organisation is responsible for ensuring that there is a process for determining the appropriateness of treatments, interventions and services, and the strategy for accomplishing this should be available to relevant staff.

Systems that may support the assessment and evaluation of appropriateness include the credentialling and scope of clinical practice system, peer review meetings and/or clinical audit reviews. As the delivery of appropriate care is dependent upon many factors, aspects to consider include:

• What is the size of the organisation?

• Are clinicians with expertise in undertaking specific procedures available? Are they correctly credentialled with the necessary scope of practice? What supervision is available?

• What facilities and resources are required to ensure that care is appropriate? For example, plant and equipment, emergency department, inpatient care?

• What backup is available if required, such as intensive care or a senior consultant?

• What corporate and support structures and systems are in place, such as clinical governance or quality improvement mechanisms, clinical audits or a credentialling system?

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Criterion 1.3.1

Health care and services are appropriate and delivered in the most appropriate setting. (continued)

Many services already use inclusion and exclusion criteria to enable the appropriate admission of consumers / patients to their service. Examples include:

• admission to a day surgery or children for surgery where there are no dedicated facilities, as outlined by the Australian and New Zealand College of Anaesthetists4, 5 in their professional standards and The Royal Australian College of Physicians Standards for the care of children and adolescents in health services,6 or

• admission to a post traumatic stress disorder treatment program as outlined by the Australian Centre for Post Traumatic Mental Health or the relevant Workers Compensation system.

Further information on inclusion and exclusion criteria is available in criterion 1.2.2.

Clinician level – The clinician is responsible for determining the most appropriate test, procedure or intervention for a consumer / patient, and for discussing the appropriateness with the consumer / patient and then documenting this discussion in the health record. Appropriate care or treatment should be based on established and accepted standards, such as evidence-based clinical guidelines or the treatment protocols used in oncology, electroconvulsive therapy7 and the treatment of adults with acute stress disorder and post traumatic stress disorder.8

Treatments for similar conditions may vary according to the consumer / patient needs and this may take into account factors such as:

• allergies or adverse reactions

• preference for treatment at home or in a medical facility

• a choice between aggressive treatment versus palliative care

• elective versus emergency procedures

• the stage of the disease process or severity of injury

• cultural influences and religious beliefs.

Serious issues are also raised about whether organisations should provide services that are considered in the literature to be of little benefit, unnecessary or inappropriate, simply because the consumer / patient has requested it.

Many thousands of interventions are provided to consumers / patients in Australian health services every day. The challenge is to ensure that as many of those interventions as possible are needed and are going to provide benefit to the consumer / patient. There is a strong correlation between the effectiveness and the appropriateness of an intervention.

Organisations should also take into account any research or quality improvement work being undertaken that specifically relates to appropriate use of interventions. For example, a healthcare organisation may undertake research on how to improve adherence to scientific evidence and clinical practice guidelines to reduce variation in the management of consumers / patients with the same clinical condition.

Prompt points

¼ What policies address appropriateness of services? Are there policies about appropriateness of settings?

¼ How does the organisation access evidence-based guidelines? How are these made available to relevant staff?

¼ Do service planning documents address appropriateness? What evaluation of these documents has occurred?

An appropriate settingThe appropriateness of the setting in which care is provided is determined by matching consumer / patient needs for treatment with the setting in which it should be provided; this may vary from individual to individual. This aspect is closely related to the processes of credentialling and defining clinicians’ scope of practice, as addressed within Criterion 3.1.3.

Appropriate services can be provided in inappropriate settings. For example, major surgery should not be undertaken in an environment where senior consultant and/or potential intensive care back up is unavailable, or too far away. An individual recently diagnosed with diabetes will require several interventions, but in most cases it will not be necessary for these services to be provided as an inpatient. They should more appropriately be provided as ambulatory services.

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Co-location of children and adolescents with adults in health services is a common practice. Organisations should consider the medical and psychosocial needs of children and adolescents as different from those of adults when allocating beds / wards. The Royal Australian College of Physicians has developed Standards for the care of children and adolescents in health servicesI9, available at: http://www.racp.edu.au/page/policy-and-advocacy/paediatrics-and-child-health. The goal of the standards is to ensure that children and adolescents attending health services receive quality care in an environment that is safe and appropriate for their age and stage of development.

As health care is increasingly being delivered outside of the inpatient setting, consideration should always be given to the most appropriate setting for the provision of care. Support for self management of chronic conditions is most appropriately delivered in ambulatory care or community settings, with the potential for some aspects to be provided in a sporting facility, such as a gym or hydrotherapy pool, under the supervision of allied health professionals. Running regular allied health clinics located, and in partnership with a local Aboriginal and Torres Strait Islander cooperative, can increase the access to physiotherapy or other allied health treatments by Aboriginal and Torres Strait Islander consumers / patients.

When either the appropriateness of a setting or of the intervention is considered10, it is assumed that services are provided in a high quality, safe and technically correct manner. However, in the case of inappropriate healthcare delivery, the setting and service should be considered separately. A service that is inappropriate for a specific type of consumer / patient should not be provided in any setting. If the service is appropriate but the setting is inappropriate, the care could be provided in an alternative setting.

When considering care settings, the assessment of appropriateness will depend on the availability of alternative settings, such as moving new mothers to hotel rooms11, or delivering intravenous antibiotic treatment for an acute but stable condition via a Hospital In The Home program if the home environment is assessed as suitable.

Prompt points

¼ What processes are used to evaluate the appropriateness of setting for the organisations procedures?

¼ How is appropriateness of setting included when any proposed change to a clinical service is assessed for feasibility?

Assessing appropriatenessAppropriateness of the service can be examined on an individual consumer / patient basis or by taking an organisational approach.

Appropriate care for a consumer / patient is considered to be relevant to their needs and based on established standards. The questions to be asked could be:

• Is the treatment / intervention / service based on established standards?

• Is the treatment / intervention / service provided relevant to this consumer / patient’s needs?

The approach that considers the appropriateness of the care or service provided to an individual underpins clinical peer review activities, where care provided to an individual is compared against a normative standard of care. This may be documented in several ways including a clinical pathway, and/or against intervention / care selection criteria. Based on the best available evidence, a list of criteria can be developed to determine when it is appropriate to use a certain intervention. This will provide more assurance to the consumer / patient, the organisation and the funders of health care that those interventions recommended are only undertaken in the most appropriate circumstances. Examples of procedures that should be used only when determined to be appropriate are hysterectomies in young women, and tonsillectomies.

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Criterion 1.3.1

Health care and services are appropriate and delivered in the most appropriate setting. (continued)

When using admission rates to improve the appropriateness of care it should be borne in mind that:

• the rates need to be focused on a specific admission type or procedure group

• determining the ‘right rate’ is extremely complex and is not necessary to improve the appropriateness of care

• there may be advantages in comparing data with high-rate, median-rate and low-rate organisations

• active participation by clinicians at the local level in identifying relevant local factors and implementing strategies is essential. The importance of involving at least one locally recognised leading clinician cannot be over-emphasised

• no single technique will be effective in all instances, and a combination of techniques will be required.

When an organisation reviews the appropriateness of its service provision, variations between consumers / patients may be considered and hints gained from statistical analysis. However, while review of such analysis may identify variations in utilisation patterns, alone this will not allow conclusions to be made regarding the appropriateness of the services provided. If variations are found, analysis of the reasons for the differences will be required.

Evidence of inappropriate care can be seen in data that would indicate either overuse or underuse of services. The ability to determine and identify which care is overused and which is underused is essential. Incident management data can also be utilised to assess appropriateness of care.

The National Institute of Clinical Studies has identified a series of interventions that, despite evidence of their effectiveness, are inconsistently actioned by Australian healthcare providers.12 It may be feasible to assess whether and how these interventions are used by the organisation. Information on these interventions is available at: http://www.nhmrc.gov.au/nics/material_resources/resources/identifying_barriers.htm

Examining admission rates for particular conditions and rates of particular interventions (relative utilisation rates) may give an organisation some idea of the appropriateness of those admissions and interventions. Large variations in admission rates or relative utilisation rates over time or between departments or facilities are signals of inconsistencies in the factors affecting admission and intervention use. These signals could identify opportunities to achieve better health outcomes for individual consumers / patients through quality improvement processes and adopting best practice. Where variations are seen, the healthcare organisation has a responsibility to examine the reasons for the variation and improve appropriateness of care where necessary.

Health services will need to identify a suite of performance indicators that are relevant to the services they provide. Performance indicators may be, but are not always, clinical; financial outcomes may also be relevant in a few limited circumstances. While the best indicators show changes in outcome, many outcomes are based on multiple inputs, making it difficult to determine the driver for the changes observed. In these cases, indicators that demonstrate a process has been followed may be more useful.

Further benefit will be gained from indicators if there are opportunities for comparison with similar health services, which may create opportunities to consider appropriateness of care through evaluation of the data. Further review with input from staff operating the relevant service(s) will be needed to determine sources of variation and whether there are opportunities for positive change. There are several well-documented methods for examining and maintaining, or increasing the level of, appropriateness and progressively reducing inappropriate care.

Clinical information in the health record can be reviewed to determine the indicators for the interventions and any relevant risk factors or co-existing illnesses. To assess the appropriateness of the setting, the health record may be reviewed to determine the severity of the illnesses and the intensity of services needed to care for the consumer / patient. Where sample sizes are large enough, consumers / patients experiencing a similar intervention and matched by severity of illness or other risk factors, could be compared between settings. This technique can be very useful when the intervention involves variations in education / training, such as between individuals newly diagnosed with Type 2 diabetes trained in diabetes management in a large group workshop, and those given personal consultations with different professionals.

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Prompt points

¼ What indicators are used to evaluate the appropriateness of care?

¼ How are clinicians involved in the evaluation of appropriateness of care? What other staff members are involved?

¼ How are consumers involved in the evaluation of appropriateness?

Evidence commonly presented

Consider whether the following will help to address criterion 1.3.1

¼ Policies, guidelines and procedures

¼ Adherence to by-laws

¼ Evidence of the use of criteria of appropriateness, such as Criteria of Appropriateness of Blood Transfusions (NHMRC guidelines)

¼ Evidence of the use of analysis of indicators of appropriateness

¼ Clinical service plans

¼ Demographic / population studies and data

¼ Organisational profile

¼ Consumer / patient pathways / care plans

¼ Contracts with other service providers such as Home and Community Care (HACC)

¼ Operational plan

¼ New interventions policy

¼ Staffing levels and skill mix

¼ Education

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Criterion 1.3.1

Health care and services are appropriate and delivered in the most appropriate setting. (continued)

Performance measurementThis criterion states that: “Health care and services are appropriate and delivered in the most appropriate setting”. The organisation should have policy, by-laws, guidelines and/or procedures in place to ensure that consumers / patients receive appropriate care in the most appropriate setting, while avoiding wherever possible, inappropriate care in an inappropriate setting. It should be recognised that the organisation itself is not always the most appropriate setting for consumer / patient care.

Some common suggested performance measures are as follows:

Note: Utilisation rates for surgical, medication or diagnostic interventions are useful indicators for monitoring compliance with published best-practice guidelines. Rates may be determined using data based on ICD-10-AM, Medicare Benefits Schedule or Diagnostic Related Group codes.

The National Institute of Clinical Studies (NICS) has identified a number of areas where clinical practice does not always reflect the best evidence. Change in these areas is likely to result in more appropriate care. Organisations should consider whether monitoring their performance in these areas would promote more appropriate care. For more information, see: National Institute of Clinical Studies (NICS). Evidence-Practice Gaps Report: A review of developments: 2004–2007. Vol. 1. Canberra ACT; National Health and Medical Research Council; 2008. This document can be accessed from the NICS website: http://www.nhmrc.gov.au/nics/index.htm

Number of admissions for selected potentially preventable hospitalisations

Total number of admissions

Comment: e.g. diabetes / asthma; ‘preventable hospitalisation’ to be defined by the organisation

Number of provided services with identified / documented criteria of appropriateness

Total number of provided services in a particular organisation / in a particular location

Comment: consider the blood NHMRC guidelines as an example. Organisational policy may identify criteria of appropriateness for a particular intervention

Number of smokers / non-smokers who presented for screening chest x-rays

Total number of chest x-rays

Number of consumers / patients receiving treatment from the service for a common cold or acute bronchitis who are prescribed antibiotics

Total number of consumers / patients receiving treatment from the service for a common cold and / or acute bronchitis

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Number of consumers / patients undergoing postoperative colorectal cancer surveillance who undergo a colonoscopy for surveillance within 3 years

Total number of consumers / patients undergoing postoperative colorectal cancer surveillance

Number of consumers / patients prescribed contraindicated medication

Total number of prescriptions

Number of clinical interventions that varied from clinical guidelines / best-practice protocols without documented rationalisation for variation

Total number of health records audited

References1. International Society for Quality in Health Care (ISQua).

The ISQua surveyor training standards programme. Dublin IRL; ISQua; 2009.

2. Brook RH, Chassin MR, Fink A et al. A method for the detailed assessment of the appropriateness of medical technologies. Int J Technol Assess Health Care 1986 (Reprint 1991); 2(1): 53-63.

3. National Health and Medical Research Council (NHMRC) and Australasian Society of Blood Transfusion (ASBT). Clinical practice guidelines on the use of blood components. Canberra ACT; NHMRC & ASBT; 2001.

4. Australian & New Zealand College of Anaesthetists (ANZCA). PS29: Statement of anaesthesia care of children in healthcare facilities without dedicated paediatric facilities. Sydney NSW; ANZCA; 2008.

5. Australian & New Zealand College of Anaesthetists (ANZCA). PS15: Recommendations for the perioperative care of patients selected for day surgery. Sydney NSW; ANZCA; 2006.

6. Royal Australasian College of Physicians (RACP). Standards for the care of children and adolescents in health services. Sydney NSW; RACP; 2008.

7. Royal Australian and New Zealand College of Psychiatrists (RANZCP). Clinical Memorandum #12: Guidelines on the administration of electroconvulsive therapy (ECT). Melbourne VIC; RANZCP; Revised 2007.

8. Australian Centre for Post-traumatic Mental Health. Australian guidelines for the treatment of adults with acute stress disorder and post-traumatic stress disorder. Melbourne VIC; National Health and Medical Research Council (NHMRC); 2007.

9. Royal Australasian College of Physicians (RACP). Standards for the care of children and adolescents in health services. Sydney NSW; RACP; 2008.

10. Hunter DJ. Measuring the appropriateness of hospital use. Can Med Assoc J 1997; 154(3): 901–902.

11. Benson K. Suite deal for new mums. Sydney Morning Herald, Sydney NSW; Fairfax; 9 October 2008.

12. National Institute of Clinical Studies. Identifying barriers to evidence uptake. Melbourne VIC; NICS; 2006.

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1.4 Effectiveness Standard

The standard is: The organisation provides care and services that achieve effective outcomes.

The intent of the Effectiveness standard and criterion is three fold. It is to ensure that:

• healthcare organisations use interventions that have been proven to be effective

• all other care, services and interventions are based on the best available evidence

• care is provided in the most effective way possible.

There is one criterion in this standard. This is:

1.4.1 Care and services are planned, developed and delivered based on the best available evidence and in the most effective way.

Appropriateness is doing the right treatment, intervention or service in the right way and effectiveness is the extent to which those treatments, interventions or services achieve the desired outcomes.

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Criterion LA – Awareness sA – ImplementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 1.4.1

Care and services are planned, developed and delivered based on the best available evidence and in the most effective way.

a) Documented processes exist for implementing best available evidence into clinical practice.

b) Policy / guidelines exist on how to manage and minimise risk to consumers / patients accommodated outside the specialty ward area.

a) The organisation supports healthcare providers in the implementation of evidence-based care.

b) Care process mapping is documented and undertaken by a multidisciplinary team when applicable.

c) Policy and procedures are implemented for the management of consumers / patients accommodated outside the specialty ward area to ensure care is safe and effective.

a) Indicators are used to evaluate the use of evidence-based care and improvements are made as required.

b) Processes for ensuring the use of effective care, services and practice are evaluated and improved as required.

c) Processes for managing consumers / patients accommodated outside the specialty ward are evaluated and improved as required.

a) The system for ensuring the use of effective practice is compared externally and improvements are made to ensure better practice.

and/or

b) The organisation benchmarks identified key care processes and outcomes with like organisations, and improvements are made to ensure better practice.

and/or

c) The organisation undertakes research into the effectiveness of interventions and services and the adoption of evidence into practice.

a) The organisation demonstrates it is a leader in effective, evidence-based care.

IntentThe intent of the Effectiveness standard and criterion is three-fold. It is to ensure that:

• healthcare organisations use, as first line, interventions that have been proven to be effective

• all other care, services and interventions are based on current best available evidence

• care is provided in the most effective way possible (as confirmed by evaluation).

Relationships of 1.4.1 with other criteriaThe effectiveness of health care is significantly connected with all aspects of the care journey (Standard 1.1). Care planning and delivery (Criterion 1.1.2), consumer / patient access (Criterion 1.2.2) and processes for ongoing care (Criterion 1.1.6) will all impact upon effectiveness, which is closely associated with, but distinct from, appropriateness. While appropriate care (Criterion 1.3.1) relates to providing the right treatment, intervention or service in the right way, effectiveness addresses the extent to which those treatments, interventions or services achieve desired outcomes.

Effectiveness of care should be evident when evaluating outcomes of clinical care (Criterion 1.1.4).

Evidence-based care should be embedded in the organisation’s policies and procedures (Criterion 3.1.5). Planning, development and delivery of effective care based upon the best available evidence is an aspect of the organisation’s integrated risk management framework (Criterion 2.1.2), and failures in this area may lead to incidents (Criterion 2.1.3) and complaints (Criterion 2.1.4).

Implementing evidence-based practiceThe effectiveness of health care relates to the extent to which a treatment, intervention or service achieves the desired outcome, and follows on from the appropriateness of that treatment, intervention or service.

In 2009, the National Health Performance Framework,1 designed for measuring health system performance, was updated. Effectiveness was identified as one of the six key domains of health system performance, with the other domains being safety, responsiveness, continuity of care, accessibility, and efficiency and sustainability.

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Criterion LA – Awareness sA – ImplementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 1.4.1

Care and services are planned, developed and delivered based on the best available evidence and in the most effective way.

a) Documented processes exist for implementing best available evidence into clinical practice.

b) Policy / guidelines exist on how to manage and minimise risk to consumers / patients accommodated outside the specialty ward area.

a) The organisation supports healthcare providers in the implementation of evidence-based care.

b) Care process mapping is documented and undertaken by a multidisciplinary team when applicable.

c) Policy and procedures are implemented for the management of consumers / patients accommodated outside the specialty ward area to ensure care is safe and effective.

a) Indicators are used to evaluate the use of evidence-based care and improvements are made as required.

b) Processes for ensuring the use of effective care, services and practice are evaluated and improved as required.

c) Processes for managing consumers / patients accommodated outside the specialty ward are evaluated and improved as required.

a) The system for ensuring the use of effective practice is compared externally and improvements are made to ensure better practice.

and/or

b) The organisation benchmarks identified key care processes and outcomes with like organisations, and improvements are made to ensure better practice.

and/or

c) The organisation undertakes research into the effectiveness of interventions and services and the adoption of evidence into practice.

a) The organisation demonstrates it is a leader in effective, evidence-based care.

In this context, effectiveness is defined as: care / intervention / action that is relevant to the consumer / patient’s needs and based on established standards. Care, intervention or action achieves the desired outcome.

Organisations should consider the following questions2:

• What is the right thing to do?

• Did we do the right thing? (appropriateness)

• Did we do the right thing 100% right? (effectiveness)

There is evidence available to inform healthcare organisations of the strategies and methods that can be used to provide the most effective care, services and interventions.

This standard and criterion require healthcare organisations to focus on three key strategies underpinned by evidence demonstrating a contribution to more effective care and service delivery.

They are:

• using interventions / treatments that are determined to be most effective

• using evidence in the development and delivery of care and services and in the development and implementation of policy and other practices

• mapping and documenting key processes to ensure that they will be undertaken in a consistent manner in order to minimise variation.

In the current healthcare environment, clinicians and managers can no longer rely solely on experience, rationale and opinion-based processes. Healthcare organisations need to be sure that all policy development, care processes and services are based on the best available evidence.

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Criterion 1.4.1

Care and services are planned, developed and delivered based on the best available evidence and in the most effective way. (continued)

Policy should be in place that clearly describes how to identify, access, critically select, implement, monitor and review the application of current, relevant best practice for all clinical practice that is provided by the healthcare organisation. Clear processes and procedures that guide the introduction and ongoing utilisation of evidence-based guidelines support clinicians in putting such guidelines into practice. Regular review of this approach enables evaluation of the currency, relevance and effectiveness of such practice and provides opportunities to measure the effectiveness of, and potentially revise, care provided.

Clinical practice guidelines should be used whenever available, and organisations should ensure that such clinical practice guidelines are current. Best practice can only be based on the best, currently available evidence, as practices that are considered to be best at one point in time can become redundant if the evidence changes as a result of advances in research. The National Health and Medical Research Council (NHMRC) has launched a national Clinical Practice Guidelines Portal that provides links to current Australian guidelines developed by governments, professional colleges, specialty societies and non-government agencies. These can be accessed at: http://www.clinicalguidelines.gov.au

The National Institute of Clinical Studies (NICS) in Australia has also published several reports3,4,5 that raise awareness of, and review, the gaps between what is known from the best available research and what is actually done in current daily practice over time. The latest report looks at the evidence, data on current practice and new policies and initiatives, and provides an update for each of the following identified evidence-practice gaps5:

• advising on smoking cessation

• advising on smoking cessation in pregnancy

• screening for lung cancer with chest X-rays

• preventing stroke in consumers / patients with atrial fibrillation

• using ACE inhibitor and beta-blocker therapies in heart failure

• measuring glycated haemoglobin in diabetes management

• prescribing antibiotics for upper respiratory tract infections and acute bronchitis

• preventing venous thromboembolism in hospitalised patients

• preparing for elective colorectal surgery

• using colonoscopy in colorectal cancer surgery follow-up

• managing acute and cancer pain in hospitalised consumers / patients.

Different interventions are more relevant in different healthcare settings. The listing of these areas in which there is an identified evidence-based practice gap is not intended to suggest that all health services need to provide all identified initiatives to help close the gaps. Health services need to assess which of these, and any other proven interventions, are appropriate to their case mix and how they will ensure their consistent use in all relevant circumstances. Just as important as increasing the uptake of beneficial forms of care is the removal of harmful or ineffective practices, and processes to guide this should also be in place.

Prompt points

¼ What is the process for appraising and implementing best available evidence into clinical practice?

¼ What methods are used to support and encourage the implementation of evidence-based care?

¼ How are these evaluated? What improvements have been made from this evaluation?

Key care processes mapped and recorded by a teamOrganisations need to be assured that clinical teams are examining the evidence available when determining care plans and clinical pathways. It is recognised that some proven interventions may be cost-prohibitive and that not all proven interventions will necessarily be available for use in all relevant circumstances, such as new drugs that are not yet on the Pharmaceutical Benefits Scheme. Further, implementation may be dependent on many external factors, for example, government purchasing policies and practices, corporate office policies, etc.

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The best way for healthcare organisations to ensure that they provide care and services in the most effective way is to:

• understand their most common care processes, including the admission and pre-operative processes

• document the best way to carry out those processes

• put mechanisms in place to ensure that all who are involved understand and carry out the process in this expected way.

It is not expected that a care map or process flow chart will suit all consumers / patients with a particular condition. It can be expected, however, that approximately 80% of individuals with a particular condition will require the same components of care. Examination of the variation from this pathway should lead to improvements.

In larger organisations, the purpose of process redesign is to achieve effective care from a consumer / patient perspective. This means identifying where delays, unnecessary steps or potential threats are built into the process and then redesigning the process to remove them, thus improving the quality of care. Typical steps in such a process might include:

• mapping the existing care process (sometimes described as the ‘as is’ stage)

• analysing where problems exist in that process and questioning why each step is done, by whom, where, in what sequence, and whether there is a better way

• imagining what an ‘ideal’ process might look like

• identifying practical changes to the current process to make it closer to the ideal process

• testing these changes and evaluating whether they result in improvement.6

This process of review or redesign may result in a clinical pathway or care pathway, however named. Such documents ensure that all steps in the process that are undertaken are necessary, that all multidisciplinary care providers are aware of all necessary steps, and that no essential steps are forgotten.

Prompt points

¼ How are key care processes identified and mapped? Who is involved?

¼ How are they evaluated? What improvements have resulted from evaluation?

Evidence-based treatment outside the specialty wardA consumer / patient accommodated outside the specialty ward area is one who is being treated in an area of the health service that normally treats a different case mix. A consumer / patient accommodated outside the specialty ward area may be known as a ‘home-ward outlier’. For example, a consumer / patient with a medical condition such as diabetes may be admitted to a surgical ward because of a shortage of available beds. Where a child is admitted to a non-paediatric ward, organisations should refer to the Standards for the care of children and adolescents in health services7 that have been developed for use in the Australian healthcare system. The goal of these standards is to ensure that children and adolescents attending health services receive quality care in an environment that is safe and appropriate for their age and stage of development, and organisations should refer to these where both children / adolescents and adults are cared for. The Standards are relevant to all areas of the health service, including inpatient wards, intensive care units, emergency departments, day-care facilities, surgery and recovery, outpatients, ambulatory care and community health centres. The Standards are available from: http://www.racp.edu.au/page/child-adol

It may be considered that a consumer / patient who suffers from dementia is a ‘home-ward outlier’ in any environment, especially if they are the only consumer / patient in that area suffering from dementia. In a day procedure centre, a consumer / patient undergoing orthopaedic surgery who is added to the end of an ophthalmic surgical list is also a ‘home-ward outlier’ consumer / patient.

Consumers / patients accommodated outside the specialty ward area are at greater risk of being forgotten or receiving the wrong treatment and/or medications, and of increased length of stay and increased morbidity.

In addition, signs of deterioration in a consumer / patient accommodated outside the home ward are often missed, as the staff may be less familiar with the condition for which the consumer / patient is being treated.8

Organisations must consider how to manage the risk of consumers / patients who have requirements beyond the familiar expertise of the care unit. The process should direct how staff manage the challenges of high consumer / patient load and consumers / patients with complex disorders that require multidisciplinary input.

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Performance measurementThis criterion states that: “Care and services are planned, developed and delivered based on the best available evidence and in the most effective way”. Organisations should be able to demonstrate that they deliver effective care based upon current, best-practice evidence. In assessing the effectiveness of care, organisations should ask the question, Did we do the right thing 100% right?

Some common suggested performance measures are as follows:

Note: Clinical indicators may be used as supporting evidence for this criterion. Please refer to the Clinical Indicator Summary Guide on the ACHS website, http://www.achs.org.au

Number of unplanned re-presentations for a particular service within X days of discharge

Total number of consumers / patients receiving a particular service

Comment: organisation to define ‘X’ in the context of the specific service

Number of clinical practice guidelines with evidence-based references

Total number of clinical practice guidelines

Comment: consider policies and procedures as well as clinical practice guidelines

Criterion 1.4.1

Care and services are planned, developed and delivered based on the best available evidence and in the most effective way. (continued)

Prompt points

¼ How does the organisation manage consumers / patients accommodated outside the home-ward area?

¼ What methods have been used to evaluate these processes?

¼ What changes have been made to the processes following evaluation?

Evidence commonly presented

Consider whether the following will help to address criterion 1.4.1

¼ Collection of clinical indicator data

¼ Changes in clinical indicators collected

¼ Evidence-based policies, and clinical practice guidelines

¼ Identification of common care processes of principal conditions treated

¼ Processes to access information on non-principal conditions treated

¼ Consumer / patient feedback

¼ Information available on the use of clinical pathways / care maps

¼ Audits of clinical pathways/care maps

¼ Review of unplanned readmissions

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Number of clinical care processes with documented steps

Total number of clinical care processes in an organisation / service unit

Comment: an example of ‘documented steps’ is a flow chart

Number of children for whom a medication prescription was written but a current weight was not recorded

Total number of children receiving a medication prescription

Number of consumers / patients who have had a stroke and are commenced on a clinical pathway on admission

Total number of consumers / patients who have had a stroke

Number of consumers / patients presenting with acute asthma who have a documented, completed, early management pathway or care plan in the health record

Total number of consumers / patients with acute asthma

Number of consumers / patients commencing haemodialysis with appropriate vascular access

Total number of consumers / patients commencing haemodialysis

Comment: organisation to define ‘appropriate vascular access and timing of acute deterioration for which venous catheters may be considered appropriate’ based on their consumer / patient pool and surgical approach.

Number of consumers / patients with osteoporosis-related fractures discharged on a preventative regimen

Total number of consumers / patients with osteoporosis-related fractures

Comment: a ‘preventative regime’ may include, but does not imply, prescription medication

Number of consumers / patients on in vitro fertilisation with documented recommended intake of folate in the periconceptual period

Total number of consumers / patients on in vitro fertilisation treatment

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Criterion 1.4.1

Care and services are planned, developed and delivered based on the best available evidence and in the most effective way. (continued)

Number of women receiving postnatal care provided with documented advice about placing infants on their backs

Total number of women receiving postnatal care

Number of consumers / patients with schizophrenia on atypical antipsychotics

Total number of consumers / patients with schizophrenia

Number of consumers / patients with schizophrenia on more than one regular antipsychotic agent

Total number of consumers / patients with schizophrenia

Comment: measure of polypharmacy

Number of consumers / patients aged over 65 years prescribed regular benzodiazepines for more than 4 weeks

Total number of consumers / patients aged over 65 years prescribed regular benzodiazepines

References1. National Health Information Standards and Statistics

Committee (NHISSC). National health performance framework. 2nd edn. Canberra ACT; AIHW; 2009.

2. Leape LL. Patient safety: What have we learned? Where are we going? 4th Australasian Conference on Safety and Quality in Health Care. Melbourne VIC; 21–23 August 2006.

3. National Institute of Clinical Studies (NICS). Evidence-practice gaps report. Vol. 2. Melbourne VIC; NICS; 2005.

4. National Institute of Clinical Studies (NICS). Evidence-practice gaps report. Vol. 1. Melbourne VIC; NICS; 2003.

5. Ireland P and National Institute of Clinical Studies (NICS). Evidence practice gaps report. A review of developments: 2004–2007. Melbourne VIC; NICS; 2008.

6. Locock L. Healthcare redesign: meaning, origins, application. Qual Saf Health Care 2003; 12(1): 53–58.

7. Royal Australasian College of Physicians (RACP). Standards for the care of children and adolescents in health services. Sydney NSW; RACP; 2008.

8. Garling P, SC. Final report of the special commission of inquiry: Acute care services in NSW public hospitals. Sydney; NSW Special Commission of Inquiry; 2008.

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1.5 Safety Standard

The standard is: The organisation provides safe care and services.

This standard should be read in conjunction with criteria 1.1.5 clinical handover / discharge / transfer of care, 2.1.2 risk management, 2.1.3 incident management, 2.1.4 complaints management and 3.2.5 security management.

A degree of flexibility is provided in this standard. Some of the criteria will be more relevant to some healthcare organisations than to others. The flexibility in these criteria is explained in the guidelines under each criterion. Organisations should determine the level of achievement required in each of these criteria.

Further, organisations should determine those issues that do pose the biggest safety risks in their organisations. These should be managed effectively under an alternative criterion, for example the risk management criterion or the security management criterion for the management of aggression in mental health services.

The intent of this standard is to ensure that healthcare organisations focus efforts on reducing harm to consumers / patients and staff. This standard expects that organisations will develop a system for reducing the incidence of harm, specifically the most common causes of harm in Western health systems. They are:

• medication errors

• healthcare acquired infections

• breakdowns in skin integrity

• falls

• errors in the management of blood products

• patient identification errors

• malnutrition.

There are seven criteria in this standard. They are:

1.5.1 Medications are managed to ensure safe and effective consumer / patient outcomes.

1.5.2 The infection control system supports safe practice and ensures a safe environment for consumers / patients and healthcare workers.

1.5.3 The incidence and impact of breaks in skin integrity, pressure ulcers and other non-surgical wounds are minimised through wound prevention and management programs.

1.5.4 The incidence of falls and fall injuries is minimised through a falls management program.

1.5.5 The system to manage sample collection, blood, blood components / blood products and patient blood management ensures safe and appropriate practice.

1.5.6 The organisation ensures that the correct consumer / patient receives the correct procedure on the correct site.

1.5.7 The organisation ensures that the nutritional needs of consumers / patients are met.

Healthcare organisations should recognise that ensuring safety for both consumers / patients and all staff requires a far broader focus than the seven issues covered by this standard, and that efforts to improve safety within an organisation should therefore extend beyond these seven criteria. Potential for consumer / patient harm should be identified and prevented, with barriers built into the system, making it resilient to the impact of errors. Opportunities for staff harm should be managed in the same way.

Several aspects of safety are dealt with in other EQuIP standards and criteria. These include:

• Standard 1.1 Continuity of care

• Criterion 2.1.2 the risk management criterion, which provides the basis of an effective safety system

• Criterion 2.1.3 the incident management criterion, which provides the cornerstone to any good consumer / patient safety system

• Criterion 2.2.3 Performance review

• Criterion 2.2.4 Staff education

• Criterion 2.3.3 Data and information use

• Criterion 3.1.2 External service providers

• Criterion 3.1.3 Credentialling and defining the scope of clinical practice.

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Criterion LA – Awareness sA – ImplementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 1.5.1

Medications are managed to ensure safe and effective consumer / patient outcomes.

this is a mandatory criterion

a) There is policy / guidelines for medication management that is consistent with the Australian Pharmaceutical Advisory Council (APAC) guidelines together with jurisdictional legislation.

b) A multidisciplinary body oversees the management of medication safety.

c) Healthcare providers have access to published guidelines for medication management.

d) A standardised list of approved abbreviations for medications is used throughout the organisation.

e) Medication risks are identified, evaluated and acted upon with particular focus on high risk medications.

a) Clinical staff are provided with orientation and ongoing education on the policy and procedures of safe medication management.

b) Procedures are implemented to reduce the risk and number of medication errors.

c) Medication documentation is standardised across the organisation.

d) There is a system to report medication errors, near misses and adverse drug reactions and this is linked to the incident management system.

e) The orientation system is updated when new risks are identified.

f) There is pharmacy involvement in the storage, transport and distribution system.

g) A system is implemented to ensure medication review of individual consumers / patients.

h) Consumers / patients and carers are educated about prescribed medications to encourage ongoing safe use of medications and compliance after discharge.

a) The system for safe medication management is evaluated and improved as required.

b) Medication errors, near misses and adverse drug reactions are reported, analysed and trended, and further strategies to reduce medication incidents are implemented.

c) Medication storage, distribution and transport processes are evaluated and improved as required.

a) The organisation compares medication management systems and medication error data internally and externally and improvements are made to ensure better practice.

and/or

b) The organisation implements evidence-based advanced systems for medication management.

and/or

c) The organisation conducts research and develops innovative methods to improve medication management.

a) The organisation demonstrates it is a leader in medication management.

IntentSafe, high quality care and effective consumer / patient outcomes depend upon the correct management of medications. The intent of this criterion is to ensure that medications are managed to:

• reduce the incidence of error in the prescription, dispensing and administration of medications to consumers / patients

• reduce the harm caused to consumers / patients in healthcare organisations by medication errors.

Relationships of 1.5.1 with other criteriaMedications and their management are relevant throughout the care journey of the consumer / patient (Standard 1.1). Medication management is an important aspect of the organisation’s integrated risk management framework (Criterion 2.1.2), and errors in this area may result in incidents, including sentinel events (Criterion 2.1.3), which may lead to complaints (Criterion 2.1.4).

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Criterion LA – Awareness sA – ImplementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 1.5.1

Medications are managed to ensure safe and effective consumer / patient outcomes.

this is a mandatory criterion

a) There is policy / guidelines for medication management that is consistent with the Australian Pharmaceutical Advisory Council (APAC) guidelines together with jurisdictional legislation.

b) A multidisciplinary body oversees the management of medication safety.

c) Healthcare providers have access to published guidelines for medication management.

d) A standardised list of approved abbreviations for medications is used throughout the organisation.

e) Medication risks are identified, evaluated and acted upon with particular focus on high risk medications.

a) Clinical staff are provided with orientation and ongoing education on the policy and procedures of safe medication management.

b) Procedures are implemented to reduce the risk and number of medication errors.

c) Medication documentation is standardised across the organisation.

d) There is a system to report medication errors, near misses and adverse drug reactions and this is linked to the incident management system.

e) The orientation system is updated when new risks are identified.

f) There is pharmacy involvement in the storage, transport and distribution system.

g) A system is implemented to ensure medication review of individual consumers / patients.

h) Consumers / patients and carers are educated about prescribed medications to encourage ongoing safe use of medications and compliance after discharge.

a) The system for safe medication management is evaluated and improved as required.

b) Medication errors, near misses and adverse drug reactions are reported, analysed and trended, and further strategies to reduce medication incidents are implemented.

c) Medication storage, distribution and transport processes are evaluated and improved as required.

a) The organisation compares medication management systems and medication error data internally and externally and improvements are made to ensure better practice.

and/or

b) The organisation implements evidence-based advanced systems for medication management.

and/or

c) The organisation conducts research and develops innovative methods to improve medication management.

a) The organisation demonstrates it is a leader in medication management.

Planning for medication safety This criterion relates to all healthcare organisations that prescribe, dispense and/or administer medications. Support service providers will need to consider the medications prescribed by other services when assessing their consumers / patients.

The use of medication remains the most common intervention in health care. Medicine misuse, underuse, overuse and adverse reactions annually result in an estimated 140,000 hospital admissions in Australia1; up to 75% of these adverse drug events are potentially preventable.2

Medication management policies and procedures should be based on quality use of medicines principles as developed by the National Prescribing Service (NPS) as part of the Australian National Medicines Policy.3 Quality Use of Medicines (QUM) has a consumer focus and is based on three simple principles:

• select appropriate therapeutic management option (not always pharmaceutical)

• choose suitable medications

• use medications safely and effectively.

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Criterion 1.5.1

Medications are managed to ensure safe and effective consumer / patient outcomes. (continued)

Although medical and some allied health staff, rather than organisations, prescribe medications, organisations should provide guidance through position statements or procedures on issues such as the dispensing of medications at discharge, support for and access by pharmaceutical representatives, selection of medications for the organisation’s formulary (including generic vs branded items), off-label prescribing, the use of complementary medicines and guidance on specific medications or conditions.

All strategies aimed at reducing medication errors and the harm caused by medication errors should be focused on decreasing the complexity of processes by reducing the number of steps and promoting standardisation. Some of these strategies include:

• standardised medication charting across the organisation, such as the National In-Patient Medication Chart4

• medication reconciliation at the time of admission

• specific actions5 to reduce adverse events associated with identified high-risk medicines

• automated dispensing throughout the organisation, particularly when linked to bar-coding

• individual medication reviews for consumers / patients

• ensuring that staff prescribing medications comply with best practice guidelines though audit and ongoing education.

A medication management system should:

• address medication safety across the continuum of care; from the community into the acute service and on return to the community

• cover all drugs, drug delivery devices (including infusion pumps with safety features), labelling processes and information transfer processes relating to drug therapy

• consider the choice of the drug distribution system, its level of automation, and relationships between different internal systems such as ward stock and the central supply system6, bedside lockers, individually dispensed medicines or automated dispensing devices

• recognise that uninterrupted focus during dispensing is key to reducing errors7

• be tied to the risk management system and specifically the incident management system

• refer to the Australian Pharmaceutical Advisory Council’s Guiding Principles8, 9 to achieve continuity in medication management.

Prompt points

¼ What policies / guidelines relate to medication management? How does the organisation ensure these reflect relevant legislation, and are updated in response to any changes in legislation? Has the organisation reviewed consistency of its policies / guidelines with APAC guidelines?

¼ What body oversees the management of medication safety in the organisation? How is membership determined? What are the responsibilities of this group? How frequently does the group meet? Is this body involved in evaluating the system for safe medication management? If so, what actions have been taken to improve safety through better medication management?

¼ What procedures reduce the risk of medication errors? What other systems exist to improve medication safety? How is compliance with these procedures monitored? What actions have been taken in response to any medication safety issues or near misses at this or other similar organisations?

Access to guidelinesIt is important that clinical staff have ready access to up-to-date editions or digital copies of medication references such as MIMS, the Australian Medicines Handbook, the Therapeutic Guidelines series and the ‘PBS Yellow Book’.

Most State / Territory health departments will have policies and implementation guidelines for medication management.10 The Australian Pharmaceutical Advisory Council (APAC) has developed guidelines for the use of medicines in settings such as residential aged care11 and the community9. They have also developed guidelines for ensuring continuity in medication management as consumers / patients move between healthcare settings.8

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Most State / Territory health departments have also developed policies and procedures assisting or directing staff in decision making on high-risk, high-cost and controversial drugs and conditions.12 The Society of Hospital Pharmacists (SHPA) developed a specific process for evaluating drug use (DUE) in a hospital setting. The SHPA Standards of Practice for Drug Use Evaluation in Australian Hospitals provides a useful starting point for continuously improving the use of specific medications and adopts a continuous quality improvement approach to evaluating current drug use and then making changes to improve how medications are used.13

Prompt points

¼ How do healthcare professionals access medication information when working at the organisation?

¼ What medication reference sources are available to healthcare professionals? Who is responsible for ensuring that the information / editions are regularly updated?

Standardised medication recordingThe Australian Commission on Safety and Quality in Health Care (the Commission) has identified medication safety as one of their priority areas and offers information and resources14 to assist organisations to reduce error and harm from medications. Included in the Commission’s recommendations is the use of a common medication chart15 across all health services in Australia.16

Healthcare organisations are encouraged to implement a common chart when possible.

In addition, the Commission has developed recommendations regarding the standardisation of language, including abbreviations used in medication prescribing, that have been adopted by some organisations and State / Territory health departments17 to avoid identified sources of error. Further information and access to these resources is at: http://www.safetyandquality.gov.au/internet/safety/publishing.nsf/Content/PriorityProgram-06

Prompt points

¼ How are staff introduced to the standardised list of abbreviations and trained in its use?

¼ How does the organisation monitor health records to ensure that entries follow standards for medication recording? When inconsistencies / problems are detected through incidents or audits of consumer / patient records, what action(s) are taken?

Medication risk management and error reporting A healthcare organisation is responsible for ensuring that it has a culture for medication management and reporting systems that enables the identification and notification of as many medication errors, near misses and adverse drug events and/or reactions as possible. This is essential if potential risks are to be identified, evaluated and acted upon. Incident reports provide valuable information about incidents and near misses, however additional systems should be in place to gather information about adverse drug events. These include health record reviews, audits, reviews of the literature and various reports.

High-risk medications often have a small therapeutic range, for example anticoagulants, particularly warfarin, intravenous potassium and insulin. Other medications can pose a high risk due to the possibility of them being transcribed incorrectly, such as products with sound-alike names18 or brand names that include numbers. Some packaging or the medications themselves can be similar in appearance.

Prompt points

¼ What medication risks or potential risks have been identified at the organisation? What actions have been taken to minimise risks associated with the use of these medications?

¼ What system is used to track incidents / near misses at this organisation? How are those related to medication management differentiated from other types of incidents? Based on monitoring across the organisation, have any causative issues been identified? What actions have been taken to reduce the risk of medication incidents?

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Criterion 1.5.1

Medications are managed to ensure safe and effective consumer / patient outcomes. (continued)

Staff education Clinical pharmacology and medication management are areas that are constantly changing as new medications and treatment modalities become available. Ongoing education and training in pharmacology for all staff involved in prescribing, dispensing and administering medications is essential.

Staff new to the organisation should be oriented to the medication records used, systems of clinical handover and to equipment used for medication delivery, including devices such as infusion pumps. ‘Hands on’ practice will improve efficiency and may reduce error.

Strategies for identifying potential medication risk should rely on:

• external information (for example, the National Prescribing Service (NPS) promotes quality use of medicines through newsletters such as Australian Prescriber, RADAR, Prescribing Practice Review and Nurses Update, and State / Territory health departments publish alerts following investigations of serious incidents)

• the organisation’s own incident monitoring processes, which may identify local issues.

Prompt points

¼ How is medication management integrated into clinical staff orientation programs? How are any organisation- or ward-specific aspects of medication recording and clinical risk management addressed during orientation? How does orientation differ for Visiting Medical Officers compared to employed clinical staff?

¼ How are medication-related areas requiring additional training / education identified in newly appointed staff? Is medication management included in ongoing performance evaluation?

Storage, transport and distribution Storage, transport and distribution refer to the manner in which medications are stored and the movement of pharmaceutical products around the healthcare organisation.

The Society of Hospital Pharmacists (SHPA) has developed Standards of Practice for the Distribution of Medications in Australian Hospitals19 to assist in ensuring the right consumer / patient receives the right medicine, in the right presentation, that will deliver the prescribed treatment in the right dose at the right time with the least potential for error, at the lowest cost. These Standards of Practice provide information on packaging and labelling of medications, as well as the types of areas that need to be considered for storage of medications outside of the pharmacy. This includes security of medications, as well as refrigeration where necessary and systems to maintain and monitor cold chain.

Cold chain and security / access requirements apply to all lockers and fridges in which medications are stored on site. It includes the wards, emergency departments, surgeries and the centralised drug purchasing, distribution and storage system. However, this criterion does not address the transport chains used to supply organisations with products; this is addressed within criterion 3.1.4, which deals with external service provision.

The storage, distribution and transport system should:

• comply with all legislative requirements

• provide medicines to consumers / patients in a timely manner

• carry the lowest possible risk of error

• minimise the cost of medicine storage, distribution and use

• minimise wastage

• provide data on medicine utilisation, preferably to the level of the individual consumer / patient

• identify unusual medicine usage patterns.

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Prompt points

¼ What pharmacy staff (if any) are employed by the organisation? What roles do pharmacy staff undertake in the storage, transport and distribution of medications around the organisation?

¼ Who / what committee is involved in the evaluation of medication storage, distribution and transport processes?

¼ What has been discovered as a result of evaluating these processes? Have any improvements been made to the system?

¼ How does the organisation know that medicines are being distributed accurately, appropriately, efficiently and cost-effectively?

Consumer / patient medication review and education Australian clinical pharmacy practice standards describe goals and procedures for ten activities aimed at optimising the use of medicines and consumer / patient outcomes. They are:

• accurate medication history

• assessment of current medication management

• clinical review

• decision to prescribe a medicine

• therapeutic drug monitoring

• ward round participation

• provision of medicines information to health professionals

• provision of medicines information to consumers / patients

• information for ongoing care

• adverse drug reaction management.

To further assist safe use of medicines, in 2004 Australian Health Ministers called for every public organisation to have in place a process of pharmaceutical review of medication prescribing, dispensing, administration and documenting processes for the use of medicines. Organisations should strive to follow these directives, which would greatly benefit medication management.

It is not expected that all organisations will have access to a clinical pharmacist, however a pharmacist provides specific pharmaceutical expertise to help to maximise medicine efficacy and minimise medicine toxicity in individual consumers / patients. Including pharmacists as part of the clinical team may help to reduce medication errors.

In the absence of a pharmacist, other healthcare professionals should undertake the medication review. The review should evaluate a consumer / patient’s current medication8 as soon as practicable after admission with a view to:

• identifying the appropriateness and effectiveness of current medication, rationalising current medications if appropriate

• paying particular attention to any problems associated with current drug therapy including any possible relationship with current medical condition

• documenting allergies and any previous adverse drug reactions.

Wherever appropriate, consultation should occur with the consumer / patient’s primary practitioner.

Consumers / patients can benefit from the NPS-initiated, consumer-focused program that aims to provide information about medicines and to reinforce the importance of consumers / patients working with their healthcare providers.20

Prompt points

¼ Who undertakes medication reviews in the organisation? How are consumers / patients requiring medication reviews identified and the review scheduled?

¼ How are consumers / patients educated about their medications before discharge? How is the effectiveness of this process assessed?

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Performance measurementThis criterion states that: “Medications are managed to ensure safe and effective consumer / patient outcomes”. The organisation should be able to demonstrate that it has processes in place aimed at reducing the incidence of error in the prescribing, dispensing and administering of medications, and to reduce harm caused to the consumer / patient as a result of such errors.

Indicators have a useful role in medication safety as near misses and sentinel events can play a significant role in alerting risky practices. Frequently reported risk or error without harm should be investigated fully. It provides an opportunity to avert catastrophic harm.

Because the administration of medicines is so frequent in a hospital setting, variations in indicators offer statistical evidence that has potential for interesting and insightful investigation. Results can be compared over time and against other organisations. After ensuring that differences are not the result of variation in definitions or counting practices, variations in consumer / patient pool and practices may be considered and risky practices avoided.

Some common suggested performance measures are as follows:

Number of reported near misses that are medication incidents

Total number of near misses

Criterion 1.5.1

Medications are managed to ensure safe and effective consumer / patient outcomes. (continued)

Evidence commonly presented

Consider whether the following will help to address criterion 1.5.1

¼ Audits of:

– medication error rates – adverse reaction rates – prescriptions – compliance with medications

¼ Policies, including reference to APAC

¼ Medication chart review

¼ Medicines reconciliation procedures or audit of activity

¼ Standard list of abbreviations

¼ Evidence of pharmacy or pharmacist involvement in the distribution system

¼ Health record review

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Number of notified incidents that are medication incidents

Total number of notified incidents

Number of notified medication incidents associated with an adverse event

Total number of notified medication incidents

Number of medication incidents which were reviewed and where the recommendations were implemented

Total number of notified medication incidents

Number of medication charts with illegible writing

Total number of medication charts audited

Comment: for instance, the pharmacist does not know what to dispense

Number of consumers / patients who have received information about their medication

Total number of consumers / patients prescribed medication

Number of consumers / patients satisfied with information received about their medications

Total number of consumers / patients surveyed

Number of consumers / patients who are satisfied with postoperative pain control

Total number of consumers / patients surveyed

Number of consumers / patients who have received written information about facility-initiated drugs that are to be continued post-discharge

Total number of consumers / patients prescribed facility-initiated drugs that are to be continued post-discharge

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Criterion 1.5.1

Medications are managed to ensure safe and effective consumer / patient outcomes. (continued)

Number of consumers / patients who experience morbidity as a result of a preventable adverse drug event

Total number of consumers / patients who experience morbidity

Number of consumers / patients who did not bring their medication

Total number of consumers / patients admitted

Comment: this could be due to different reasons such as that the consumer / patient had not been informed or forgot

Number of newly admitted consumers / patients that had a medication reconciliation completed within 24 hours

Total number of consumers / patients admitted

Number of consumers / patients with a length of stay greater than X days who are reviewed by a clinical pharmacist

Total number of consumers / patients with a length of stay greater than X days

Comment: organisation to define ‘X’; not all organisations have access to a clinical pharmacist; a medication review may be undertaken by another appropriate means

Number of elective procedures delayed or cancelled due to medication issues

Total number of elective procedures delayed or cancelled

Comment: e.g. consumer / patient taking inappropriate medication

Number of ‘at-risk’ consumers / patients recommended for a Home Medicines Review in a community-based health setting

Total number of consumers / patients ‘at-risk’ of medication misadventure in a community-based health setting

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References1. Stowasser DA, Allison YM and O’Leary KM. Understanding

the medicines management pathway. J Pharm Pract Res 2004; 34(4): 293-296.

2. Runciman WB, Roughead EE, Semple SJ and Adams RJ. Adverse drug events and medication errors in Australia. Int J Qual Health Care 2003; 15(Suppl 1): i49-i59.

3. Commonwealth of Australia. National strategy for quality use of medicines. Canberra ACT; Commonwealth of Australia; 2002.

4. Leach H. National inpatient medication chart implementation. J Pharm Pract Res 2006; 36(1): 1-2.

5. UK National Health Service (NHS). The ‘how to’ guide for reducing harm from high risk medicines. In: Clarke J (ed). Patient Safety First Campaign. London UK; NHS; 2008.

6. Rodriguez EM and Hickey K. A multi-vendor approach to restructuring medication management systems. Pharmacy Purchasing and Products 2008; January: 14-15. Accessed from http://www.pppmag.com/documents/V5N1/p14_16.pdf on 1 September 2010.

7. Westbrook J, Woods A, Rob M et al. Association of interruptions with an increased risk and severity of medication administration errors. Arch Intern Med 2010; 170(8): 683-690.

8. Australian Pharmaceutical Advisory Council (APAC). Guiding principles to achieve continuity in medication management. Canberra ACT; APAC; 2005.

9. Australian Pharmaceutical Advisory Council (APAC). Guiding principles for medication management in the community. Canberra ACT; Commonwealth of Australia; 2006.

10. Queensland Health. Medication management manual. In: Lynne T (ed). Brisbane; Qld Health; 2003.

11. Australian Pharmaceutical Advisory Council (APAC). Guidelines for medication management in residential aged care facilities. 3rd edn. Canberra ACT; APAC; 2002.

12. WA Therapeutic Advisory Group (WATAG). Publications and guidelines. Perth WA; WATAG. Accessed from http://www.watag.org.au/watag/publications.cfm#guidelines on 1 March 2010.

13. Society for Hospital Pharmacists of Australia (SHPA) Committee of Speciality Practice in Clinical Pharmacy. Guidelines for self-administration of medication in hospitals and residential care facilities. J Pharm Pract Res 2002; 32(4): 324-325.

14. Dearne K. Toolkit to reduce hospital dispensing errors. The Australian, Canberra ACT; News Limited; 1 September 2009: 31.

15. Australian Commission on Safety and Quality in Health Care (ACSQHC). National inpatient medication chart. Sydney NSW; ACSQHC. Accessed from http://www.safetyandquality.gov.au/internet/safety/publishing.nsf/content/NIMC_001 on 8 January 2010.

16. Australian Health Ministers’ Conference. Joint communiqué: Health ministers agree to reform agenda. Canberra ACT; Australian Council for Safety and Quality in Health Care; 2004.

17. WA Department of Health. Operational Directive: Standardisation of terminology, abbreviations and symbols in the prescribing and administration of medicines. Perth; WA Health; 2009.

18. Joint Commission on Accreditation of Healthcare Organisation (JCAHO), Joint Commission International and WHO Collaborating Centre for Patient Safety Solutions. Look-alike, sound-alike medication names. Patient Saf Solns 2007. 1(Solution 1): 1–4. Accessed from http://www.health.vic.gov.au/qum/downloads/sound_alike.pdf on 25 February 2010.

19. Society for Hospital Pharmacists of Australia (SHPA). Standards of practice for the distribution of medicines in Australian hospitals. J Pharm Pract Res 2006; 36(2): 143-149.

20. National Prescribing Service (NPS). Information for consumers, and information for health professionals. Sydney NSW; NPS. Accessed from http://www.nps.org.au/# on 14 October 2009.

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Criterion LA – Awareness sA – ImplementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 1.5.2

The infection control system supports safe practice and ensures a safe environment for consumers / patients and healthcare workers.

this is a mandatory criterion

a) There is an infection control policy / guidelines, including notifiable diseases, sterilisation and reprocessing where applicable, that is referenced to:

(i) Australian standards

(ii) jurisdictional legislation

(iii) codes of practice

(iv) industry guidelines.

b) The infection control management plan is approved, supported and resourced by the organisation’s executive.

c) There is policy / guidelines for food handling that includes storage, preparation and distribution in accordance with jurisdictional regulations and/or standards.

d) There is policy / guidelines for the collection of dirty linen, management, transport and storage of clean linen within the healthcare facility.

e) Healthcare providers are educated and information is available on the risks of infection including their responsibilities in preventing infection.

f) Healthcare providers are supplied with equipment and an environment that enables them to implement the infection control policy / guidelines.

g) External service providers, students, carers and visitors are advised of the organisation’s infection control requirements.

a) The infection control management plan is reviewed and adequate resources are provided to ensure implementation of the plan and related policies.

b) Infection prevention strategies are integrated into all stages of healthcare planning, including health facility planning, construction and/or refurbishment.

c) There is a documented program of continuous education for staff about infection control issues.

d) A standardised hand hygiene observation assessment tool is used throughout the organisation.

e) The infection control system includes isolation and containment of infections when required.

f) Policy / guidelines for collection of dirty linen, management, transport and storage of clean linen are implemented within the health facility.

g) A system is implemented for appropriate use of antibiotics and antimicrobials.

h) An effective surveillance system is implemented to monitor healthcare associated infections.

i) The infection control system ensures effective communication of infection risks and management to consumers / patients and their carers.

a) The infection control system is evaluated and improved as required.

b) The system for the reprocessing of medical devices demonstrably complies with:

(i) Australian Standards

(ii) jurisdictional requirements

c) Hand hygiene practices are evaluated and improved as required.

d) The appropriate use of antibiotics and antimicrobials is evaluated and improved as required.

a) Performance indicators for the infection control system are compared with internal and external systems, and improvements are made to ensure better practice.

and/or

b) The organisation communicates results of its performance in its infection control publicly to inform consumers / patients, colleagues and peers.

and/or

c) The organisation undertakes research in areas of infection control and utilises results to improve clinical practice.

and/or

d) The organisation demonstrates innovation in its infection control program.

a) The organisation demonstrates it is a leader in infection control systems.

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Criterion LA – Awareness sA – ImplementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 1.5.2

The infection control system supports safe practice and ensures a safe environment for consumers / patients and healthcare workers.

this is a mandatory criterion

a) There is an infection control policy / guidelines, including notifiable diseases, sterilisation and reprocessing where applicable, that is referenced to:

(i) Australian standards

(ii) jurisdictional legislation

(iii) codes of practice

(iv) industry guidelines.

b) The infection control management plan is approved, supported and resourced by the organisation’s executive.

c) There is policy / guidelines for food handling that includes storage, preparation and distribution in accordance with jurisdictional regulations and/or standards.

d) There is policy / guidelines for the collection of dirty linen, management, transport and storage of clean linen within the healthcare facility.

e) Healthcare providers are educated and information is available on the risks of infection including their responsibilities in preventing infection.

f) Healthcare providers are supplied with equipment and an environment that enables them to implement the infection control policy / guidelines.

g) External service providers, students, carers and visitors are advised of the organisation’s infection control requirements.

a) The infection control management plan is reviewed and adequate resources are provided to ensure implementation of the plan and related policies.

b) Infection prevention strategies are integrated into all stages of healthcare planning, including health facility planning, construction and/or refurbishment.

c) There is a documented program of continuous education for staff about infection control issues.

d) A standardised hand hygiene observation assessment tool is used throughout the organisation.

e) The infection control system includes isolation and containment of infections when required.

f) Policy / guidelines for collection of dirty linen, management, transport and storage of clean linen are implemented within the health facility.

g) A system is implemented for appropriate use of antibiotics and antimicrobials.

h) An effective surveillance system is implemented to monitor healthcare associated infections.

i) The infection control system ensures effective communication of infection risks and management to consumers / patients and their carers.

a) The infection control system is evaluated and improved as required.

b) The system for the reprocessing of medical devices demonstrably complies with:

(i) Australian Standards

(ii) jurisdictional requirements

c) Hand hygiene practices are evaluated and improved as required.

d) The appropriate use of antibiotics and antimicrobials is evaluated and improved as required.

a) Performance indicators for the infection control system are compared with internal and external systems, and improvements are made to ensure better practice.

and/or

b) The organisation communicates results of its performance in its infection control publicly to inform consumers / patients, colleagues and peers.

and/or

c) The organisation undertakes research in areas of infection control and utilises results to improve clinical practice.

and/or

d) The organisation demonstrates innovation in its infection control program.

a) The organisation demonstrates it is a leader in infection control systems.

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Criterion 1.5.2

The infection control system supports safe practice and ensures a safe environment for consumers / patients and healthcare workers. (continued)

IntentThe intent of this criterion is to ensure that, whenever possible, infections are prevented from occurring in health services; and that where prevention is not possible, infections are managed effectively.

Relationships of 1.5.2 with other criteriaStrategies to address the risk of infection in healthcare settings should be an aspect of the organisation’s maintenance of a safe environment for its consumers / patients and staff (Standard 3.2). Facility design, cleaning protocols (Criterion 3.2.2) and waste management systems (Criterion 3.2.3) may impact upon the control of infection.

The organisation will help to protect staff via its immunisation program (Criterion 2.2.5). Where sterilisation is outsourced to an external service provider (Criterion 3.1.4), processes must ensure the quality of the service. Infection presents a significant challenge to the provision of safe care and services (Standard 1.5). Appropriate care delivered in the most appropriate setting will help to reduce the incidence of infection (Criterion 1.3.1). The organisation must address infection control through its integrated risk management framework (Criterion 2.1.2), and failure to do so effectively may lead to incidents (Criterion 2.1.3) and complaints (Criterion 2.1.4).

Infection prevention and controlInfection control in healthcare organisations is a key area for safe practice. Because of the nature of health care, consumers / patients and staff can be sources and recipients of infection. Infections can be transmitted from person to person or may be sourced from the environment, including from consumer / patient care equipment. Consumers / patients, staff and any visitors to the facility may be a source or the receiver of infection-causing organisms.

Adopting evidence-based, quality infection control measures can potentially prevent many instances of infection, and minimise the risk of others1, 2.

Standard precautions should be used routinely and extended when there are additional risks.3 Standard precautions include:

• hand hygiene and respiratory etiquette

• use of personal protective equipment (aprons, gowns, face and eye protection, gloves, footwear, etc.)

• handling and disposing of sharps, including the removal and disposal of scalpel blades from scalpel handles, according to AS/NZS 3825:1998 Procedures and devices for the removal and disposal of scalpel blades from scalpel handles

• decontamination of the physical environment, including consumer / patient care equipment

• reprocessing of instruments and other medical devices

• management of blood and body substance spills.

Additional precautions should be undertaken when staff know or suspect a specific infectious agent. These can be initiated while confirmation by testing is pending. Appropriate responses, including duration of response3 and management of any immunocompromised consumers / patients3, will vary depending on the infectious agent and its mode of transmission.

Management support An outline of the overall infection control (IC) strategy should be documented in an IC plan or manual. In addition to adopting legislated and policy processes, the strategy has to respond to the unique circumstances of the organisation, such as its physical features, climate, casemix, procedural and service profile, its staffing and visitors. The manual should include a risk management plan that covers management of infection outbreaks, a funding model for the program’s areas of activity and a description of resources necessary to implement and sustain these activities.4

The infection control management plan (ICMP) outlines the program structure, overall aims and objectives, the associated quality management activities, program evaluation criteria and timeframes for review.5 The document should identify:

• who is at risk and from what

• the hazards involved

• the procedures for minimising risk

• appropriate measures for infection control, based on standard precautions and, when required, additional precautions.

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The plan should address the governance of infection control – including articulation with other committees and structures (internal and external).5 The plan should be reviewed regularly5 and updated accordingly.

Prompt points

¼ What groups or persons play key roles in executing the infection control plan? Who is ultimately responsible for issues relating to infection control?

¼ How is the Board or General Manager involved in infection control planning? Who is responsible for budgeting and signing off on budgets that arise from the infection control plan?

¼ What actions have been taken in the past 2 years to improve infection control at the organisation? How will the effectiveness of the change(s) be monitored?

Facility design, renovations and refurbishmentAll areas of a healthcare facility should be designed, constructed, furnished and equipped to minimise the risk of transmission of infection. In particular, the design and layout of the facility should assist the application of standard and additional precautions by the staff.

In any modification to the healthcare environment, such as renovations, aim to reduce:

• airborne transmission

• surface contamination and transmission

• water-borne contamination and transmission of infection.

Where consultant planners have been appointed to design or renovate a facility, the briefing documents will list healthcare requirements; infection control issues must be clearly stated. The infection control officer should be accessible during design. Many States / Territories have formal guidelines to facilitate building planning6, 7, 8

Renovations in an existing facility may involve relocating staff and consumers / patients, altered access, different supply procedures and/or the presence of additional people (architects, consultants, tradesmen). All of these may compromise pre-existing physical features of a building that limit the spread of infection.

Prompt points

¼ What building design features currently make infection control challenging for this organisation? What potential is there to make physical changes to improve these features? What practices have been adopted to reduce the risks associated with these features?

¼ How is the infection control manager or a knowledgeable IC consultant involved in any planning for a new health facility design or for changes to existing buildings?

Policy and processOrganisations should have infection control policies as an aspect of the Infection Control Management Plan / Infection Control Manual. Policy and particularly procedures should be based upon the organisation’s services, licences and risks, and therefore be both relevant and achievable. Policy and procedures should address all legislated requirements, include performance standards, and be based on existing jurisdictional directives, such as notifiable disease identification and reporting, guidelines and Australian standards.

Policy should also address cleaning of the environment in which health care is provided, single use items and reprocessing of sterile instruments.

Sterilisation and reprocessing should be directly addressed in the infection control manual. Purchased sterile disposables should comply with specifications in Therapeutic Goods Orders issued under the Commonwealth Therapeutic Goods Act 1989; examples include gloves for different purposes, suture materials, and packaging of blood and blood components.

Policy should also address risks to employees from infection within the workplace, such as:

• protection from, and response to, needlestick injuries and other blood exposure9

• testing for previous exposure / carrier status for some specific diseases9

• immunisation requirements - auditing, provision and recording – based on workplace risk categorisation9, 10

• education and training in relation to infection risks.

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Criterion 1.5.2

The infection control system supports safe practice and ensures a safe environment for consumers / patients and healthcare workers. (continued)

Organisations should be aware of relevant standards in regard to food safety, cleaning and laundry, and how and when external service providers may enter patient areas. Consideration of infection control issues should also be made in care situations where visiting hairdressers, podiatrists and companion animals, etc., attend.

Staff working in informal settings or a setting that may be considered to be low risk, such as office-based practices, community settings or long-term care establishments with a home-like atmosphere, should be provided with the same hand hygiene facilities, protective clothing and protective equipment as staff working in larger healthcare settings. Waste should be disposed of in accordance with Australian standards in any healthcare setting.

Prompt points

¼ What legislation, regulations or codes of practice influence policies operating in the organisation?

¼ How does the organisation monitor compliance with infection control procedures? Has monitoring identified any areas requiring further action? What actions were proposed, and what has been their impact?

Antibiotics and antimicrobialsAustralia has a growing problem with multiresistant bacterial pathogens. Initially this was focused in hospitals, however resistance in the community is also rising.11

Inappropriate use of antimicrobials leads to11:

• the emergence of resistant bacteria

• an increase in the risk of consumer / patient harm from side effects

• infection with multiresistant bacteria (such as Staphylococcus aureus (MRSA) or vancomycin-resistant enterococci (VRE) or Clostridium difficile)

• unnecessary costs.

The Australian Commission on Safety and Quality in Health Care (the Commission) includes antibiotic stewardship in their multifaceted, multidisciplinary approach to preventing emergence of antimicrobial resistance and decreasing preventable healthcare-associated infections.

Stewardship programs aim to change antibiotic prescribing behaviour to reduce unnecessary use and promote the choice of agents less likely to select resistant bacteria, in line with guidelines and demonstrated patterns of antibiotic resistance.

Guidelines should be available on the use of prophylactic antimicrobials, covering high-risk classes of consumers / patients and specific procedures, and cases where staff experience occupational exposure to blood.

Further information can be found on the Commission’s website at: http://www.safetyandquality.gov.au/ internet/safety/publishing.nsf/Content/PriorityProgram -03_Antimicrobial-Ss

Prompt points

¼ What, if any, antibiotic prophylaxis is used for procedures at the organisation? Who is responsible for prescribing the drug? And its provision?

¼ How is antibiotic prescribing monitored?

¼ How is the Quality Use of Medicines (QUM) promoted, particularly in relation to antibiotics?

¼ What actions have been taken to limit the use of broad spectrum antimicrobials in the organisation?

Infectious disease Guidance should be available for staff on managing highly infectious diseases and recommendations for isolation. Many respiratory infections have the potential for rapid, epidemic spread. Infection management procedures for a wide range of diseases are available via State / Territory governments.12

Planning should focus on control of infection through13:

• elimination of potential exposures, e.g. restricted entry for workers and visitors who are sick

• engineering controls, e.g. partitioning triage areas, isolation rooms, closed suctioning systems on airways of intubated consumers / patients, limiting movement of consumers / patients for diagnostic procedures

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• administrative controls, e.g. vaccination, surface disinfection, managing consumer / patient flow, hand hygiene / cough etiquette

• personal protective equipment, e.g. surgical masks, respirators, goggles

• additional precautions tailored to the specific infectious agent and its mode of transmission.

Prompt points

¼ How do clinical staff access information and forms for the notification of infectious disease?

¼ What actions can be taken to gain pathology, microbiological or diagnostic imaging results sooner when an infectious disease is suspected?

¼ How are infectious consumers / patients who may spread infection through aerosols or droplets managed in the organisation when admitted as an inpatient? e.g. during the swine flu outbreaks or annual influenza season?

Healthcare-associated infections Care in a health facility should not provide greater risks to the consumer / patient than the risks associated with the reason for admission to a facility. Healthcare-associated infections can be serious and life-threatening. Care workers and equipment can be vectors for the transmission of a number of pathogens. Managing infections through antibiotics, rather than preventing infections, has contributed to growing resistance14 in some bacteria, particularly Staphylococcus aureus and Escherichia coli. Clostridium difficile also presents unique challenges, particularly in environments where antibiotics are used.15

In today’s care environment, inpatients will be exposed to a series of care providers, any of whom might transfer infection. Only through disciplined behaviours by all care providers, supported by visitors and other staff, will healthcare-associated infections be effectively prevented.

Prompt points

¼ How are levels of healthcare-associated infection (HAI) monitored and tracked over time in the facility? If a rise in incidence of HAIs were detected, how and by whom would the problem be investigated?

¼ What is the most problematic resistant micro-organism for the organisation? What non-antibiotic-based approaches have been taken to manage the spread or increasing resistance of this organism?

Device reprocessingAS 4187:2003 Cleaning, disinfecting and sterilising reusable medical and surgical instruments and equipment, and maintenance of associated environments in health care facilities should be referred to when developing policy and the infection control management plan. In many States / Territories, compliance with this standard is legislated, usually within the professional practice acts for doctors and other procedural practitioners (e.g. NSW Medical Practice Regulation 2008).

There should be a process to ensure that the sterilising facility is alerted to instruments and associated materials used on consumers / patients with suspected or confirmed tuberculosis, measles, Creutzfeldt-Jakob disease or other conditions requiring additional precautions.

Designated personnel with skills, training and experience are responsible for the reprocessing of medical devices. Maintaining surgical asepsis relies on correct cleaning. The quality of cleaning should be monitored by an approved person to ensure that standards are maintained at all times. Where water quality is ‘hard’, appropriate cleaning products and disinfectants should be selected.16

When sterilising is outsourced, there should be a mechanism for monitoring any breaks in due process, keeping an overall record and reporting back to the supplier. Examples might include incomplete sealing of sterile packaging or inadequate cleaning.

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Criterion 1.5.2

The infection control system supports safe practice and ensures a safe environment for consumers / patients and healthcare workers. (continued)

Prompt points

¼ How does the organisation ensure that there are appropriately trained personnel supervising sterilising in the CSSD and at other sites where sterilising occurs?

¼ How are endoscopes reprocessed? Does this process comply with all legislation? What precautions have been taken to ensure that reprocessing will not cause delays for physicians?

Hand hygieneCorrect hand hygiene limits the transmission of micro-organisms by a healthcare worker:

• from one site on a consumer / patient’s body to another body site

• from one consumer / patient to another

• from the environment or healthcare equipment to a consumer / patient.

Non-procedural facilities and departments should also promote and practise good hand hygiene. Prolonged serious illness may impair the immune response of consumers / patients, increasing their vulnerability to infection.

In 2009, the World Health Organization (WHO) released findings of their evidence- and performance-based research aimed to improve hand hygiene in health care. This formed the basis for their guidelines on hand hygiene17, which under leadership from the Commission on Safety and Quality in Health Care have now been adopted throughout Australia.

The Australian National Hand Hygiene Initiative (NHHI) draws upon the WHO program. There is extensive information on implementation and planning for hand hygiene promotion activities and also detailed information on auditing compliance with an organisation’s program.18 Education program materials, auditor training and forms for auditing (audit forms and coding sheets) are available online from: http://www.hha.org.au/ForHealthcareWorkers.aspx.

A key requirement of the NHHI is placement of alcohol-based hand rub / gels / foams at the point of consumer / patient care, such as at the foot of the bed, to facilitate compliance with hand hygiene.

Prompt points

¼ What measures have been taken to provide clinicians with easy access to hand hygiene between every consumer / patient?

¼ How is hand hygiene compliance monitored in the facility? What are the target levels for compliance, and how close is the organisation coming to achieving these levels?

¼ How would an individual clinician who demonstrated poor adherence to hand hygiene be managed by the organisation?

Linen managementLinen management is outsourced by many healthcare facilities. The selection of appropriate external service providers and the contractual agreement process is addressed within criterion 3.1.4.

Linen management refers to the role of the organisation in coordinating the collection of dirty linen, its transfer to the laundry or to an external contractor, and how clean linen is stored, distributed and managed within the healthcare facility. The separation of clean linen from dirty linen should be maintained at all times.

Organisations, and individual departments19, should have clear procedures on how linen is to be managed. Staff should be trained in, or at least familiar with, these procedures and their purpose. Each ward will require its own regular, yet flexible, schedules for changing beds to minimise the risks associated with infected linen while responding to consumer / patient, nursing and physician needs. Consideration should also be given to the loads in skips, so that over-filling does not occur.

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Prompt points

¼ How do management procedures ensure that linen does not become a vector for transmission of infection? Who is responsible for monitoring compliance?

Food handlingFood can be a source of toxins and micro-organisms and there are clear guidelines and legislation for the storage, preparation and distribution of food.24 Reheating frozen and other pre-prepared foods is a risk factor in the spread of enteric diseases that can be life threatening for consumers / patients who are weak and/or immunosuppressed.

Family members may seek to bring food to the healthcare organisation for cultural reasons, dietary preferences or as a reward or enticement. Organisations should have procedures to manage these situations and should brief family members.20 ‘Nil by mouth’ signage should also be explained. Safety in storage and reheating of food is important; wherever possible, organisations should assist in providing refrigeration designated for food storage only, and microwaves to ensure adequate reheating.

Prompt points

¼ What actions ensure that food service does not become a source of illness in the facility?

¼ What actions are taken to protect consumers / patients from food-transmitted disease when food is brought from home?

¼ Is there a designated food storage refrigerator and a safe means of reheating food?

Education and information – staff, contractors, visitorsEducation and training in infection control, both internal and external to the organisation, should be current, documented and relevant to the organisation and staff roles.

Information provided to intending consumers / patients and their carers should include details pertinent to the infection control program. High dependency and intensive care units may limit attendances by number of people or duration of visit.

In situations where a consumer / patient is potentially infectious, access and contact may also be restricted; the associated risks and actions should be explained to a consumer / patient’s carers personally by a healthcare professional.

Hand hygiene, sharps management and respiratory hygiene reminders are well-suited to signage, which may overcome cultural barriers using visual elements. More in-depth explanations of these and other infection control aspects of care may be covered by discussions or in printed materials.

Web-based information can be updated quickly and easily, and disseminated widely. This is particularly useful for staff and/or the general public when responding to changing circumstances, such as during an influenza outbreak or following an emergency such as bushfires or floods.

Contracts and negotiations with external service providers should cover these contingencies to the satisfaction of the organisation’s lawyers:

• visits to the healthcare organisation site should follow infection control procedures – hand hygiene, separation of infective materials from non-infective

• regular service providers who visit the wards or sterile areas (e.g. cleaners, food delivery) should be trained, preferably by an infection control person from the organisation, to follow preferred practice.

A booklet or information sheet can be provided to individual personnel by the organisation; this will formalise infection control as an issue that may affect their role.

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Performance measurementThis criterion states that: “The infection control system supports safe practice and ensures a safe environment for consumers / patients and healthcare workers”. The organisation should be able to demonstrate that it has best evidence-based processes in place to prevent healthcare-associated infection whenever possible, in consumers / patients and staff members alike, and to manage effectively any infections that do occur.

Some common suggested performance measures are as follows:

Number of clusters / trends of infections which are reviewed and followed up

Total number of clusters / trends of infections

Comment: e.g. an outbreak of gastroenteritis

Number of staff who attended annual infection control training

Total number of staff required to attend annual infection control training

Comment: it is suggested that organisations collect data on different staff groups such as cleaners, kitchen staff, nurses, etc.

Criterion 1.5.2

The infection control system supports safe practice and ensures a safe environment for consumers / patients and healthcare workers. (continued)

Prompt points

¼ What information provided to consumers / patients covers infection control issues? In high-risk areas such as intensive care, how are family members educated about the risks and their management?

¼ Which contracts with external service providers include reference to infection control risks?

¼ What infection control information is provided to students and volunteers prior to them beginning a term of service?

¼ What is the response to outbreaks of healthcare-associated infections? How long is the response time? How is it evaluated and what are the results?

Evidence commonly presented

Consider whether the following will help to address criterion 1.5.2

¼ Infection control policies

¼ Infection control systems

¼ Sterilising process monitoring

¼ Meeting minutes

¼ Support services

¼ Evidence of staff immunisation

¼ Sterilisation tracking systems

¼ Evidence of advice given to external service providers, students, carers and visitors

¼ Staff training

¼ Risk assessment audits

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Number of consumers / patients whose prophylactic antibiotics were discontinued within 24 hours after surgery end time

Total number of consumers / patients who received prophylactic antibiotics prior to surgery

Number of percutaneous occupational exposures from recapping

Total number of needlestick injuries

Number of body fluid exposures

Total number of incidents

Number of non-percutaneous occupational exposures

Total number of occupational exposures

Number of consumers / patients who received antimicrobial prophylaxis

Total number of consumers / patients for whom antimicrobial prophylaxis was indicated

Comment: it is recommended that consumers / patients receive this within 1 hour prior to surgical incision (or 2 hours if receiving vancomycin)

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Criterion 1.5.2

The infection control system supports safe practice and ensures a safe environment for consumers / patients and healthcare workers. (continued)

References1. Gillespie EE, ten Berk de Boer FJ, Stuart RL et al.

A sustained reduction in the transmission of methicillin resistant Staphylococcus aureus in an intensive care unit Crit Care Resusc 2007; 9(2): 161-165.

2. Herzer KR and Seshamani M. A success story in health care in America: Eliminating infections and saving lives. Keystone USA; Michigan Health & Hospital Association and Johns Hopkins University; 2009.

3. National Health and Medical Research Council (NHMRC). Australian guidelines for the prevention and control of infection in healthcare. Canberra ACT; Australian Government; 2010. Accessed 15 October 2010 from http://www.nhmrc.gov.au/node/30290

4. Tropea J, Brand CA and Roberts C. A national stakeholder review of Australian infection control programs: the scope of practice of the infection control professional. Melbourne VIC; Australian Commission on Safety and Quality in Health Care; 2008.

5. Queensland Communicable Diseases Unit. Infection control guidelines – extract. 2nd edn. Brisbane; Queensland Health; 2001.

6. Health Projects International. Design guidelines for hospitals and day procedure centres. Melbourne; Victorian Department of Human Services; 2005.

7. Health Department of WA, Facilities & Assets Branch. Guidelines for the construction, establishment and maintenance of private hospital and day procedure facilities. 3rd edn. Perth; WA Health; 1998.

8. AHIA (formerly Health Capital and Asset Management Consortium) and UNSW Centre for Health Assets Australasia. Australasian Health Facility Guidelines (AusHFG). Sydney; UNSW. Accessed from http://www.healthfacilityguidelines.com.au/guidelines.htm on 11 December 2009.

9. Communicable Diseases Network Australia. Guidelines for managing blood-borne virus infection in health care workers. Canberra ACT; Commonwealth Department of Health and Aged Care; 2005.

10. Australian Technical Advisory Group on Immunisation (ATAGI) and National Health and Medical Research Council (NHMRC). Australian Immunisation Handbook. Canberra ACT; Australian Dept of Health and Ageing. Accessed from http://www.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook-home on 8 March 2010.

11. Australian Commission on Safety and Quality in Health Care (ACSQHC). Windows into safety and quality in health care 2009. Sydney NSW; ACSQHC; 2009.

12. NSW Health. A-Z of Infectious diseases. Sydney; NSW Health. Accessed from http://www.health.nsw.gov.au/publichealth/Infectious/a-z.asp on 10 March 2010.

13. Centers for Disease Control and Prevention (CDC). Interim guidance on infection control measures for 2009 H1N1 influenza in healthcare settings, including protection of healthcare personnel. Atlanta USA; US CDC. Accessed from http://www.cdc.gov/h1n1flu/guidelines_infection_control.htm on 10 March 2010.

14. Cars O, Diaz Högberg L, Murray M et al. Meeting the challenge of antibiotic resistance. Br Med J 2008; 337: a1438.

15. Kelly CP and LaMont JT. Clostridium difficile — More difficult than ever. N Engl J Med 2008; 359(18): 1932-1940.

16. Centre for Healthcare Related Infection Surveillance and Protection (CHRISP). Disinfection and sterilization infection control guidelines. Extract from Queensland Health infection control guidelines. Brisbane; Qld Health; 2006.

17. World Alliance for Patient Safety. WHO guidelines on hand hygiene in health care. Geneva, CH; World Health Organization; 2009.

18. Hand Hygiene Australia. 5 Moments for hand hygiene. In: Grayson ML, Russo P et al. (eds). Sydney NSW; Australian Commission on Safety and Quality in Health Care; 2009.

19. NSW Health. Infection control policy. Sydney; NSW Health; 2007.

20. Children’s Hospital Westmead (CHW). A handbook for families. Sydney NSW; CHW; 2005.

Relevant Australian StandardsHospital acquired infectionsHB 260:2003 Hospital acquired infections – Engineering down the risk.

GlovesAS/NZS 4011:1997/Amdt 1-1998 Single-use examination gloves – specification.

AS/NZS 4179:1997/Amdt 1-1998 Single-use sterile surgical rubber gloves – specification.

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MasksAS/NZS 4381:2002 Single-use face masks for use in health care. Second edn.

AS/NZS 1716:2003/Amdt 1-2005 Respiratory protective devices. Sixth edn.

AS/NZS 1715:2009 Selection, use and maintenance of respiratory protective equipment. Fifth edn.

eyewear / gogglesAS/NZS 4381:2002 Single-use face masks for use in health care. Second edn.

GownsAS 3789.2:1991/Amdt 1-1992 Textiles for health care facilities and institutions. Part 2: Theatre linen and pre-packs.

AS 3789.3:1994 Textiles for health care facilities and institutions – Apparel for operating theatre staff.

Handling and disposing of sharpsAS 4031:1992/Amdt 1-1996 Non-reusable containers for the collection of sharp medical items used in health care areas.

AS/NZS 4261:1994/Amdt 1-1997 Reusable containers for the collection of sharp items used in human and animal medical applications.

AS/NZS 3825:1998 Procedures and devices for the removal and disposal of scalpel blades from scalpel handles.

Processing of instruments and equipmentAS 1079.1:1993 Packaging of items (sterile) for patient care – Selection of packaging materials for goods undergoing sterilization. Second edn.

AS 1410:2003 Sterilizers—Steam—Pre-vacuum. Fourth edn.

AS 2182:1998 Sterilizers—Steam—Benchtop. Fourth edn.

AS 2192:2002 Sterilizers—Steam—Downward-displacement. Third edn.

AS 2437:1987/Amdt 1-1988 Flusher/sanitizers for bed pans and urine bottles. Second edn.

AS 2487:2002 Dry heat sterilizers. Second edn.

AS 2514:1999 Drying cabinets for medical equipment. Second edn.

AS 2773.1:1998 Ultrasonic cleaners for health care facilities. Part 1: Non-portable. Second edn.

AS 2773.2:1999 Ultrasonic cleaners for health care facilities. Part 2: Benchtop.

AS 2774:1985 Drying cabinets for respiratory apparatus.

AS 2945(Int):2002 Batch-type washer/disinfectors for health care facilities. Revised second edn.

AS 3836:1998 Rack conveyor washers for health care facilities.

AS/NZS 4146:2000 Laundry practice.

AS/NZS 4187:2003 Cleaning, disinfecting and sterilizing reusable medical and surgical instruments and equipment, and maintenance of associated environments in health care facilities.

AS/NZS 4815:2006 Office-based health care facilities—Reprocessing of reusable medical and surgical instruments and equipment, and maintenance of the associated environment. Second edn.

Facility designHB 260:2003 Hospital acquired infections – Engineering down the risk.

AS 1668.2:2002 (inc. Amdts 1 and 2) The use of ventilation and airconditioning in buildings – Ventilation design for indoor air contaminant control.

waste disposalAS/NZS 3816:1998 Management of clinical and related wastes.

HB 202:2000 A management system for clinical and related wastes—Guide to application clinical and related wastes.

AS/NZS 3825:1998 Procedures and devices for the removal and disposal of scalpel blades from scalpel handles.

AS 4939:2001 Non-reusable personal use containers for the collection and disposal of hypodermic needles and syringes.

AS 4031:1992/Amdt 1-1996 Non-reusable containers for the collection of sharp medical items used in health care areas.

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Criterion LA – Awareness sA – ImplementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 1.5.3

The incidence and impact of breaks in skin integrity, pressure ulcers and other non-surgical wounds are minimised through wound prevention and management programs.

a) Policy / guidelines exist for the maintenance of skin integrity, and for managing pressure ulcers and other non-surgical wounds.

b) Healthcare providers use an evidence-based risk assessment process / tool to assess skin integrity.

c) Strategies for the prevention of pressure ulcers and preservation of skin integrity are evidence-based and reflect jurisdictional guidelines.

d) Policy and procedures for the management of wounds include consideration and strategies for managing pain.

a) Multidisciplinary wound prevention and management programs are implemented and adapted to local needs and healthcare settings.

b) Clinical staff are provided with ongoing education on the preservation of skin integrity and management of wounds.

c) Risk assessment processes occur on admission, at transitions of care, following changes in health status and prior to commencement of high risk procedures.

d) Wound documentation systems are implemented that support continuity of care and assessment of progress towards goals.

a) Frameworks for skin integrity preservation and wound management are evaluated and improved as required.

b) Education programs for clinical staff in skin integrity preservation and wound management are evaluated and improved as required.

c) Rates of skin integrity breaks, including pressure ulcer rates where applicable, are trended over time and improvements are made to the prevention and management strategy as required.

a) Skin integrity maintenance and wound management programs are compared with internal and external systems and improvements are made to ensure better practice.

and/or

b) Rates of skin integrity breaks, including pressure ulcer rates where applicable, are compared with internal and external systems and improvements are made to ensure better practice.

and/or

c) The organisation develops partnerships with other stakeholders to facilitate wound prevention and management across the continuum of care.

and/or

d) The organisation undertakes research into skin integrity maintenance and/or wound management.

a) The organisation demonstrates it is a leader in skin integrity maintenance and wound management.

IntentThe intent of this criterion is to ensure that the occurrence of healthcare-associated, non-surgical breaks in skin integrity is prevented whenever possible and minimised at all times.

This criterion is applicable to all organisations across the spectrum of health care, as a break in skin integrity can occur as the result of health care itself, can affect a wide variety of consumers / patients (neonates, the frail aged, the immobile and/or insensate, those with reduced sensory perception, individuals undergoing lengthy procedures), and can occur in all environments and situations involving bed care, the use of support devices or physical interaction (emergency departments, wards, transport vehicles, operating theatres, day hospitals, community nursing).

However, consumers / patients may present with compromised skin in any healthcare setting. Assessment and management of pre-existing breaks in skin integrity must be built into the consumer / patient’s care plan whether or not it is the primary cause of his or her admission.

Relationships of 1.5.3 with other criteriaThe process of health care itself may result in a compromise of skin integrity. It is therefore essential that the consumer / patient is assessed during each phase of care (Criterion 1.1.1), and at each transfer of care (Criterion 1.1.5). When consumers / patients are managed in an inappropriate setting, it is more likely that skin breaks will occur, or that a skin break will not be detected (Criterion 1.3.1). An appropriate diet will

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Criterion LA – Awareness sA – ImplementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 1.5.3

The incidence and impact of breaks in skin integrity, pressure ulcers and other non-surgical wounds are minimised through wound prevention and management programs.

a) Policy / guidelines exist for the maintenance of skin integrity, and for managing pressure ulcers and other non-surgical wounds.

b) Healthcare providers use an evidence-based risk assessment process / tool to assess skin integrity.

c) Strategies for the prevention of pressure ulcers and preservation of skin integrity are evidence-based and reflect jurisdictional guidelines.

d) Policy and procedures for the management of wounds include consideration and strategies for managing pain.

a) Multidisciplinary wound prevention and management programs are implemented and adapted to local needs and healthcare settings.

b) Clinical staff are provided with ongoing education on the preservation of skin integrity and management of wounds.

c) Risk assessment processes occur on admission, at transitions of care, following changes in health status and prior to commencement of high risk procedures.

d) Wound documentation systems are implemented that support continuity of care and assessment of progress towards goals.

a) Frameworks for skin integrity preservation and wound management are evaluated and improved as required.

b) Education programs for clinical staff in skin integrity preservation and wound management are evaluated and improved as required.

c) Rates of skin integrity breaks, including pressure ulcer rates where applicable, are trended over time and improvements are made to the prevention and management strategy as required.

a) Skin integrity maintenance and wound management programs are compared with internal and external systems and improvements are made to ensure better practice.

and/or

b) Rates of skin integrity breaks, including pressure ulcer rates where applicable, are compared with internal and external systems and improvements are made to ensure better practice.

and/or

c) The organisation develops partnerships with other stakeholders to facilitate wound prevention and management across the continuum of care.

and/or

d) The organisation undertakes research into skin integrity maintenance and/or wound management.

a) The organisation demonstrates it is a leader in skin integrity maintenance and wound management.

promote wound healing. Conversely, malnutrition is a risk factor for a loss of skin integrity, and moderate to high-risk consumers / patients should undergo nutritional assessment (Criterion 1.5.7).

Breaks in skin integrity are a risk that must be managed throughout the health care process (Criterion 2.1.2), and when control processes fail, incidents and complaints may result (Criteria 2.1.3 and 2.1.4).

Maintenance of skin integrity and management of non-surgical woundsA wide variety of medical conditions can give rise to, or present as, a break in skin integrity. Consumers / patients may be admitted with pre-existing acute / traumatic wounds, such as lacerations, abrasions, infections, abscesses or skin tears, or with chronic

wounds such as ulcers, malignant or fungating wounds, lymphoedema with ulceration, or wounds with osteomyelitis. Where any of these conditions exist, they must be assessed and managed.

The focus of this criterion, however, is upon iatrogenic breaks in skin integrity. The most recognised and studied form of healthcare-associated skin break is the pressure ulcer, which is defined as any lesion caused by unrelieved pressure resulting in damage of the skin and underlying tissue.1

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Criterion 1.5.3

The incidence and impact of breaks in skin integrity, pressure ulcers and other non-surgical wounds are minimised through wound prevention and management programs. (continued)

Pressure ulcers most commonly occur over bony prominences. Skin tears, which result from friction and/or shearing, are common amongst the frail aged due to the pathophysiology of older skin and the increased incidence of falls and manual handling requirements.2 They can be caused by incorrect consumer / patient handling in any healthcare setting. Urinary and/or faecal incontinence can give rise to incontinence-associated dermatitis, which is characterised by skin inflammation manifested as redness with or without blistering, erosion, or loss of the skin barrier function, which occurs as a consequence of chronic or repeated exposure of the skin to urine or faecal matter.3

Friction or tearing injuries may also result from the prolonged and/or inappropriate use of medical devices such as neck braces, casts, splints, prostheses, indwelling catheters and cannulae, and adhesive tape.

In order to minimise and manage breaks in skin integrity, organisations must have a skin integrity policy that is multidisciplinary in scope and based upon national and State / Territory guidelines. The policy should encompass:

• risk assessment

• wound documentation

• care planning

• pressure relief

• appropriate equipment

• staff education

• consumer / patient and family education

• auditing and reporting

• appropriate referral to medical, nursing and allied health professionals.

Ideally, implementation of wound prevention and management strategies will result in an ongoing reduction in the incidence of healthcare-associated wounds. Policies should be regularly reviewed, and improvements made with reference to current evidence-based best practice.

Prompt points

¼ What documentation (legislation, guidelines, current evidence) did the organisation draw upon when drafting its skin integrity policy?

¼ What departments / disciplines were consulted in the development of the organisation’s policy?

¼ What practical action(s) has the organisation taken to reduce the incidence of iatrogenic wounds? How are improvements in this area determined?

Identifying ‘at-risk’ consumers / patientsRisk assessment processes can include a range of screening and assessment tools that assist in identifying ‘at-risk’ consumers / patients and shaping the planning of their care. The same risk assessment tool(s) should be used across the organisation. Documentation outlining the risk assessment process should include the timing and frequency of administration of the tool. It should also list any complicating factors that might alter a consumer / patient’s risk category. For example, while it is generally considered that a consumer / patient is at increased risk for the development of a pressure ulcer if undergoing a procedure of 2.5 hours or longer, a consumer / patient already in poor physical condition may be at increased risk from a much shorter procedure.

Risk assessments must not only be carried out upon a consumer / patient’s admission, but following any change in condition or transfer of care, and prior to any high-risk procedure. (NB: ‘high-risk’ refers to the individual’s condition, not only to the procedure.)

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Prompt points

¼ What pressure ulcer scoring system is used in this organisation?

¼ How are consumers / patients assessed for the risk of developing incontinence-associated dermatitis?

¼ At what points during the consumer / patient’s care journey are risk assessments carried out?

¼ How is the information gained from assessment translated into the consumer / patient’s care plan?

¼ How is the information gained from assessment translated into the consumer / patient’s discharge plan?

Wound managementThe primary focus of this criterion is on prevention of healthcare-associated skin breaks. However, if consumers / patients enter the healthcare system with a pre-existing wound, or if a wound subsequently develops, it must be managed in the most effective way. An appropriate treatment regime must encompass a pain management strategy. Certain categories of consumers / patients, such as young children or those suffering dementia, may be unable to provide verbal information regarding their pain levels, and other forms of assessment must be employed.4 Conversely, it is recognised that in some consumers / patients the loss of, or reduction in, sensory perception may play a significant role in the breakdown of skin integrity and the development of wounds.

All staff should be aware that monitoring and surveillance must be ongoing with respect to consumers / patients identified as being at risk of developing a break in skin integrity, and that consumer / patient management must continue across the care continuum. Effective and successful consumer / patient discharge will depend upon appropriate measures and equipment being in place, together with written and verbal information for consumers / patients and carers about prevention and assessment.

Prompt points

¼ How is pain assessed in consumers / patients who are unable to describe their pain levels?

¼ How does the existing wound documentation system support continuity of care throughout the consumer / patient’s journey?

¼ What information about maintenance of skin integrity is provided for consumers / patients and carers at the time of discharge?

Staff education Organisations should ensure that all staff members involved in assessment and management of skin integrity have access to clinical expertise in wound management and ongoing education where applicable.

Education and information programs should be developed and evaluated by a multidisciplinary team, and draw upon experience in wound management from a variety of care situations, including aged care, spinal units, incontinence nursing, etc. The team should also include consumers / patients and their carers, in order for the full spectrum of experience to be represented. Education must be based upon the screening and assessment tool(s) used organisation-wide, in order to ensure consistency of assessment, and encompass the practical aspects of wound care such as the correct use of pressure-relieving equipment and the positioning of consumers / patients. Related facets of the prevention of iatrogenic skin breaks such as consideration of the most appropriate cleaning regimes for incontinent consumers / patients5 are also appropriate.

Prompt points

¼ How often are wound management education sessions held?

¼ Who participates in the organisation’s education sessions?

¼ What role does management / administration play in wound care education?

¼ How often is the content of the education program reviewed?

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Criterion 1.5.3

The incidence and impact of breaks in skin integrity, pressure ulcers and other non-surgical wounds are minimised through wound prevention and management programs. (continued)

Evidence commonly presented

Consider whether the following will help to address criterion 1.5.3

¼ Policies on admission of consumers / patients with pre-existing wounds

¼ Policy on management of consumers / patients during surgical procedures

¼ Healthcare-associated wound management systems

¼ Pressure area assessment tools, including the use of these in all areas of care such as paediatrics, ICU, general surgical, medical wards, rehabilitation units, community-based services

¼ Health record audits

¼ Education / information for staff and consumers / patients

¼ Equipment register

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Performance measurementThis criterion states that: “The incidence and impact of breaks in skin integrity, pressure ulcers and other non-surgical wounds are minimised through wound prevention and management programs”. The organisation should be able to demonstrate that it has procedures in place to prevent the occurrence of iatrogenic wounds in the consumer / patient wherever possible, and also to manage any breaks in skin integrity present upon admission or that do subsequently develop. Improvements to the organisation’s rate of skin integrity maintenance can be demonstrated via a quantitative expression of the collected data. Many of the guidelines listed at the end of this document will provide direction in this respect.

Some common suggested performance measures are as follows:

Number of consumers / patients receiving skin integrity risk assessment

Total number of consumers / patients admitted to a particular unit / ward / service

Number of ‘at-risk’ consumers / patients who develop a break in skin integrity

Total number of consumers / patients determined ‘at-risk’ of developing a break in skin integrity

Comment: the organisation should determine what constitutes ‘at-risk’

Number of ‘at-risk’ consumers / patients who do not receive a risk assessment and develop a break in skin integrity

Total number of ‘at-risk’ consumers / patients who do not receive a skin integrity risk assessment

Number of consumers / patients who develop new stage 1 – 4 pressure ulcer as inpatients

Total number of overnight bed days

Number of consumers / patients developing stage 1 – 4 pressure ulcer without risk assessment documentation

Total number of consumers / patients developing stage 1 – 4 pressure ulcers

Number of consumers / patients admitted with stage 1 – 4 pressure ulcer who then develop more, or more severe, pressure ulcers

Total number of consumers / patients admitted with stage 1 – 4 pressure ulcers

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Criterion 1.5.3

The incidence and impact of breaks in skin integrity, pressure ulcers and other non-surgical wounds are minimised through wound prevention and management programs. (continued)

References1. NSW Health. Policy directive: clinical practices – pressure

ulcer prevention. Sydney; NSW Health; 2005.

2. Carville K, Lewin G, Newall N et al. STAR: a consensus for skin tear classification. Prim Intent 2007; 15(1): 18-28.

3. Gray M, Bliss D, Doughty D et al. Incontinence-associated dermatitis: a consensus. Wound Ostomy Cont Nurs 2007; 34(1): 45-54.

4. Herr K, Coyne P, Key T et al. Pain assessment in the nonverbal patient: position statement with clinical practice recommendations. Pain Mgmt Nurs 2006; 7(2): 44-52.

5. Ersser S, Getliffe K, Voegeli D and Regan S. A critical review of the inter-relationship between skin vulnerability and urinary incontinence and related nursing intervention. Int J Nurs Stud 2005; 42(7): 823-235.

GuidelinesNational Pressure Ulcer Advisory Panel (NPUAP) and European Pressure Ulcer Advisory Panel (EPUAP). Prevention of pressure ulcers: quick reference guide. Washington DC; NPUAP. Accessed from http://www.epuap.org/guidelines/Final_Quick_Prevention.pdf on 10 September 2010.

National Pressure Ulcer Advisory Panel (NPUAP) and European Pressure Ulcer Advisory Panel (EPUAP). Treatment of pressure ulcers: quick reference guide. Washington DC; NPUAP. Accessed from http://www.epuap.org/guidelines/Final_Quick_Treatment.pdf on 10 September 2010.

Australian Wound Management Association (AMWA). Standards for wound management. Leederville WA; Cambridge Publishing; 2010.

Australian Wound Management Association (AMWA). Clinical Practice Guidelines for the Prediction and Prevention of Pressure Ulcers. West Leederville WA; Cambridge Publishing; 2001.

WA Department of Health, Silver Chain and Curtin University. Wounds west. Perth; Government of WA. Accessed from http://www.health.wa.gov.au/WoundsWest/home/ on 10 September 2010.

Queensland Patient Safety Centre. Pressure ulcer prevention and management resource guidelines. Brisbane; Queensland Health; 2009.

Joanna Briggs Institute. Pressure sores – Prevention of pressure related damage. Best Practice 2008; 12(2): 1-6.

Victorian Department of Health. Pressure ulcers – including the Pressure Ulcer Point Prevalence Surveys (PUPPS). Melbourne; Victorian Health. Accessed from http://www.health.vic.gov.au/pressureulcers/ on 30 April 2010.

Further readingBaranoski S. Skin tears: Staying on guard against the enemy of frail skin. Nursing2010; 33: 14-21. Accessed from http://journals.lww.com/nursing/Fulltext/2003/10001/SKIN_TEARS__Staying_on_guard_against_the_enemy_of.5.aspx# on 17 September 2010.

Baranoski S. How to prevent and manage skin tears. Adv Skin Wound Care 2003; 16(5): 268-270.

Carville K. Wound Care Manual, 5th edn. Perth WA; Silver Chain Nursing Assn; 2005.

WA Department of Health. Wounds prevalence survey 2007; State-wide report overview. WoundsWest. Perth WA; Government of Western Australia; 2007.

Joanna Briggs Institute. Topical skin care in aged care facilities. Best Practice 2007; 11(3): 1-4.

Northern Sydney Central Coast Health Wound Care Committee 2008. Skin Tears: A guide for patients and their carers. Sydney; NSW Health; 2009.

Romanelli M, Clark M, Cherry G et al. (eds). Science and practice of pressure ulcer management. London UK; Springer-Verlag; 2006.

Wound Ostomy and Continence Nurses Society (WOCN). Position paper on avoidable versus unavoidable pressure ulcers. Mt Laurel USA; WOCN Society. Accessed from http://www.wocn.org/About_Us/News/37/ on 8 June 2010.

White W. Skin tears: a descriptive study of the opinions, clinical practice and knowledge base of RNs caring for the aged in high care residential facilities. Prim Intent 2001; 9(4): 138-149.

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Criterion LA – Awareness sA – ImplementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 1.5.4

The incidence of falls and fall injuries is minimised through a falls management program.

a) Policy / guidelines exist for falls management.

b) Evidence-based falls prevention information is provided to staff through education programs and access to policy, procedures and other relevant resources.

c) Consumers / patients are assessed for risk of falls:

(i) on admission

(ii) following a change of risk factor

(iii) after a fall

and the level of risk is conveyed to the consumer / patient, carer and clinical team.

d) Appropriate evidence-based multidisciplinary falls reduction strategies are implemented according to identified risk factors.

e) Written and verbal falls prevention information is provided for consumers / patients and carers.

f) Consumers / patients and where appropriate their carers, are involved in their falls prevention / management plan.

a) The risk assessment and falls policy / guidelines are implemented across the organisation.

b) Staff are educated on falls, and on falls injury risk assessment, prevention and management, and staff are trained in use of falls prevention equipment.

c) An individualised falls prevention plan addresses the falls risk factors identified during assessment.

d) Falls and fall injury prevention equipment is available for consumers / patients following appropriate education and training for use.

e) Falls risk is considered as part of discharge planning for ‘at risk’ consumers / patients.

f) A system to report falls incidents is implemented and reflects jurisdictional requirements.

a) The falls and fall injury prevention and management education program provided to staff and consumers / patients is evaluated and improved as required.

b) Effectiveness of individual falls prevention management plans is reviewed and evaluated.

c) Falls and fall injury data are analysed and tracked over time and improvements are made to the falls prevention and management strategy as required.

a) Falls data management programs are compared with internal and external systems and improvements are made to ensure better practice.

and/or

b) The organisation develops partnerships with other stakeholders to facilitate falls prevention across the continuum of care.

and/or

c) The organisation undertakes research into falls and fall injury prevention.

a) The organisation demonstrates it is a leader in the areas of falls prevention and management.

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Criterion LA – Awareness sA – ImplementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 1.5.4

The incidence of falls and fall injuries is minimised through a falls management program.

a) Policy / guidelines exist for falls management.

b) Evidence-based falls prevention information is provided to staff through education programs and access to policy, procedures and other relevant resources.

c) Consumers / patients are assessed for risk of falls:

(i) on admission

(ii) following a change of risk factor

(iii) after a fall

and the level of risk is conveyed to the consumer / patient, carer and clinical team.

d) Appropriate evidence-based multidisciplinary falls reduction strategies are implemented according to identified risk factors.

e) Written and verbal falls prevention information is provided for consumers / patients and carers.

f) Consumers / patients and where appropriate their carers, are involved in their falls prevention / management plan.

a) The risk assessment and falls policy / guidelines are implemented across the organisation.

b) Staff are educated on falls, and on falls injury risk assessment, prevention and management, and staff are trained in use of falls prevention equipment.

c) An individualised falls prevention plan addresses the falls risk factors identified during assessment.

d) Falls and fall injury prevention equipment is available for consumers / patients following appropriate education and training for use.

e) Falls risk is considered as part of discharge planning for ‘at risk’ consumers / patients.

f) A system to report falls incidents is implemented and reflects jurisdictional requirements.

a) The falls and fall injury prevention and management education program provided to staff and consumers / patients is evaluated and improved as required.

b) Effectiveness of individual falls prevention management plans is reviewed and evaluated.

c) Falls and fall injury data are analysed and tracked over time and improvements are made to the falls prevention and management strategy as required.

a) Falls data management programs are compared with internal and external systems and improvements are made to ensure better practice.

and/or

b) The organisation develops partnerships with other stakeholders to facilitate falls prevention across the continuum of care.

and/or

c) The organisation undertakes research into falls and fall injury prevention.

a) The organisation demonstrates it is a leader in the areas of falls prevention and management.

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Criterion 1.5.4

The incidence of falls and fall injuries is minimised through a falls management program. (continued)

IntentFalls-related injury is a leading cause of morbidity and mortality amongst older Australians. The intent of this criterion is to:

• whenever possible, prevent falls from occurring

• minimise injury from those falls that could not be prevented.

Relationships of 1.5.4 with other criteriaThe risk of a fall should be considered throughout all phases of the care journey (Standard 1.1). In particular, falls risk should be included as part of the consumer / patient assessment process (Criterion 1.1.1). Falls can be reviewed in the evaluation of a consumer / patient’s care (1.1.4), and the ongoing risk of falls considered in clinical handover (Criterion 1.1.6) and planning for transfer of care or discharge (Criterion 1.1.5).

Building arrangements and the equipment used at a facility can impact on the type, severity and number of falls (Criterion 3.2.2), and addressing this issue is an aspect of the organisation’s safety management system (Criterion 3.2.1). Falls within a facility are a significant healthcare incident (Criterion 2.1.3), which must be managed within the organisation’s integrated risk management framework (Criterion 2.1.2).

Policy and process Falls prevention requires a multifactorial approach to achieve the following objectives1:

• to identify consumers / patients at high risk of falling

• to take precautions appropriate to individual consumers / patients to reduce falls

• to take precautions to minimise injuries from falls that cannot be prevented

• to respond to immediate injuries and assist consumers / patients to gain strength and confidence following a fall.

The possibility of a fall and the potential need for assistance post-fall is relevant for every healthcare organisation, including day procedure centres and community health centres. However, the focus will vary between organisations and wards.

Policies and guidelines for falls prevention for the whole organisation should include:

• roles and responsibilities

• education for consumers / patients and staff

• available equipment

• risk assessment of consumers / patients on admission or when changes occur in their health status

• environmental hazards and plans to minimise their impact

• post-falls responses

• falls reduction strategies

• standard reporting systems

• falls data, event monitoring and their review.

There is now significant evidence-based information from Australia and overseas that is useful in planning policy and procedures, and in daily management of the ward / facility. The Australian Commission on Safety and Quality in Health Care’s Guidelines for preventing falls and harm from falls in older people is a comprehensive evidence-based resource1 that can guide organisations in the creation and implementation of their falls management plan. It includes a description of tools that have been developed for assessing and responding to falls risk in different healthcare settings.

Regardless of the tool(s) selected, organisations should have procedures describing responses that may be appropriate for consumers / patients with different levels of risk.

Policies and procedures should reflect current knowledge, be carried through to operational responses, and be accessible to all staff involved in their implementation.

Because risk factors for falls are often multifactorial, it is important to identify contributing factors to any incident. A suggested minimum dataset for recognising areas to focus improvement of care is:1

• What risk factors for falls and injury were present?

• What was the activity at the time of the fall?

• Has the consumer / patient had a falls risk assessment?

• What was the mechanism of the fall?

• What interventions were in place at the time of the fall?

• Was it a confirmed or suspected fall?

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Prompt points

¼ What issues are covered by this organisation’s falls policy?

¼ Has the organisation undertaken a risk assessment for falls? What consumer / patient or procedural characteristics (duration of care, anaesthetics or psychoactive medications) present the greatest challenges for the organisation in relation to falls?

¼ Based on tracking data, how effective has the organisation’s policy / guideline been in combating falls? What changes have been introduced in response to analysis of falls data? Have the changes made any measurable difference?

Individual risk assessment and planning There is a danger in assuming that falls risk is limited to the frail aged; it is possible for young and relatively fit people to suffer isolated falls due to trip hazards, light-headedness or temporary confusion in the face of an acute illness or medication. Individual risk assessment should take into account the specific circumstances of each consumer / patient episode of care.

Many risk factors for falling in a healthcare setting have been identified.1,2 These include:

• intrinsic factors: such as a previous fall, postural instability / muscle weakness, cognitive impairment, delirium, disturbed behaviour, urinary frequency, incontinence, postural hypotension, some medications and/or visual impairment

• extrinsic factors: particularly a hospitalisation of more than 18 days

• environmental factors: most falls happen around the bedside and in the bathroom, and at times when there is less observation, such as outside visiting hours, when showering, and at meal times.

A falls assessment will focus on the consumer / patient’s intrinsic risk factors. In individual wards or facilities, the relative importance of different risk factors will vary based on the characteristics of their consumers / patients and the environment; this should be reflected in the management of assessment and discharge planning. Risk assessment documents should be easily accessible to all staff and there should be communication with the consumer / patient and any carers about the proposed measures to mitigate risk.

To draw conclusions about the effectiveness of individual management plans, good record keeping is needed. Organisations should ensure that records are kept together and all events are reported and followed up through the incident management system.

Reviewing the effectiveness of individual management plans could involve:

• recording consumers / patients’ falls during their stay with consideration of pre-identified risk factors at time of discharge

• retrospective audits of consumer / patient health records in the light of the risk assessment plan

• including a falls risk management question in satisfaction surveys.

Prompt points

¼ What proportion of consumers / patients have a full risk assessment for falls following preliminary screening at the time of admission? For consumers / patients who have longer term inpatient care, how frequently are these updated in response to changes in a falls risk factor?

¼ At what stage of an admission is falls risk discussed with consumers / patients and/or their carers? Who has these conversations? (Responses to this question should vary between wards or departments.) What role can the consumers / patients and their carers play in managing falls risk?

¼ What actions are taken to assist consumers / patients identified to be at risk of falling following discharge?

¼ How is the effectiveness of falls prevention and management planning evaluated?

Organisational risk assessment and reportingThe Australian Commission on Safety and Quality in Health Care has prepared an implementation guide based on their best-practice guidelines for preventing falls and harm from falls in older people.3 The proposed implementation process for a falls prevention program includes consideration of risk factors, and the guide provides templates for planning a falls management program.3 There are now evidence-based reviews that collate information on the efficacy of falls prevention. The evidence is described in the Commission’s best practice guidelines for preventing falls and harm from falls in older people.1

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Criterion 1.5.4

The incidence of falls and fall injuries is minimised through a falls management program. (continued)

Falls are included as a ‘category’ for describing incidents in most State / Territory health department incident report programs.

Prompt points

¼ What falls reduction strategies have been implemented to alleviate falls risk factors? Have they had an impact on the number or severity of falls, or made it easier to prevent people falling?

¼ How do staff access policy and procedure documents on falls? How are new staff familiarised with the facility’s falls management program? What communication vehicles are used to update ‘frontline’ staff about new evidence in relation to falls?

¼ What incident reporting system is used to record falls at this facility? Who is responsible for following up and investigating incidents that involve falls?

Equipment to reduce fallsActivity is central to recovery and return to the community after hospitalisation. Efforts to maintain and improve mobility of consumers / patients are important despite the risks involved. Reminders in a healthcare organisation’s entry brochure that consumers / patients bring spectacles and mobility aids can reduce the need for their provision in the facility.

If a need for equipment is identified, the organisation should provide access through its own reserves, purchase by families, or hiring and lease schemes. Where available, multidisciplinary care that includes rehabilitation specialists, occupational therapists, physiotherapists and other allied health and ancillary services as appropriate may provide information and improve access. A review of footwear may also assist consumers / patients to manage risk during their rehabilitation. Under other circumstances, it is important that staff have access to relevant contact numbers to facilitate consumers / patients gaining appropriate equipment for inpatient use and at time of

discharge. Examples of contacts that might be relevant are hiring services for walking frames and rollators, suppliers of wheelchairs and other equipment and home modification consultants or services.

Hip protectors, and in the longer term, medication to promote bone strength, for example Vitamin D, calcium and osteoporosis drugs, may be protective for consumers / patients who do fall. Assessment of whether these measures would benefit a consumer / patient should be followed up by a clinician.

In some instances, equipment can be the cause of the fall. Equipment stored just out of reach, the wrong equipment supplied and insufficient education on the use of it should be avoided.

The placement of walking aids, call buttons and meal trays can also cause falls. Cleaners and other relevant staff should be educated about returning equipment to its former position when it is moved for cleaning or consumer / patient access. In addition, spills, clutter and the placement of furniture can contribute to a fall.

Prompt points

¼ What equipment is used within the facility to reduce the risk of falls while (ideally) encouraging mobility? Is there any training on falls prevention or the effective use of mobility supports for consumers / patients requiring them?

¼ Are hip protectors used for high-risk consumers / patients who are likely to fall? How are consumers / patients selected for hip protector use?

¼ What arrangements does the organisation have to assist consumers / patients at risk of falls to access appropriate equipment following discharge?

Education – internal and external All staff should be aware of universal strategies for falls prevention in their setting, for example the appropriate supervision of consumers / patients, and understand which consumers / patients are at increased risk in order to prevent falls.

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Education should include:

• training in understanding risk factors and prevention and management strategies (generic and sector / profession specific)

• understanding the use of the organisation’s selected assessment materials in various contexts with particular consumers / patients. It is also important that consumers / patients and their carers / visitors understand the potential risk from falls and the actions being taken to prevent a fall occurring while consumers / patients are within a healthcare facility.

Ideally, all consumers / patients at risk of falling would be regularly checked by staff and offered assistance.4 The term used for regular, proactive checks by nurses of consumers / patients in wards of a healthcare facility is ‘rounding’. The goal is to reduce the need for weak consumers / patients to attempt unassisted travel by pre-empting their need to go to the bathroom or seek a drink.

Training in protective OH&S strategies and in the use of lifting equipment is important. Repositioning and transferring consumers / patients are associated with the majority of manual handling incidents.5 Obese consumers / patients6 who are at risk of falling present even greater challenges to staff.

Education programs are now routinely evaluated in most organisations. Regardless of whether falls training for staff, volunteers and consumers / patients is provided by internal educators or by external contractors, nursing staff and others who are familiar with the specific issues should be involved in evaluating the program and its provision, ideally against some predetermined goals.

Prompt points

¼ What information is provided to consumers / patients to assist them (and their carers) to better manage falls risk – in the facility, and when they return home?

¼ How do clinical staff access information about falls prevention?

¼ Is rounding used in the inpatient wards? If so, has rounding had any impact on the numbers or severity of falls?

¼ What training programs are available to staff to improve their knowledge of falls risk assessment, prevention and management? How are new staff members familiarised with the falls prevention equipment used in the organisation? What efforts are made to ensure staff members do not injure themselves through their efforts to prevent consumers / patients from falling?

¼ How are any falls education programs monitored? When staff attend training by an external provider, how is the value of this training to the staff member and to the organisation assessed?

Evidence commonly presented

Consider whether the following will help to address criterion 1.5.4

¼ Falls prevention and management policies

¼ Health record audits

¼ Falls risk assessments and action plans

¼ Falls data and outcomes arising from their evaluation / review

¼ Investigation / follow-up of a serious falls event

¼ Signage, providing information on reduction of falls for consumers / patients, carers and other visitors

¼ Consumer / patient information sheets

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Criterion 1.5.4

The incidence of falls and fall injuries is minimised through a falls management program. (continued)

Performance measurementThis criterion states that: “The incidence of falls and fall injuries is minimised through a falls management program”. The organisation should be able to demonstrate policy, procedures and education aimed at minimising consumer / patient falls and falls injury during an episode of care, and assisting consumers / patients and their carers to manage falls risk following discharge.

Some common suggested performance measures are as follows:

Number of consumers / patients who suffer or experience slips, trips and falls

Total number of overnight bed days

Number of consumers / patients experiencing two or more falls

Total number of consumers / patients who experience a fall

Number of consumers / patients aged over 65 years who fall

Total number of overnight bed days of consumers / patients aged 65 years and older

Number of consumers / patients with a documented falls risk assessment

Total number of consumers / patients admitted to a particular unit / ward

Number of consumers / patients who fall following an intra-organisational incident of aggression

Total number of consumers / patients who fall

Number of ‘at-risk’ consumers / patients provided with injury prevention devices

Total number of ‘at-risk’ consumers / patients

Comment: the definition of ‘at-risk’ should be based upon categories of risk determined using the organisation’s falls risk assessment processes

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Number of ‘at-risk’ consumers / patients who fall

Total number of ‘at-risk’ consumers / patients as determined by a falls risk assessment

Number of consumers / patients at high risk of a fall who are seen by at least one relevant clinician capable of influencing that risk

Total number of consumers / patients assessed as being at high risk of a fall

Comment: a ‘relevant clinician’ might be a physiotherapist, occupational therapist, continence nurse, etc.

Follow-up falls assessments (in response to changes in consumer / patient condition)

Number of changes to consumer / patient condition that meet organisation-defined conditions for a falls reassessment

Comment: organisational procedures should state circumstances where a falls reassessment is to be undertaken

Number of falls resulting in any injury

Total number of falls

Comment: it is recommended to collect the different types of injuries

References1. Australian Commission on Safety and Quality in Health Care

(ACSQHC). Preventing falls and harm from falls in older people: best practice guidelines for Australian hospitals. Sydney NSW; ACSQHC; 2009.

2. National Ageing Research Institute and Centre for Applied Gerontology. An analysis of research on preventing falls and falls injury in older people: community, residential care and hospital settings. Canberra ACT; Australian Government; 2004.

3. Australian Commission on Safety and Quality in Health Care (ACSQHC). Implementation guide for preventing falls and harm from falls in older people: Best practice guidelines for Australian hospitals and residential aged care facilities. Sydney NSW; ACSQHC; 2009.

4. Szumlas S, Groszek J, Kitt S et al. Take a second glance: a novel approach to inpatient fall prevention. Joint Comm J Qual & Patient Safety 2004; 30(6): 295-302.

5. NSW Nurses Association and Workcover NSW. Manual handling guide for nurses. Sydney NSW; Workcover NSW; 1998.

6. Australian Safety and Compensation Council (ASCC). Manual handling risks associated with the care, treatment and transportation of bariatric (severely obese) patients in Australia. Canberra ACT; ASCC; 2009.

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Criterion LA – Awareness sA – ImplementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 1.5.5:

The system to manage sample collection, blood, blood components / blood products and patient blood management ensures safe and appropriate practice.

a) Policy exists for:

(i) consumer / patient identification at the time of sample collection

(ii) completion of the request form, safe collection, identification and labelling of the consumer / patient sample

(iii) prescription and documentation of blood component / product therapy

(iv) obtaining and documenting informed consent

(v) managing consumers / patients who decline administration of blood components / products

(vi) the timely availability and safe administration of blood components / products

(vii) monitoring and review of the appropriateness of blood component / product therapy

(viii) consumer / patient blood management including blood conservation strategies and alternatives to blood component / product therapy

(ix) reporting and management of adverse effects of blood component / product therapy.

b) Policy exists for the storage conditions and transportation of samples and blood components / products and includes:

(i) validating, monitoring and recording of temperature for all blood fridges

(ii) response to blood fridge alarms

(iii) maintenance standards for all blood fridges

(iv) delivery, placement and removal of blood components / products from any blood fridge / controlled storage

(v) a documented audit trail.

c) The sample collection and blood component / product management policy is compliant with:

(i) jurisdictional legislation

(ii) ANZSBT / ASTH / NBA / NHMRC / RCNA guidelines

(iii) Australian standards

(iv) ARCBS Circular of Information

(v) NPACC requirements

(vi) NATA requirements

as appropriate.

a) The sample, blood component / product management system ensures:

(i) verification of consumer / patient identification at the time of sample collection

(ii) timely and safe collection and labelling of samples

(iii) documented indication and prescription for blood components

(iv) the consumer / patient and carer is informed of the risks, benefits and appropriateness of the blood component / product for their clinical situation and consents to administration

(v) timely availability of blood components / products

(vi) verification of correct consumer / patient and component / product and safe administration of blood components / products

(vii) adverse events and near misses are reported and linked to the incident management system.

b) The system for the safe transportation and storage of samples and blood components / products includes:

(i) a blood components / products inventory register

(ii) allocated responsibilities for responding to storage alarms and taking corrective action

(iii) documentation accompanying samples and blood components / products

(iv) labels being checked each time the component / product is handled

(v) policy for monitoring blood component usage and wastage.

c) Relevant staff are provided with orientation and education on procedures for safe sample and blood component / product management, which include:

(i) consumer / patient identification and sample collection

(ii) storage and transportation of samples and blood components / products

(iii) blood component / product therapy prescription and safe administration

(iv) recognition, management and reporting of adverse effects of blood component / product therapy.

a) All aspects of the sample and blood component management systems are monitored, evaluated and trended, and improvements are made as required.

b) The staff orientation, training and competency program is evaluated and improvements are made as required.

c) Staff skills and competence are defined, assessed, and evaluated and improvements are made as required.

d) The system for transportation and storage of samples and blood components is evaluated and improvements are made as required.

e) The blood components inventory register system is evaluated and improvements are made as required.

f) Sample and blood component / product errors, near misses and adverse events are analysed and trended and further strategies to reduce sample and blood component incidents are implemented.

a) The systems for sample and blood component management are compared with internal and external systems and improvements are made to ensure better practice.

and/or

b) The system for transporting and storage of samples and blood components / products is compared with internal and external systems and improvements are made to ensure better practice.

and/or

c) The organisation undertakes research into blood component / product and consumer / patient blood management practices.

a) The organisation demonstrates that it is a leader in sample collection, blood, blood components / blood products and consumer / patient blood management.

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Criterion LA – Awareness sA – ImplementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 1.5.5:

The system to manage sample collection, blood, blood components / blood products and patient blood management ensures safe and appropriate practice.

a) Policy exists for:

(i) consumer / patient identification at the time of sample collection

(ii) completion of the request form, safe collection, identification and labelling of the consumer / patient sample

(iii) prescription and documentation of blood component / product therapy

(iv) obtaining and documenting informed consent

(v) managing consumers / patients who decline administration of blood components / products

(vi) the timely availability and safe administration of blood components / products

(vii) monitoring and review of the appropriateness of blood component / product therapy

(viii) consumer / patient blood management including blood conservation strategies and alternatives to blood component / product therapy

(ix) reporting and management of adverse effects of blood component / product therapy.

b) Policy exists for the storage conditions and transportation of samples and blood components / products and includes:

(i) validating, monitoring and recording of temperature for all blood fridges

(ii) response to blood fridge alarms

(iii) maintenance standards for all blood fridges

(iv) delivery, placement and removal of blood components / products from any blood fridge / controlled storage

(v) a documented audit trail.

c) The sample collection and blood component / product management policy is compliant with:

(i) jurisdictional legislation

(ii) ANZSBT / ASTH / NBA / NHMRC / RCNA guidelines

(iii) Australian standards

(iv) ARCBS Circular of Information

(v) NPACC requirements

(vi) NATA requirements

as appropriate.

a) The sample, blood component / product management system ensures:

(i) verification of consumer / patient identification at the time of sample collection

(ii) timely and safe collection and labelling of samples

(iii) documented indication and prescription for blood components

(iv) the consumer / patient and carer is informed of the risks, benefits and appropriateness of the blood component / product for their clinical situation and consents to administration

(v) timely availability of blood components / products

(vi) verification of correct consumer / patient and component / product and safe administration of blood components / products

(vii) adverse events and near misses are reported and linked to the incident management system.

b) The system for the safe transportation and storage of samples and blood components / products includes:

(i) a blood components / products inventory register

(ii) allocated responsibilities for responding to storage alarms and taking corrective action

(iii) documentation accompanying samples and blood components / products

(iv) labels being checked each time the component / product is handled

(v) policy for monitoring blood component usage and wastage.

c) Relevant staff are provided with orientation and education on procedures for safe sample and blood component / product management, which include:

(i) consumer / patient identification and sample collection

(ii) storage and transportation of samples and blood components / products

(iii) blood component / product therapy prescription and safe administration

(iv) recognition, management and reporting of adverse effects of blood component / product therapy.

a) All aspects of the sample and blood component management systems are monitored, evaluated and trended, and improvements are made as required.

b) The staff orientation, training and competency program is evaluated and improvements are made as required.

c) Staff skills and competence are defined, assessed, and evaluated and improvements are made as required.

d) The system for transportation and storage of samples and blood components is evaluated and improvements are made as required.

e) The blood components inventory register system is evaluated and improvements are made as required.

f) Sample and blood component / product errors, near misses and adverse events are analysed and trended and further strategies to reduce sample and blood component incidents are implemented.

a) The systems for sample and blood component management are compared with internal and external systems and improvements are made to ensure better practice.

and/or

b) The system for transporting and storage of samples and blood components / products is compared with internal and external systems and improvements are made to ensure better practice.

and/or

c) The organisation undertakes research into blood component / product and consumer / patient blood management practices.

a) The organisation demonstrates that it is a leader in sample collection, blood, blood components / blood products and consumer / patient blood management.

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Criterion 1.5.5:

The system to manage sample collection, blood, blood components / blood products and patient blood management ensures safe and appropriate practice. (continued)

IntentThe intent of this criterion is to ensure that healthcare organisations responsible for transfusing blood, blood components or blood products have effective management systems that promote safe and appropriate blood management.

This criterion applies to all organisations that may be responsible for transfusing blood or administering any blood product or component, regardless of how infrequently it occurs.

This criterion is not applicable where organisations:

• do not collect blood samples from consumers / patients for the purposes of transfusion of blood or blood products / components

• do not store, transport or administer blood or blood products / components.

Requirements for samples of blood, body fluids and tissues that are not related to blood transfusion are addressed within criterion 1.5.6.

In this criterion, the term ‘sample’ refers to blood samples collected from a consumer / patient to enable human-derived blood or blood component / product transfusion, or for other blood grouping procedures, as per the National Pathology Accreditation Advisory Council (NPAAC) Requirements for Transfusion Laboratory Practice available at: http://www.ocs.gov.au/internet/main/publishing.nsf/Content/npaac-trans-2008-toc~npaac-trans-2008-1

The term ‘blood’ has been used in this criterion to describe homologous and autologous whole blood; ‘blood component’ to describe fresh components (red cells, platelets, fresh frozen plasma, cryoprecipitate, cryodepleted plasma); and ‘blood product’ to describe plasma derivatives and recombinant products.

The term ‘sampling’ has been used to describe the collection of a blood sample from a consumer / patient.

Relationships of 1.5.5 with other criteriaComplete and accurate patient identification, and the matching of consumer / patient, sample, test and test results, is critical for pathology sample collection and also for administration of blood components / products (Criterion 1.5.6). Another vital aspect of blood management is ensuring informed consent for the transfusion is obtained prior to administering any blood components / products (Criterion 1.1.3). Blood components / products may play a critical role in managing a deteriorating consumer / patient (Criterion 1.1.2).

The administration of blood and blood components / products has associated risks (Criterion 2.1.2) that, if not managed correctly, are likely to lead to adverse and sentinel events (Criterion 2.1.3).

External service providers such as private pathology services are frequently subcontracted to manage blood collection or inventory, and this arrangement must be managed by the organisation (Criterion 3.1.4).

Management systemThis criterion is based on the many evidence-based standards, guidelines and circulars that have been developed in recent years by individuals, organisations and associations and experts in the field of blood and blood component / product management and blood component therapy. These include:

• Australian and New Zealand Society of Blood Transfusion (ANZSBT)1,2 / Australasian Society of Blood Transfusion3

• Australian Red Cross Blood Service (ARCBS)4, 5

• Royal College of Nursing Australia (RCNA)2

• National Health and Medical Research Council (NHMRC)6

• National Blood Authority.7, 8

The various standards, guidelines and circulars with which organisations should be compliant, are listed at the end of this criterion in the references.

Accreditation of laboratory processes is undertaken by the NPAAC and the National Association of Testing Authorities (NATA).

The management of samples, blood and blood components / products beyond the laboratory involves:

• consumer / patient identification at all points along the process

• correct labelling of consumer / patient samples

• storage and transportation of samples, blood and blood components / products

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• appropriateness of blood component therapy

• documentation of all aspects of the blood / blood component / product administration process including the reason for administration

• appropriate training for sample collection and the administration of blood components / products

• competency assessment of staff directly involved in sample collection, blood and blood component / product administration

• consent for blood, blood component / product administration

• governance

• staff responsibility.

Policies and procedures should be available to all staff. Issues that should be covered in policy / procedures include:

• consumer / patient identification

• the minimum information required (as a standardised data set) for samples and request forms2, sampling and sample labelling

• timeliness including handling of urgent requests

• obtaining and documenting consent for transfusion and procedures in the event of failure to gain consent for blood, blood component / product therapy

• consumer / patient blood management

• prescription, documentation, and administration of blood and blood components / products

• adverse event management.

Healthcare facilities should have a local emergency blood management plan in accordance with jurisdictional and National Blood Authority requirements.8

The identification of the consumer / patient and, where applicable, the blood component / product must be verified at every stage. Where possible, the consumer / patient should be asked to state his/her full name and date of birth. Policy should include the management of unidentified consumers / patients. All consumers / patients, including any individual whose identity is unknown, should have a completed identification band attached at all times.1–3

Consumers / patients should be informed of the risks of, benefits of and alternatives to blood transfusion, and the risks from non-administration. Information brochures on blood components / products should be provided to consumers / patients and carers.2, 9

As a general principle, every effort should be made to implement appropriate consumer / patient blood management. Strategies that should be considered, particularly when surgery is elective, include:

• optimising consumer / patient haemoglobulin prior to surgery

• correction of iron deficiency with parenteral and oral iron.

Although the Australasian Society of Blood Transfusion has prepared a guideline for autologous blood collection3 in Australia, there are few circumstances when autologous transfusion should be recommended; this is addressed by the Australian Red Cross Blood Service (ARCBS) on their website: www.transfusion.com.au.10, 11

Complete documentation of administration of blood components / products should be kept in the consumer / patient health record. This includes the blood component / product compatibility report, forms used for prescription, observations taken during administration, documentation of the administration of blood components / products, management information including the management of adverse effects, and a record of the component or donation numbers.

Clinical governance of blood samples and transfusions is the responsibility of the Hospital Transfusion Committee (HTC). Where there is no HTC or equivalent body, discussion of transfusion-related issues should be incorporated as a standing agenda item in meetings of a committee appropriate to the organisation, such as a Hospital Management Committee or Quality Committee.

Errors associated with samples may impact at any phase of transfusion activity, leading to adverse events / near misses. Data that track levels of use of blood components and blood products over time should be provided to meetings of the HTC in a consistent format for its consideration.

A range of approaches may be used to evaluate the blood component / product management system. Where the organisation has clear and detailed systems for sample and blood component / product management, review may involve an audit of activity against policy and protocols. There is a wide variety of tools, including audit tools, available; the National Blood Authority has links to most under ‘Best Practice Tools’ at http://www.nba.gov.au/bptools/index.html

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Criterion 1.5.5:

The system to manage sample collection, blood, blood components / blood products and patient blood management ensures safe and appropriate practice. (continued)

Laboratories and healthcare organisations should monitor wastage of blood and blood components / products, and record reasons for discard. Review of this information will identify aspects of blood management that could be improved. For example, blood may have been discarded because it could not be returned to inventory due to being stored in non-compliant refrigerators. Waste linked to exceeding the expiry date may indicate that excessive inventory is being held.

Massive transfusion can strain the inventories of organisations and can deplete product. The ARCBS website describes a range of responses to massive transfusion including for emergency and elective surgery settings.12 Organisations should develop policy and/or procedures to guide decision making in response to massive transfusion that includes liaison with the appropriate supplier of blood components / products.

Where private pathology companies are involved in blood sampling related to transfusion, the organisation should include a set of key performance indicators (KPIs) in the service contract, to ensure that services and their delivery meet a predetermined standard.

Prompt points

¼ Does the organisation’s sample collection policy address consumer / patient identification and include the minimum data set required for labelling and request forms?

¼ Does the organisation’s consent policy separately address the administration of blood components / products? How does it cover refusal of consent? Does the organisational policy refer to potentially controversial situations, such as may occur when failing to transfuse could lead to death of a consumer / patient?

¼ What written information on transfusion is provided for consumers / patients?

¼ Does the organisation’s policy address blood conservation strategies and alternatives to transfusion?

¼ Does the organisation have a protocol for massive transfusion? If there is a protocol, how is compliance assessed?

¼ Does the organisation have a perioperative blood management program? In the lead up to elective surgery, how does the organisation identify consumers / patients who are anaemic or confirm that this check has been done by the referring physician / surgeon?

Safe transport and storageBlood components / products should be stored only in dedicated, temperature-controlled blood transfusion refrigerators in accordance with AS 3864:1997 Medical refrigeration equipment – for the storage of blood and blood products.13

The documented ‘audit trail’ should ensure that all blood components / products can be traced from receipt to recipient, or to final destination if not administered. Where a health facility has a blood refrigerator that is not situated within the transfusion laboratory (such as in operating rooms), the audit trail should be maintained so that the delivery, placement and removal of blood components / products can be traced. The security of this area must be maintained while also ensuring there is immediate access in an emergency. A register must be in the proximity of the blood refrigerator and correctly maintained.

Access for removal, collection, transport and delivery of blood components / products should be restricted to authorised staff members.

There should be a backup procedure in place in case of blood refrigerator failure that includes an alternative storage site (e.g. at another nearby hospital)2 and that:

• can be locked if in an unsupervised area

• is connected to emergency power

… as well as resources to adequately store blood components / products until transfer to the alternative site.

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Blood components / products (not for immediate use) should be stored and transported only in boxes / eskies validated satisfactory for this purpose with the validated time for satisfactory storage indicated on the box / esky. Transfusion providers must record the time when blood components / products were placed into a box / esky, the time for which storage will be satisfactory, and indicate that the blood components / products should be returned to a blood transfusion refrigerator if not used within that time.

Prompt points

¼ How does the organisation’s policy address allocated responsibilities and corrective actions for responding to storage alarms?

¼ Can the organisation demonstrate a documented audit trail for blood components / products?

¼ Does the organisation have a blood refrigerator located outside the transfusion / laboratory service (such as in the operating rooms)? If so, who is responsible for maintaining this register? How frequently is the register audited, and to whom are the results reported?

¼ How does the organisation’s policy address removal of blood components / products from controlled refrigeration and transport requirements / responsibilities?

¼ How does the organisation monitor blood component / product usage and wastage?

Education, training and assessment Education, training and assessment of competence in respect to consumer / patient identification, sample collection, blood and blood component / product policies and procedures, including collection and transport, prescription, administration and management of adverse events should be in place for new staff, and regular updates for all staff should occur at least biennially. The training may include medical, nursing, midwifery and phlebotomy staff. Non-clinical ancillary staff, such as porters, orderlies and ward assistants, require training that covers the transportation of blood. Training and competence assessment records should be maintained.

Staff should be assessed as being competent to carry out the tasks they are performing.2 All staff working in areas where blood components / products are handled or who may be questioned by consumers / patients about transfusions should have some knowledge of the organisation’s blood management systems and processes, and any related policies.

Clinicians who will administer blood and blood components / products should be trained in the correct procedures for transfusion, in the organisation’s sites for storage, correct use of forms and any unique procedures. All staff who will administer blood should be competency-tested and the assessment outcome recorded on their personnel file. The training database / register should nominate clinical and non-clinical staff who need to maintain their training in blood management, and use this record to schedule education, as discussed within criterion 2.2.4. There are numerous online sites that offer education and training in aspects of blood transfusion, an example of which is http://www.bloodsafelearning.org.au/14 The organisation can gain insight into the ease of understanding, relevance and applicability of its education / training by surveying participants about their learning experience. It is imperative that staff understand the information provided and its application.

Prompt points

¼ Does the organisation’s policy address the requirement for education and training for new and existing staff?

¼ Does the training register / database specify staff who require clinical and non-clinical training in blood management? How does the organisation use this database to schedule its education course(s) in blood management?

¼ Can the organisation demonstrate that education and training programs are regularly reviewed?

¼ How does the organisation track blood management education / training for its staff?

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Criterion 1.5.5:

The system to manage sample collection, blood, blood components / blood products and patient blood management ensures safe and appropriate practice. (continued)

Errors, near misses and adverse eventsThe governing body is responsible for ensuring that appropriate staff are informed of and follow policy and procedures for sample collection and blood component therapy and report all adverse events and near misses relating to the blood component / product administration process.

Such incidents should be examined by the executive committee / HTC. Serious incidents require detailed review. The incidence of near misses / less serious adverse events, particularly when these cluster with an identifiable setting, timing or product type, should also be examined. A nominated staff member should be allocated responsibility for developing procedures and coordinating training to respond to identified weaknesses in transfusion-related processes or their application.

Prompt points

¼ How does the organisation’s policy address the requirements for reporting and review of near misses and adverse events?

¼ Does the organisation have a HTC / executive committee to monitor and respond to transfusion-related near misses / adverse events? How are transfusion data and the actions taken in response to monitoring adverse events and near misses communicated to the governing body?

¼ What training do transfusion and blood management staff receive in incident reporting? Do the staff have ready access to a computer linked to the incident management system, or an alternative means of recording any adverse events / near misses?

Evidence commonly presented

Consider whether the following will help to address criterion 1.5.5:

¼ Policies and procedures

¼ Consent and refusal processes

¼ Information provided to consumers / patients

¼ Evidence of compliance with policies and procedures

¼ Staff education and training programs and records

¼ Results of review of near misses and adverse events

¼ Audit / KPI data

¼ Evaluation of systems

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Performance measurementThis criterion states that: “The system to manage sample collection, blood, blood components / blood products and patient blood management ensures safe and appropriate practice”. Organisations responsible for transfusing blood, blood components or blood products should be able to demonstrate that they have in place effective systems that promote safe and appropriate blood management, including processes to manage issues of consent and programs for staff education.

Some common suggested performance measures are as follows:

Number of transfusion episodes where informed consumer / patient consent was documented

Total number of transfusion episodes audited

Number of transfused blood component episodes with documented evidence of two checking signatures

Total number of transfused blood component episodes audited

Number of episodes of transfused blood components / products with reason for transfusion documented in health record

Total number of transfused blood component / product episodes audited

Comment: Reason for transfusion should be documented on both the request form and in the health record

Number of pre-transfusion samples that do not meet requirements for labelling described in current clinical practice guidelines6 / NPAAC* standards15 labelling requirements

Total number of pre-transfusion samples

*National Pathology Accreditation Advisory Committee

Number of transfusion episodes in stable adults undertaken in accordance with current national clinical practice guidelines6 for the appropriate use of blood components

Total number of adult transfusion episodes audited

Comment: Auditing to address this indicator requires good knowledge of the guidelines and so this indicator should be calculated by trained staff

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Criterion 1.5.5:

The system to manage sample collection, blood, blood components / blood products and patient blood management ensures safe and appropriate practice. (continued)

Number of consumers / patients who experienced a reaction that was reported

Total number of consumers / patients who experienced a reaction

Comment: Calculating this indicator may require the matching of health record information to the incident management system

Number of transfusion episodes in stable adults undertaken in accordance with current national clinical practice guidelines6 for the appropriate use of blood components

Total number of adult transfusion episodes audited

Comment: Auditing to address this indicator requires good knowledge of the guidelines and so this indicator should be calculated by trained staff

Number of administered blood components / products that have a unit / product number documented in the consumer / patient’s health record

Total number of blood component / product episodes audited

Comment: This indicator might be calculated from health records updated over a specified time period OR health records might be examined for blood component / product administration until a target number of blood component / product administrations is reached

Number of clinical staff required to manage blood transfusions whose education / competency testing is current

Total number of clinical staff required to manage blood transfusions

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References1. Australian & New Zealand Society of Blood Transfusion.

Guidelines for pretransfusion laboratory practice. 5th edn. Sydney NSW; ANZBT; 2007.

2. Australian & New Zealand Society of Blood Transfusion Inc. and Royal College of Nursing Australia. Guidelines for the administration of blood components. Sydney NSW; ANZBT; 2004.

3. Australasian Society of Blood Transfusion. Guidelines for autologous blood collection. Topics in Transfusion Medicine 2002; 9(2): 1-54. Accessed from http://www.anzsbt.org.au/publications/documents/2002_Vol9_2.pdf on 26 August 2010.

4. Australian Red Cross Blood Service (ARCBS). Label and component information. 4th edn. Melbourne VIC; ARCBS; 2008.

5. Australian Red Cross Blood Service (ARCBS). Blood component information: Circular of information. An extension of blood component labels. Melbourne VIC; ARCBS; 2009.

6. National Health and Medical Research Council (NHMRC). Clinical practice guidelines for the use of blood components. Canberra ACT; Australian Government. Accessed from http://www.nhmrc.gov.au/publications/synopses/cp77syn.htm on 24 August 2010.

7. National Blood Authority (NBA). Guidelines on the prophylactic use of Rh D immunoglobulin (anti-D) in obstetrics. Canberra ACT; National Health and Medical Research Council (NHMRC); 2003.

8. National Blood Authority (NBA) and Australian Health Ministers’ Conference. National blood supply contingency plan (NBSCP): Australia’s response to blood shortages. Canberra ACT; Australian Government; 2008.

9. National Health and Medical Research Council (NHMRC) and Australasian Society of Blood Transfusion (ASBT). Clinical practice guidelines on the use of blood components. Canberra ACT; NHMRC & ASBT; 2001.

10. Australian Red Cross Blood Service (ARCBS). Transfusion medicine manual: Autologous, allocated and directed donations. All states; ARCBS. Accessed from http://www.manual.transfusion.com.au/Inventory-Management/Practice/Donations---specialised.aspx on 25 August 2010.

11. Australian Red Cross Blood Service (ARCBS). Transfusion medicine manual: Transfusion alternatives – techniques for minimising and avoiding allogeneic blood component therapy. Sydney NSW; ARCBS. Accessed from http://www.manual.transfusion.com.au/Transfusion-Clinical-Practice/Transfusion-Alternatives.aspx on 25 August 2010.

12. Australian Red Cross Blood Service (ARCBS). Massive transfusion: haemorrhage. Melbourne VIC; ARCBS. Accessed from http://www.manual.transfusion.com.au/Transfusion-Clinical-Practice/Disease-Therapeutics/Massive-Transfusion.aspx on 27 August 2010.

13. AS 3864:1997 Medical refrigeration equipment—For the storage of blood and blood products. 2nd edn.

14. SA Dept of Health. BloodSafe e-Learning Australia. Adelaide; SA Dept of Health. Accessed from https://www.bloodsafelearning.org.au/# on 24 August 2010.

15. National Pathology Accreditation Advisory Council (NPAAC). Requirements for transfusion laboratory practice. Canberra ACT; NPAAC; 2008.

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Criterion LA – Awareness sA – ImplementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 1.5.6

The organisation ensures that the correct consumer / patient receives the correct procedure on the correct site.

a) Policy and procedures for ensuring correct patient, correct procedure and correct site identification prior to any clinical intervention are consistent with international and jurisdictional policy / guidelines.

b) Information on consumer / patient identification and correct procedure, correct site policy / guidelines is provided to healthcare providers and to consumers / patients and carers.

a) The consumer / patient identification and correct procedure, correct site policy / guidelines and documentation are implemented throughout the organisation by staff / teams involved in healthcare interventions.

b) Staff are educated on the consumer / patient identification and correct procedure, correct site policy and procedures.

c) Consumers / patients and carers are involved in ensuring correct patient, correct procedure and correct site.

d) A system to report near misses and errors in consumer / patient identification is implemented, and is linked to the incident management system.

a) The organisation implements standard consumer / patient identification processes that correspond with national specifications.

b) Compliance with policy and procedures on consumer / patient identification, correct procedure and correct site are evaluated, and improved as required.

c) Any confirmed incident of wrong patient, wrong procedure or wrong site is investigated, and strategies implemented as required.

a) The organisation implements evidence-based advanced systems and technology to ensure correct patient, correct procedure and correct site is achieved.

and/or

b) The organisation conducts research and develops innovative methods to improve correct consumer / patient identification, correct procedure and correct site.

a) The organisation demonstrates it is a leader in consumer / patient identification, ensuring that the correct patient receives the correct procedure on the correct site.

IntentThis criterion is relevant for all organisations that undertake surgical and/or interventional procedures. It applies to all operative and other invasive procedures that could potentially expose consumers / patients to harm, including procedures performed in settings outside operating theatres, administration of medications, transfusions and diagnostic testing.

The intent of this criterion is to expand the use of the Correct Patient, Correct Site, Correct Procedure Protocol into other therapeutic areas, ensuring consumer / patient identification procedures are implemented and adhered to throughout the organisation.

Relationships of 1.5.6 with other criteriaSafe care and service provision (Standard 1.5) depends upon correct identification of the consumer / patient and correct documentation of the procedure and site. While these issues predominantly affect the conduct of surgical and other interventional procedures, they also impact upon medication management (Criterion 1.5.1) and all aspects of blood and blood component management (Criterion 1.5.5). All documentation associated with correct identification / site / procedure, including the issuing of unique consumer / patient identifiers, will be recorded in the consumer / patient health record (Criterion 1.1.8).

Systems for ensuring correct identification, correct site and correct procedure are an aspect of the organisation’s integrated risk management framework (Criterion 2.1.2). Failures in this area will lead to incidents, including adverse events and sentinel events (Criterion 2.1.3), and to complaints (Criterion 2.1.4).

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Criterion LA – Awareness sA – ImplementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 1.5.6

The organisation ensures that the correct consumer / patient receives the correct procedure on the correct site.

a) Policy and procedures for ensuring correct patient, correct procedure and correct site identification prior to any clinical intervention are consistent with international and jurisdictional policy / guidelines.

b) Information on consumer / patient identification and correct procedure, correct site policy / guidelines is provided to healthcare providers and to consumers / patients and carers.

a) The consumer / patient identification and correct procedure, correct site policy / guidelines and documentation are implemented throughout the organisation by staff / teams involved in healthcare interventions.

b) Staff are educated on the consumer / patient identification and correct procedure, correct site policy and procedures.

c) Consumers / patients and carers are involved in ensuring correct patient, correct procedure and correct site.

d) A system to report near misses and errors in consumer / patient identification is implemented, and is linked to the incident management system.

a) The organisation implements standard consumer / patient identification processes that correspond with national specifications.

b) Compliance with policy and procedures on consumer / patient identification, correct procedure and correct site are evaluated, and improved as required.

c) Any confirmed incident of wrong patient, wrong procedure or wrong site is investigated, and strategies implemented as required.

a) The organisation implements evidence-based advanced systems and technology to ensure correct patient, correct procedure and correct site is achieved.

and/or

b) The organisation conducts research and develops innovative methods to improve correct consumer / patient identification, correct procedure and correct site.

a) The organisation demonstrates it is a leader in consumer / patient identification, ensuring that the correct patient receives the correct procedure on the correct site.

Policy and proceduresThe Surgical Safety Checklist expands on the Universal Protocol for preventing wrong site, wrong procedure and wrong person surgery which was developed in the USA1, endorsed by the former Australian Council for Safety and Quality in Health Care2 and then adopted by a number of Australian State health departments.3, 4

It is anticipated that organisations will adapt these master checklists for the unique circumstances under which their organisation carries out surgical procedures, by adding more specific components. However, adaptations should not compromise the consistency of the process or the team participation aspects of the checklists.

A review of implementation of the Correct Patient, Correct Procedure, Correct Site protocol (based on the Universal Protocol) in 20085 identified that two phases of the process had the greatest variation between surgical teams: marking the site of the procedure and conducting the ‘team timeout’, that is, the mandatory suspension of all activity in the operating or procedure room prior to beginning the procedure, during which all necessary checks are made.

Organisational policy and associated protocols and procedures should include:

• to whom the policy pertains

• the procedural steps to be taken

• actions to be taken when there are discrepancies or disagreements in variation at the timeout

• actions to be taken in the event of a wrong patient, wrong procedure, wrong site incident

• any exceptions to the use of the policy

• dispute resolution procedures.

In spite of the introduction of checklists during the past decade, wrong patient, wrong procedure, wrong side, wrong site incidents have continued to occur, and in surgical settings can have devastating implications6–8 for both consumer / patient and the care team. The Australian Commission on Safety and Quality in Health Care (the Commission) reviewed sentinel event data from public and private hospitals across Australia and reported that for each of the three years reviewed, procedures involving the wrong consumer / patient or body part accounted for almost a third and sometimes up to two thirds of total sentinel events.

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Criterion 1.5.6

The organisation ensures that the correct consumer / patient receives the correct procedure on the correct site. (continued)

Based on a system for integrating definitions of sentinel events nationally, 62% of sentinel events in public hospitals in 2006–07 involved procedures on the wrong consumer / patient or body part.9

Responsibility for ensuring correct patient / procedure / site verification rests with all team members. However, the person in charge of the interventional procedure carries ultimate responsibility.10

In emergencies, the Royal Australasian College of Surgeons suggests that all attempts should still be made to identify the correct patient / procedure / site / side according to their principles, although it may not be possible or appropriate to complete all the checks. Any exceptions to the full protocol should be documented in the consumer / patient notes.10

Incorrect alignment of consumer / patient with procedure is not restricted to operating theatres. The Commission has investigated the applicability of their Correct Patient, Correct Procedure, Correct Site protocol in other procedural settings and has developed protocols for radiology, nuclear medicine, radiation therapy and oral surgery.11 These protocols are available from the Commission on request.

They all follow a four-step model of:

1. Verification of patient information

2. Matching that information against the request form (or the consent form where appropriate)

3. Timeout immediately prior to the procedure

4. Post-procedure confirmation and documentation.

The potentially harmful consequences of consumer / patient misidentification are not restricted to the realm of surgical and other such interventions, but must also be managed with respect to the use of medication and the collection of blood, tissue or other biological samples for cross-matching and/or pathological testing. The correct management of blood and blood components and the organisation’s responsibilities in this area are described within criterion 1.5.5, and medication management within criterion 1.5.1.

In addition, the organisation must have policy and procedures to ensure the correct matching of consumer / patient, sample and paperwork when not only blood (‘wrong blood in tube’), but any body fluid, tissue sample or cells are collected for the purpose of pathological examination. The collection of biopsy material, which will involve an invasive procedure,

should be undertaken following the same guidelines as any other surgical procedure, with the same cross-checking of consumer / patient identification, site and side. When material is taken for diagnostic purposes, the organisation must also ensure that the correct examination / testing of the material is carried out, and that the results are assigned to the correct consumer / patient health record.

Prompt points

¼ On what approach does the organisation base its policy for ensuring correct procedure on the correct patient, and correct site? How does the organisation ensure that there is a consistency in the approach taken between different surgeries and surgical teams?

¼ Are similar, or other, procedures for checking consumer / patient and procedure used in any departments beyond surgery? How is compliance with these systems monitored?

¼ How does the organisation ensure that consumer / patient, sample, paperwork and health record are correctly matched during pathology testing?

¼ What indicators or other measures would alert the organisation to failings of this system?

Consumer / patient identification bandsWith consumers / patients and clinicians increasingly moving between organisations and facilities, variations in identification bands and the alert systems tied to them can have serious implications for consumer / patient care. The Commission researched this issue and highlighted the need for a common identification band, suggesting that the specifications of such a band be developed upon the following principles16:

• All consumers / patients should wear some form of identification, and healthcare providers should have policy in place that guides this identification process.

• The primary purpose of an identification band or other identification mechanism is to identify the consumer / patient wearing the band. The use of identification bands to signify clinical alerts is secondary.

• It is up to the jurisdictions and other health service providers to determine how they meet the specifications for identification bands.

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In June 2010, the Healthcare Identifiers Act (Cth)12 was passed. The Healthcare Identifiers Regulations 201013, which set out provisions relating to the assignment, collection, use, adoption and disclosure of healthcare identifiers, are now in effect. Organisations should familiarise themselves with the requirements under this legislation and move towards their implementation.

Prompt points

¼ What changes have been made to the consumer / patient identification bands in your organisation to comply with the national standards?

¼ What clinical alerts are used with the identification banding system?

¼ To prevent confusion, how does the organisation ensure consistency in the way that consumers / patients’ names are presented on the ID band and the patient record, e.g. ordering of some Asian names?

¼ Are there any exceptions to the use of the bands on consumers / patients?

¼ What steps has the organisation taken to ensure consumers / patients have only one identification number?

¼ Has the organisation integrated the new national health identifier system into their systems?

Education – staff, consumers / patients, carers Systems developed to manage consumer / patient identification and correct matching of procedures to the consumer / patient all require compliance and consistency to be effective. Healthcare organisations must ensure that agreed processes are carried out by all relevant staff in a consistent manner; this means that pre-surgical checks are always undertaken and are complete and correct.

Leadership from senior clinicians is important for embedding in the organisation a culture that ensures these checks are habitual, but do not become habituated.

When ensuring correct patient / procedure / site / side, systems and processes should be executed and completed in a predictable sequence on every occasion. Understanding the reasons for the repetition will assist full cooperation from staff. Education about the process and its details should aim to ensure that items are not omitted from a checklist or protocol. The repetition may be boring, but it ensures that responsibilities are clear and that nothing is omitted.

Consistency in how the surgical site is marked is also important. There are concerns that the variability in types of marks used in Australia may lead to confusion, particularly where staff move between operating teams.5 Agreement should be sought about the nature of this mark. The mark should be visible in the procedural field when preparation and draping is complete. As a minimum, procedures that involve laterality (i.e. are not midline procedures), multiple structures (e.g. fingers) and spinal levels must be marked. Additional marking, including any incision marking, remains at the discretion of the person responsible for the procedure and cannot be delegated to another person. There should be no abbreviating of ‘left’ and ‘right’.

Consumers / patients, their families and carers can play an important role in preventing mismatches. By raising awareness of the potential problem, there may be greater tolerance by consumers / patients of what can appear to be pointless and repetitive questioning from a series of healthcare providers, and a greater willingness to respond to variations in the questioning. Organisations should explain the identification process to consumers / patients and their carers on admission, and that the process will be repeated prior to any intervention, to enable their active involvement in the identification process.

Focus points

¼ How does the organisation brief consumers / patients to prepare them for active collaboration in correct patient / procedure / site?

¼ How are staff members taught the organisation’s processes for correct patient / procedure / site?

¼ What is done to ensure that performance of the organisation’s procedures is undertaken reliably and in a consistent manner by surgical and other teams?

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Criterion 1.5.6

The organisation ensures that the correct consumer / patient receives the correct procedure on the correct site. (continued)

Risk management and reportingJurisdictional health department systems for tracking sentinel events, adverse events and near misses aim to identify contributing factors. There are differences in the classification schemes used by each State and Territory, but all will include the capacity to record incorrect consumer / patient identification, incorrect procedure or incorrect site. In fact, in a review of sentinel events that occurred in 2004–05, undertaken by the Commission, 53 of 130 incidents meeting the definition of ‘sentinel event’ were procedures involving the wrong consumer / patient or body part.14 Further investigation of these events suggested that the most common contributing factors for procedures involving the wrong consumer / patient or body part were lack of, problems with, or breakdown in rules / policies / procedures (this applied in 36/53 cases), followed by lack of, problems with, or breakdown in information / documentation (applied in 17/53 cases), and lack of, problems with, or breakdown in communication (applied in 18/53 cases).

Regardless of the system used for recording and tracking sentinel events, incidents and near misses associated with wrong patient / procedure / site have not fallen in recent years. (However, it has been suggested that this may be due to more complete reporting.)

Prompt points

¼ How are incidents relating to incorrect consumer / patient identification or incorrect site for a procedure recorded and tracked by the organisation? How are they investigated?

¼ Have any actions been taken in response to investigations of incidents or near misses related to incorrect consumer / patient identification, or a procedure undertaken on the wrong patient or wrong site?

Evidence commonly presented

Consider whether the following will help to address criterion 1.5.6

¼ Pre-operative policies and compliance with national protocol

¼ Staff education

¼ Evidence of compliance with policies

¼ Information provided to staff and consumers / patients

¼ Results of review of near misses and sentinel events

Performance measurementThis criterion states that: “The organisation ensures that the correct consumer / patient receives the correct procedure on the correct site”. Effective systems for consumer / patient identification and for determining correct procedure, site and side are vital to the provision of safe, high quality care and the minimisation of adverse events, including sentinel events. The organisation should be able to demonstrate that it has policy and processes to manage correct identification and matching of consumer / patient to intervention in all aspects of its service provision.

Some common suggested performance measures are as follows:

Number of incidents of wrong site surgery

Total number of surgical cases

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References1. Joint Commission on Accreditation of Healthcare

Organizations (JCAHO). Facts about the Universal Protocol. Oakbrook Terrace USA; JCAHO. Accessed from http://www.jointcommission.org/PatientSafety/UniversalProtocol/up_facts.htm on 6 May 2010.

2. Australian Council for Safety and Quality in Health Care. Ensuring correct patient, correct site, correct procedure. Canberra ACT; Australian Council for Safety and Quality in Health Care; not dated.

3. NSW Health. Correct patient, correct procedure and correct site policy. Sydney; NSW Health; 2007.

4. WA Council for Safety and Quality in Health Care, and WA Office for Safety and Quality in Health Care. Correct patient, correct procedure and correct site policy and guidelines for Western Australian health services. Perth WA; Department of Health; 2006.

5. Australian Commission on Safety and Quality in Health Care (ACSQHC). Ensuring correct patient, correct site, correct procedure protocol for surgery: Review of implementation and proposals for action. Sydney NSW; ACSQHC; 2008.

6. Donnellan E. Hospital removed wrong kidney from child. Irish Times, Dublin IRE; 21 April 2008.

7. Freyer FJ. Hospital fined in wrong-site surgery. Providence Island Journal, Rhode Island USA; 27 November 2007.

8. Freyer FJ. Surgeon operates on wrong knee at Miriam Hospital. Providence Island Journal, Rhode Island USA; 20 September 2008.

9. Australian Commission on Safety and Quality in Health Care (ACSQHC). Windows into safety and quality in health care, 2008. Sydney NSW; ACSQHC; 2008.

10. Royal Australasian College of Surgeons (RACS). RACS Guidelines for ensuring correct patient, correct side and correct site surgery. Melbourne VIC; RACS; 2009.

11. Australian Commission on Safety and Quality in Health Care (ACSQHC). Ensuring correct patient, correct site and correct procedure in radiology, nuclear medicine, radiation therapy and oral surgery. Fact Sheet. Sydney NSW; ACSQHC.

12. Healthcare Identifiers Act 2010 (Cth).

13. Healthcare Identifiers Regulations 2010 (Cth).

14. Australian Institute for Health and Welfare (AIHW) and Australian Commission on Safety and Quality in Health Care. Sentinel events in Australian public hospitals 2004–05. Canberra ACT; AIHW; 2007.

Number of wrong patient, wrong procedure or wrong site incidents investigated

Total number of wrong patient, wrong procedure or wrong site incidents reported

Number of ‘wrong blood in tube’ (WBIT) incidents associated with sampling for blood / blood component / product administration

Total number of transfusion specimens

Comment: this indicator may be collected by the pathology service and may be called a ‘mismatch’; from their whole organisation data; where relevant the service may be able to isolate those specimens relating to transfusion

Number of incidents involving mismatch of consumer / patient and pathology test / results

Total number of wrong patient, wrong procedure or wrong site incidents reported

Number of incidents involving incorrect non-surgical procedures / tests

Total number of wrong patient, wrong procedure or wrong site incidents reported

Comment: the organisation should determine service areas to examine, e.g. radiology, nuclear medicine

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Criterion LA – Awareness sA – ImplementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 1.5.7

The organisation ensures that the nutritional needs of consumers / patients are met.

a) Policy / guidelines exist for the delivery of nutritional care consistent with jurisdictional guidelines.

b) A multidisciplinary team oversees the organisation’s nutrition management strategy to ensure the provision of food and fluid to consumers / patients consistent with good nutritional care.

c) Relevant healthcare providers are educated, and aware of their role in delivering good nutritional care and preventing malnutrition.

d) Relevant healthcare providers use a validated nutrition risk screening tool to assess consumers / patients

(i) on admission

(ii) following a change of health status

(iii) weekly thereafter.

e) Nutritional care is incorporated into the consumer / patient care plan.

a) The organisation has a strategic and coordinated approach to delivering consumer / patient-centred nutritional risk screening and care for those with malnutrition.

b) The nutrition policy / guidelines are adapted to local needs and implemented across the organisation.

c) Roles and responsibilities of relevant healthcare providers in the delivery of the nutrition management strategy are clearly defined.

d) Food, fluid and nutritional care is considered as part of an intervention and medical treatment plan.

e) Referrals to nutrition-related services occur in a timely manner.

a) Nutritional care is evaluated and improved as required.

b) Education programs on nutritional care and malnutrition are evaluated and improved as required.

c) Reporting of incidents contributing to deterioration in consumer / patient nutritional status is analysed and trended, and improvements are made to the nutritional policy / guideline as required.

a) The organisation compares nutrition management systems data internally and externally and improvements are made to ensure better practice.

and/or

b) The organisation communicates results of its performance in nutrition management to inform consumers / patients, colleagues and peers.

and/or

c) The organisation undertakes research into nutritional care in healthcare settings and acts on the results.

a) The organisation demonstrates it is a leader in strategies to ensure that the nutritional needs of consumers / patients are met.

IntentThe intent of this criterion is to ensure that the nutritional needs of consumers / patients are met during their healthcare journey. Organisations have a responsibility to optimise the nutrition of their consumers / patients, so as to support wellbeing and recovery, and to prevent malnutrition.

A key focus of this criterion is on prevention of malnutrition whilst in the healthcare setting. However, if consumers / patients enter a healthcare organisation with malnutrition, or it subsequently develops, it should be managed as per established guidelines.

As nutrition care can affect a wide variety of consumers / patients across the spectrum of health care, this criterion is applicable to all organisations, although there will be different degrees of involvement depending on the nature of the organisation and the length of consumer / patient stay.

Relationships of 1.5.7 with other criteriaGood nutrition is essential to the wellbeing and recovery of the consumer / patient, and to ensure that the length of stay is not unnecessarily lengthened. Nutritional needs should be determined during assessment (Criterion 1.1.1), and nutrition care should be planned and delivered (Criterion 1.1.2). Good nutrition is an aspect of appropriate (Criterion 1.3.1) and effective (Criterion 1.4.1) care delivery, and integral in promoting resistance to infection (Criterion 1.5.2)

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Criterion LA – Awareness sA – ImplementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 1.5.7

The organisation ensures that the nutritional needs of consumers / patients are met.

a) Policy / guidelines exist for the delivery of nutritional care consistent with jurisdictional guidelines.

b) A multidisciplinary team oversees the organisation’s nutrition management strategy to ensure the provision of food and fluid to consumers / patients consistent with good nutritional care.

c) Relevant healthcare providers are educated, and aware of their role in delivering good nutritional care and preventing malnutrition.

d) Relevant healthcare providers use a validated nutrition risk screening tool to assess consumers / patients

(i) on admission

(ii) following a change of health status

(iii) weekly thereafter.

e) Nutritional care is incorporated into the consumer / patient care plan.

a) The organisation has a strategic and coordinated approach to delivering consumer / patient-centred nutritional risk screening and care for those with malnutrition.

b) The nutrition policy / guidelines are adapted to local needs and implemented across the organisation.

c) Roles and responsibilities of relevant healthcare providers in the delivery of the nutrition management strategy are clearly defined.

d) Food, fluid and nutritional care is considered as part of an intervention and medical treatment plan.

e) Referrals to nutrition-related services occur in a timely manner.

a) Nutritional care is evaluated and improved as required.

b) Education programs on nutritional care and malnutrition are evaluated and improved as required.

c) Reporting of incidents contributing to deterioration in consumer / patient nutritional status is analysed and trended, and improvements are made to the nutritional policy / guideline as required.

a) The organisation compares nutrition management systems data internally and externally and improvements are made to ensure better practice.

and/or

b) The organisation communicates results of its performance in nutrition management to inform consumers / patients, colleagues and peers.

and/or

c) The organisation undertakes research into nutritional care in healthcare settings and acts on the results.

a) The organisation demonstrates it is a leader in strategies to ensure that the nutritional needs of consumers / patients are met.

and skin integrity (Criterion 1.5.3). The organisation must also consider the dietary requirements of consumers / patients with diverse needs and from diverse backgrounds (Criterion 1.6.3).

Preventing malnutrition in the healthcare setting is an aspect of the organisation’s management of risk (Criterion 2.1.2). The development of malnutrition in a consumer / patient is a reportable incident (Criterion 2.1.3) that should be investigated.

DefinitionsNutrition care is a coordinated multidisciplinary approach to the provision of nutrition that adapts to the consumer / patient’s individual needs and preferences throughout the healthcare journey. This encompasses all aspects of the nutrition continuum of care from nutrition assessment and intervention, including access to safe, acceptable and appropriate food services, nutrition supplements and/or enteral and parenteral nutrition.1

Nutritional status is the state of a person’s health in relation to the consumption and utilisation of nutrients for energy, metabolism, normal organ function, healing and immune function.2, 3

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Criterion 1.5.7

The organisation ensures that the nutritional needs of consumers / patients are met. (continued)

Malnutrition is defined as “a state of nutrition in which a deficiency or excess (or imbalance) of energy, protein, and other nutrients causes measurable adverse effects on tissue / body form (body shape, size and composition) and function and clinical outcome”.4

Artificial nutrition support is the administration of specially formulated liquid nutrients, either orally (oral nutrition support), through a tube directly into the gastrointestinal tract (enteral nutrition), or into a vein (parenteral nutrition).5

Nutrition screening describes the process of identifying individuals with characteristics commonly associated with nutrition problems who may require comprehensive nutrition assessment and may benefit from nutrition intervention.1, 4

Nutrition assessment is a comprehensive approach to gathering pertinent data in order to define nutritional status and identify nutrition-related problems. The assessment often includes consumer / patient history, medical diagnosis and treatment plan, nutrition and medication histories, nutrition-related physical examination including anthropometry, nutritional biochemistry, psychological, social, and environmental aspects.1, 4

Nutrition policy / guidelinesOrganisations should have a nutrition policy aimed at optimising nutrition for wellbeing, recovery and preventing malnutrition.

The prevalence of malnutrition in adults in hospitals is reported in international and Australian studies to be in the order of 10-60%.6 A number of studies show deterioration in nutritional status in consumers / patients over the course of hospitalisation.7 The primary cause of malnutrition in developed countries is disease, due to associated factors including anorexia, dysphagia, malabsorption and increased nutrient requirements. Inadequate intake, due to the provision of inadequate quantities of suitable food or difficulties with eating, compounds these effects. The majority of authors describing malnutrition in institutional settings cite a lack of awareness and recognition of the problem, resulting in a lack of activities to identify, prevent and treat malnutrition.8–10 Recent Australian

studies found that a majority of consumers / patients assessed as malnourished had not been previously identified, and as such, were not receiving any specialised nutrition care.10–14

Malnutrition is recognised as having serious implications for health and recovery from illness or surgery through effects on skeletal and somatic muscle function, gastrointestinal function, immune function and wound healing.15, 16 These functional changes impact on the incidence of complications and on clinical outcome (morbidity and mortality), which in turn have major implications for length of hospital stay, readmission, quality of life, convalescence and healthcare costs.15, 16

The organisation’s nutrition policy should be multidisciplinary in scope and based on national and State / Territory guidelines. Policy should address all of the following key elements of nutrition care:

• governance

• risk screening, assessment, care planning, monitoring and discharge planning

• planning and provision of food, fluids, and nutritional supplements

• mealtime environment and assistance to eat and drink

• consumer / patient information and communication

• education and training for staff.

Prompt points

¼ What documentation (legislation, guidelines, current evidence) did the organisation draw upon when drafting its nutrition policy?

¼ What departments / disciplines were consulted in the development of the organisation’s policy?

¼ What evidence is there of implementation of the policy within the organisation?

Nutrition management strategyQuality management relates to the implementation of a nutrition management / malnutrition prevention and management strategy, based on the elements within the nutrition care policy, and development of a quality improvement program. Depending on the size of the organisation, a governance committee or responsible person should be appointed to oversee the implementation of this strategy. Dietitians are key staff

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in the development of policy and processes related to nutrition care, but delivering high quality nutrition care to customers / patients is a complex task involving many different processes and staff groups. Roles and responsibilities of staff need to be clearly defined and agreed and regularly reviewed.

In smaller organisations, where dietitians are not retained, organisations should draw upon current evidence when developing nutrition management policy / guidelines and procedures.

A nutrition management strategy should be adopted by all sections of the organisation to ensure appropriate identification and actions are taken for all consumers / patients. A systematic approach should include processes that ensure strategies are undertaken to maintain nutritional status / prevent malnutrition / manage malnutrition.17 Strategies include:

• nutrition risk screening on admission and at agreed and documented intervals during stay

• a documented nutrition care plan, including current weight and target weight

• access to safe, acceptable and appropriate food service

• meal / menu planning to suit the health service population, and individual consumer / patient needs

• a mealtime environment conducive to eating

• provision of timely assistance to eat

• monitoring of consumer / patient food intake and nutritional status

• referral to other health professionals where required

• implementation of artificial nutrition support therapy when oral intake is inadequate, as per agreed procedures

• nutrition care discharge planning and ongoing care

• identified roles and responsibilities of staff with respect to nutrition care of consumers / patients

• multidisciplinary staff education

• consumer / patient and family education

• audit and reporting.

Prompt points

¼ What evidence is there of a multidisciplinary nutrition management strategy?

¼ Where appropriate, are incidents related to nutrition reported, analysed, trended and used to improve quality procedures?

¼ Are there identified roles and responsibilities for staff related to nutrition care?

¼ How does the organisation ensure that consumers / patients receive adequate assistance to eat?

¼ Is there a procedure / guideline related to implementation of artificial nutrition?

¼ How is a consumer / patient’s nutritional status assessed and monitored during care delivery?

¼ Does the presentation of information in the consumer / patient health record make it easy to detect a deteriorating consumer / patient?

Individual nutrition screening, assessment and carenutrition risk screening

Nutrition risk screening is a critical first step to quickly identify those persons who may be at risk of poor nutrition. Where such a risk is determined, appropriate nutrition care should be implemented, which may include a more comprehensive assessment of nutritional status. There are several simple nutrition screening tools which have been validated for use in different settings.4 The choice of screening tool depends on the population group and organisational processes. Nutrition risk screening can be performed by staff who come into contact with consumers / patients, such as nursing staff, medical staff, or directly by consumers / patients or carers themselves.

nutrition care plans

‘At-risk’ consumers / patients should have a documented nutrition care plan. Nutrition care plans should be determined based on individual nutrition risk and/or a more comprehensive nutritional assessment. Nutrition care planning should be developed in consultation with dietitians, either individually for the consumer / patient or through agreed processes such as flowcharts or standards.

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Criterion 1.5.7

The organisation ensures that the nutritional needs of consumers / patients are met. (continued)

Nutrition assessment should include:

• the condition of the consumer / patient’s mouth and teeth

• use of, and condition of dentures

• capacity to swallow effectively

• ability to open packages

• ability to self feed

• diet requirements, such as vegan / vegetarian

• cultural requirements, such as halal or kosher meals.

Where a consumer / patient is admitted for simple surgical work with short length of stay, it is sufficient to have light diet or full ward diet documented on the clinical pathway / nursing care plan.

Provision of nutrition care

In order to enable consumers / patients to maintain or restore nutritional status, the meal service should be provided on a flexible basis along with practical, consumer / patient-focused support and assistance. Consumers / patients with a loss of appetite may be unable to manage standard size meals and may need to be tempted with small attractive meals and frequent nourishing snacks and drinks. Help needs to be available to those who have difficulty choosing from the menu, opening portion-control food packaging, cutting up their food and/or feeding themselves. The eating environment should be pleasant and encouraging, with minimal disruptions.

Some consumers / patients cannot manage adequate nutrition orally and require artificial nutrition. There should be established guidelines from which clinical teams can consider the appropriateness of artificial nutrition for individual consumers / patients. Artificial nutrition should be overseen by a dietician.

evaluation of nutrition care

The consumer / patient’s nutrition care should be evaluated on a regular basis, as determined in the nutrition care plan and modified as necessary to ensure meeting the goals of optimising nutrition.

Consumer / patient / carer education

Consumers / patients should be provided with information related to the importance of nutrition for recovery, the food / meal service system, and if necessary, assisted to understand the value of artificial nutrition in maintaining nutritional status / managing malnutrition.

Prompt points

¼ What nutrition screening processes are used in the organisation? Who does this?

¼ Is there a process / protocol for managing ‘at-risk’ consumers / patients?

¼ Where there is a documented nutrition care plan, does it follow a consistent structure / format?

¼ How is a consumer / patient’s nutritional status assessed and monitored during care delivery?

¼ Does the presentation of information in the consumer / patient health record make it easy to detect deteriorating nutritional status, e.g. weight loss, poor oral intake?

¼ What evidence is there that food, fluid and nutrition care is considered as part of an intervention / medical treatment plan?

¼ How do audits demonstrate nutrition compliance or initiate activity to improve nutrition care?

Staff educationEducation and training for staff should be developed, implemented and evaluated by a multidisciplinary team including consumers / patients. There should be training and an increased awareness of:

• the benefits of good nutrition care for recovery

• the organisation’s nutrition care processes, including how the food / meal service system operates

• malnutrition and its adverse effects on consumer / patient outcomes.

This is essential for the success of optimising nutrition care and reducing malnutrition prevalence.

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Training programs should be available for:

• operational staff, including consumer / patient support and food service staff

• medical staff

• nursing staff

• other allied health

• administrative staff.

Prompt points

¼ What nutrition education programs are there within the organisation and who are they aimed at?

Evidence commonly presented

Consider whether the following will help to address criterion 1.5.7

¼ Nutrition care governance structure

¼ Policy and processes related to nutrition care

¼ Monitoring and audit of results e.g. % of consumer / patients weighed, % of consumer / patients screened; % of consumers / patients with appropriate nutrition care

¼ Education and information for staff and consumer / patient

¼ Consumer / patient food service developed with multidisciplinary team to meet the consumer / patient population needs

Performance measurementThis criterion states that: “The organisation ensures that the nutritional needs of consumers / patients are met”. The focus of this criterion is upon the prevention of malnutrition within the healthcare setting; and upon correct responses to malnutrition when it is detected or developed. The organisation should be able to demonstrate that it has policy, procedures and education programs that support a multidisciplinary approach to nutrition care for consumers / patients.

Some common suggested performance measures are as follows:

Number of consumers / patients receiving nutrition risk screening

Total number of consumers / patients admitted to a particular unit / ward

Number of consumers / patients receiving nutrition risk screening weekly who were not ‘at-risk’ on admission

Total number of consumers / patients with a length of stay greater than seven days in a particular unit / ward who were not ‘at-risk’ of malnutrition on admission

Number of consumers / patients identified as malnourished

Total number of consumers / patients admitted to a particular unit / ward

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Criterion 1.5.7

The organisation ensures that the nutritional needs of consumers / patients are met. (continued)

Number of consumers / patients identified as malnourished

Total number of consumers / patients admitted to a particular unit / ward that were not identified as malnourished on admission

Number of consumers / patients receiving appropriate nutritional care

Total number of consumers / patients admitted to a particular unit / ward

Comment: the organisation should determine what constitutes ‘appropriate nutritional care’

Number of consumers / patients who were diagnosed as malnourished or ‘at-risk’ of malnutrition receiving appropriate nutritional care

Total number of consumers / patients who were diagnosed as malnourished or ‘at-risk’ of malnutrition in a particular unit / ward

Comment: the organisation should determine what constitutes ‘appropriate nutritional care’; the organisation should determine what constitutes ‘at-risk’; examples of consumers / patients at risk of malnutrition include the frail aged or those with physical limitations, such as of the upper limb(s) or spine

Number of consumers / patients referred to a dietitian

Total number of consumers / patients admitted to a particular unit / ward

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References1. American Dietetic Association. Identifying patients

at risk: ADA’s definitions for nutrition screening and nutrition assessment. Council on Practice (COP) Quality Management Committee. J Am Diet Assoc 1994; 94(8): 838-839.

2. National Cancer Institute. Dictionary of cancer terms. Bethesda USA: National Cancer Institute. Accessed from http://www.cancer.gov/dictionary/ on 31 August 2010.

3. Detsky A, McLaughlin J, Baker J et al. What is subjective global assessment of nutritional status? J Parenter Enteral Nutr 1987; 11(1): 8-13.

4. Dietitians Association of Australia. Evidence based practice guidelines for the nutritional management of malnutrition in adult patients across the continuum of care. Nutr Diet 2009; 66(Suppl.): S1-S34.

5. Council of Europe. Resolution ResAP(2003)3 on food and nutritional care in hospitals. Strasbourg FR; Committee of Ministers. Accessed from https://wcd.coe.int/ViewDoc.jsp?id=85747 on 24 July 2010.

6. Stratton R, Green CJ and Elia M. Disease-related malnutrition: an evidence-based approach to treatment. 1st edn. Wallingford UK; Cabi Publishing; 2003.

7. Braunschweig C, Gomez S and Sheean P. Impact of declines in nutritional status on outcomes in adult patients hospitalized for more than 7 days. J Am Diet Assoc 2000; 100(11): 1316-1322.

8. Cornish CA and Kennedy NP. Protein-energy malnutrition in hospital in-patients. Br J Nutr 2000; 83: 575-591.

9. Kondrup J, Johansen N, Plum L et al. Incidence of nutritional risk and causes of inadequate nutritional care in hospitals. Clin Nutr 2002; 21(6): 461-468.

10. Gaskill D, Black L, Isenring E et al. Malnutrition prevalence and nutrition issues in residential aged care facilities. Australasian J Ageing 2008; 27(4): 189-194.

11. Banks M, Ash S, Bauer J and Gaskill D. Prevalence of malnutrition in adults in Queensland public hospitals and residential aged care facilities. Nutr Diet 2007; 64(3): 172-178.

12. Middleton M, Nazarenko G, Nivison-Smith I and Smerdely P. Prevalence of malnutrition and 12-month incidence of mortality in two Sydney teaching hospitals. Int Med J 2001; 31(8): 455-461.

13. Lazarus C and Hamlyn J. Prevalence and documentation of malnutrition in hospitals: A case study in a large private hospital setting. Nutr Diet 2005; 62(1): 41-47.

14. Banks M. Malnutrition and its consequences: an opportunity cost saving for Australian healthcare. Nutr Diet 2009; 66(Suppl.): A23.

15. Isabel M, Correia T and Waitzberg DL. The impact of malnutrition on morbidity, mortality, length of hospital stay and costs evaluated through a multivariate model analysis. Clin Nutr 2003; 22(3): 235-239.

16. Green C. Existence, causes and consequences of disease-related malnutrition in the hospital and the community and clinical and financial benefits of nutritional intervention. Clin Nutr 1999; 18(Supp 2): 3-28.

17. Elia M. The Malnutrition Advisory Group consensus guidelines for the detection and management of malnutrition in the community. Nutr Bull 2001; 26: 81-83.

Relevant standardsBankhead R, Boullata J, Brantley S et al. A.S.P.E.N. Enteral nutrition practice recommendations. J Parenter Enteral Nutr 2009; 33: 122.

Dietitians Association of Australia. Evidence based practice guidelines for the nutritional management of malnutrition in adult patients across the continuum of care. Nutr Diet 2009; 66(Suppl.): S1-S34.

NHS Quality Improvement Scotland. Food, Fluid and Nutritional Care. Edinburgh UK; NHS. Accessed from http://www.nhshealthquality.org/nhsqis/1015.html on 8 September 2010.

State-based menu standards and policy documentsNSW Department of Ageing, Disability and Home Care (DADHC). Policy document: Ensuring good nutrition. Sydney; DADHC.

NSW Greater Metropolitan Clinical Taskforce. Nutrition standards for adult in-patients in NSW hospitals. Sydney; NSW Health; 2010.

Sydney South West Area Health Service (SSWAHS). Food and nutrition. Policy SSW_PD2009_030. Sydney; NSW Health; 2009.

Victorian Department of Human Services. Nutrition standards for menu items in Victorian hospitals and residential aged care facilities. Melbourne VIC; DHS; 2009.

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1.6 Consumer Focus Standard

The standard is: The governing body is committed to consumer participation.

The intent of this standard and criteria is to promote consumer participation and the need to involve consumers / patients in their health care and ensure their rights, responsibilities and needs are met.

This standard has three criteria. They are:

1.6.1 Consumers / patients, carers and the community participate in the planning, delivery and evaluation of the health service.

1.6.2 Consumers / patients are informed of their rights and responsibilities.

1.6.3 The organisation meets the needs of consumers / patients and carers with diverse needs and from diverse backgrounds.

Consumers are people who directly or indirectly make use of health services1, and includes carers, a support person or a representative of organisations of consumers.

The term consumer incorporates women, men, people from diverse cultural experiences, including Aboriginal and Torres Strait Islander people, class positions and social circumstances, sexual orientations, health and illness conditions.

1. Australian Commission on Safety and Quality in Health Care. Windows into safety and quality in health care 2008. Sydney NSW; ACSQHC; 2008.

seCtIon 5Standards, criteria, elements and guidelines

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Criterion LA – Awareness sA – ImplementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 1.6.1

Consumers / patients, carers and the community participate in the planning, delivery and evaluation of the health service.

a) Management’s commitment to consumer / patient, carer and community participation is demonstrable.

b) The organisation has identified its community and main consumer groups.

c) The organisation has policy / guidelines that address consumer / patient, carer and community participation and a documented process to manage this.

d) Consumers / patients, carers and the community are advised of the organisation’s code of conduct.

a) Consumers and consumer groups are consulted about effective ways of participating with the organisation and partnerships are established.

b) Relevant staff are trained in how to implement and evaluate consumer / patient, carer and community group participation strategies.

c) Consumers / patients and, when relevant, carers are involved in policy / guideline development and health services planning.

d) Consumers / patients and, when relevant, carers sign confidentiality agreements when appointed to committees, and as otherwise appropriate.

e) The organisation implements relevant training for interested consumers / patients and carers.

a) The consumer / patient and carer participation program is evaluated and consumers / patients and carers are involved in this evaluation and improvements are made as required.

b) Feedback on consumer / patient and carer participation is provided to the community and the organisation.

a) Consumer / patient, carer and community group participation is compared with other organisations and improvements are made to ensure better practice.

and/or

b) Consumers / patients and carers participate in the development and evaluation of existing or new services.

a) The organisation demonstrates it is a leader in consumer / patient, carer and community participation.

IntentThe intent of this criterion is to ensure that organisations recognise, and act upon, the importance of consumer / patient, carer and community participation in health care. This participation ranges from inclusion of consumers / patients and, where appropriate, their carers in decisions about care, through to community involvement in policy decisions.

Relationships of 1.6.1 with other criteriaAn important aspect of participation of consumers / patients, their carers and the wider community in the planning, delivery and evaluation of the health service is the involvement of consumers / patients and, where appropriate, carers in planning and delivery of care (Criterion 1.1.2); and the provision of appropriate information to the community by the organisation (Criterion 1.2.1). In collaborating with consumers / patients, their carers and the community, organisations should display an understanding of the diverse needs and diverse backgrounds of the population it serves (Criterion 1.6.3).

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Criterion LA – Awareness sA – ImplementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 1.6.1

Consumers / patients, carers and the community participate in the planning, delivery and evaluation of the health service.

a) Management’s commitment to consumer / patient, carer and community participation is demonstrable.

b) The organisation has identified its community and main consumer groups.

c) The organisation has policy / guidelines that address consumer / patient, carer and community participation and a documented process to manage this.

d) Consumers / patients, carers and the community are advised of the organisation’s code of conduct.

a) Consumers and consumer groups are consulted about effective ways of participating with the organisation and partnerships are established.

b) Relevant staff are trained in how to implement and evaluate consumer / patient, carer and community group participation strategies.

c) Consumers / patients and, when relevant, carers are involved in policy / guideline development and health services planning.

d) Consumers / patients and, when relevant, carers sign confidentiality agreements when appointed to committees, and as otherwise appropriate.

e) The organisation implements relevant training for interested consumers / patients and carers.

a) The consumer / patient and carer participation program is evaluated and consumers / patients and carers are involved in this evaluation and improvements are made as required.

b) Feedback on consumer / patient and carer participation is provided to the community and the organisation.

a) Consumer / patient, carer and community group participation is compared with other organisations and improvements are made to ensure better practice.

and/or

b) Consumers / patients and carers participate in the development and evaluation of existing or new services.

a) The organisation demonstrates it is a leader in consumer / patient, carer and community participation.

Understanding consumers and the communityAt both Federal and State / Territory levels, there is a commitment in Australia to consumer / patient, carer and community participation in health care. Within the organisation, this commitment should be integrated into the operation at three key levels1:

• at the level of management, with a focus upon the decision makers, and how participation can be promoted and increased

• at the program or development level, with staff developing and providing information, care, treatment and research with consumers / patients, carers and the community

• at the level of individual care, with the consumer / patient and, where appropriate, his or her carer(s) being actively involved in the planning and delivery of care.

Within the scope of this criterion, a consumer is defined as someone who makes either direct or indirect use of health services – that is, current or potential users of the health system, and/or their carer(s).2, 3 The definition is wide-ranging, encompassing both consumers with specific health needs, or who may at some time have them, and those who have a general interest in the health system and health funding. Many consumers also have an indirect influence upon the health system in the capacity of taxpayers. A carer is not necessarily a family member, but anyone who gives unpaid, informal care to an individual in need of assistance because of their physical or mental condition.4 Within this criterion, a carer is also a consumer.

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Criterion 1.6.1

Consumers / patients, carers and the community participate in the planning, delivery and evaluation of the health service. (continued)

A community is a group of people who share a common interest or background (e.g. cultural, social, political, economic, health), which may also be, but is not necessarily, geographic.5 An individual consumer will belong to a number of different communities, while any community will be made up of consumers. The community from which a healthcare organisation attracts participating consumers may be the community at large, that is, they may be members of the general population with an interest in health care; or it may be the specific community needing health care and served by the organisation.

For a private hospital, the community will consist of their visiting medical officers (VMOs) and the consumers / patients who use their services. Although VMOs are in these circumstances regarded as members of the organisation’s ‘community’, the feedback offered by such individuals, the organisation’s response to it, and the processes by which this happens, necessarily differ from situations involving members of the public.

A healthcare organisation offering specialist care may provide a narrow range of services, but to a very diverse set of consumers / patients.

Before initiating consumer participation, it is vital that organisations understand the nature of the community concerned, which will vary greatly according to the organisation’s size, location, purpose, and whether it is public or private. A large public hospital may interact with a community consisting of many different groups that:

• are culturally and linguistically diverse, including Aboriginal and Torres Strait Islanders

• have a wide range of special needs

• may be socially disadvantaged or marginalised

• are, or are not, represented by advocates.

While a healthcare organisation, especially one servicing an extensive community, is not expected to be aware of every individual group within that community, it is nevertheless essential that it have a good understanding of those likely to require or have an interest in its services. Thorough consumer / patient data collection and the use of internal surveys are essential. Organisations should also enter into

partnerships with various community and advocacy associations, and make use of their accumulated knowledge bases. However, it is also important that certain groups are not overlooked because of the absence of a public ‘voice’ or formal associations: individuals with a language or communication barrier, or marginalised consumers such as the homeless or disenfranchised, often lack recognition.

Prompt points

¼ How does the organisation demonstrate its commitment to consumer / patient, carer and community participation in health care?

¼ How does the organisation ensure that it has identified the various groups that make up the community it services?

Policies and participationOrganisations must develop policy / guidelines that address consumer / patient, carer and community participation in their planning and delivery of care, which should draw upon those issued by Federal and relevant State / Territory bodies. The basic framework for community participation, which must be addressed within organisational policy / guidelines, consists of:

• informing the community

• listening to the community

• responding to the community

• involving the community.

Consumer participation in health care has the ultimate goal of improving outcomes by giving the community what it wants and needs. There are many ways in which consumers / patients, carers and the community can participate in the planning, delivery and evaluation of the services provided by the organisation, and the processes may be formal or informal depending upon the size and the nature of the organisation. Some avenues of participation are:

• unsolicited feedback (complaints, praise)

• solicited feedback (surveys)

• individual care planning (decision making in care, consumer / patient-centred planning)

• group care planning (education sessions, consumer / patient and carer support groups)

• consultation (focus / interest groups, public meetings, discussion papers for reaction)

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• partnerships (Quality Improvement committees, advocacy groups, community advisory committees, consumer and carer committees, research committees)

• decision making (policy forums, governance structures).

One of the major ways that an organisation can shape its approach to consumer / patient, carer and community participation is by asking its community what opportunities and avenues to participation it wants. By soliciting feedback and suggestions via internal surveys, by the use of flyers and advertising, by entering into partnerships and discussions with community, advocacy and welfare groups and by employing other means of communication such as a website, the organisation will come to a better understanding of the most appropriate ways to involve consumers in its processes. Similarly, once those processes are in place, organisations can use the same pathways to inform the community of what it is doing and of how to participate. Both the means by which organisations decide upon which participation strategies to implement and the processes by which they are implemented should be thoroughly documented.

Prompt points

¼ How does the organisation decide what participation strategies to implement?

¼ By what means does the organisation solicit feedback and suggestions from the community?

¼ Does the organisation have consumers on any of its committees? On which committees? How did those consumers become members of the committees?

¼ With what special interest or professional groups has the organisation entered into partnership?

¼ What training and education is provided for staff involved with consumer / patient, carer and community participation?

¼ By what means does the organisation gather feedback on its consumer participation program? How does it respond to this feedback?

¼ What are some of the organisation’s positive outcomes from consumer participation? To whom did the organisation disseminate information of these outcomes?

Legal responsibilities, recruitment and trainingSome forms of consumer participation are quite informal, such as completion of surveys and involvement in focus groups. Others are legislatively governed and the processes by which the organisation meets its obligations in this respect should be addressed within its policy / guidelines. The specific requirements will vary from jurisdiction to jurisdiction and region to region. For example, in Victoria the establishment of community advisory committees by the Metropolitan Health Service Boards is mandatory.6

When planning to include consumers on formal committees such as consumer advisory committees, Quality Improvement committees or research ethics committees, there are several steps that should be followed.7 The committee should already have a description of its role, its terms of reference, and its intended contribution to the broader functioning of the organisation. A recruitment notice, somewhat like a position description, should then be drafted, outlining the consumer’s role on the committee and any desirable attributes / experiences, and including such details as the frequency and length of meetings. Organisations should encourage applicants from diverse backgrounds and with special needs. To this end, the application process should be straightforward, and any resources subsequently required for participation, for example, transport for someone with a disability, if required, or catering for any special dietary requirements, should be allocated. The recruitment notice and any other relevant information, such as an application form, should be made available via the organisation’s normal channels for dissemination of consumer information, as well as via broader means such as advertising.

Training should be provided where appropriate to inform and support consumer representatives and to make their participation as meaningful as possible. Consumers should be mentored and supported by a staff member or experienced consumer member of the committee when they first take up a position.

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Criterion 1.6.1

Consumers / patients, carers and the community participate in the planning, delivery and evaluation of the health service. (continued)

Prompt points

¼ On how many different committees within the organisation do consumers participate? How many of these are advisory, and how many decision making?

¼ How does the organisation recruit consumers? How does it encourage participation by people from diverse backgrounds and with special needs?

¼ What skills does the organisation require from its consumers? What training does the organisation provide for consumers prior to their taking up a committee role?

Evidence commonly presented

Consider whether the following will help to address criterion 1.6.1

¼ Inclusion of a consumer participation program in the organisation’s strategic plan

¼ Policies enabling and governing consumer participation

¼ Evidence of consumer participation on committees

¼ Terms of reference for the relevant committees, and minutes of their meetings

¼ Evidence of consumer and staff training / education

¼ Evidence of feedback / news of positive outcomes / quality improvements from consumer participation e.g. websites, newsletters

¼ Feedback from selected consumer representatives on their role and achievements

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Performance measurementThis criterion states that: “Consumers / patients, carers and the community participate in the planning, delivery and evaluation of the health service”. The organisation should be able to demonstrate that it encourages and facilitates community participation in all aspects of its service provision, from the level of individual care planning through to policy decision making.

Some common suggested performance measures are as follows:

Number of consumers / patients who have been invited to participate in surveys in a given time period

Total number of consumers / patients seen / admitted in a given time period

Number of organisational committees with consumer representation / involvement

Total number of organisational committees

Number of Quality Improvement projects with consumer participation

Total number of QI projects

Number of staff who have attended education / training sessions regarding consumer participation

Total number of staff invited to attend education / training sessions regarding consumer participation

Number of committees within the health service that have held community consultation sessions for which proceedings have been documented

Total number of committees within the health service that have held community consultation sessions

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Criterion 1.6.1

Consumers / patients, carers and the community participate in the planning, delivery and evaluation of the health service. (continued)

References1. Rural and Regional Health and Aged Care Services Division.

Doing it with us, not for us: Strategic direction 2010–13. Melbourne; Victorian Department of Health; 2009.

2. Gregory J. Consumer engagement in Australian health policy: Final report of the AIHPS research project. Melbourne VIC; Australian Institute of Health Policy Studies (AIHPS); 2008.

3. SA Health. Consumer and community participation policy directive. Adelaide SA; Government of South Australia; 2009.

4. Sydney West Area Health Service. Consumer, carer and community participation policy. Sydney; NSW Health 2008.

5. National Health and Medical Research Council (NHMRC). A model framework for consumer and community participation in health and medical research. Canberra ACT; Australian Government; 2004.

6. Victorian Department of Human Services (DHS). Community Advisory Committee guidelines: Non-statutory guidelines for metropolitan health services. Melbourne VIC; DHS; 2000.

7. Health Issues Centre. Getting started: Involving consumers on committees. Melbourne VIC; La Trobe University; 2008.

Guidelines and toolkitsHealth Issues Centre. Recommended suite of consumer, carer and community participation standards for Victorian public health services; final report. Melbourne VIC; La Trobe University; 2009.

Health Consumers Queensland. Your voice in health: Strategic plan 2008-2010. Brisbane; Queensland Health; 2008.

Domiciliary Care SA. Bringing care home: consumer participation strategy. Norwood SA; Government of South Australia 2007.

South Australian Community Health Research Unit (SACHRU). Community participation evaluation tool. Adelaide SA; Flinders University; 2009.

National Health and Medical Research Council (NHMRC). Resource pack for consumer and community participation in health and medical research. Canberra ACT; Australian Government; 2004.

Victorian Rural and Regional Health and Aged Care Services Division. Participation indicators. Melbourne VIC; Department of Human Services (DHS), Victorian Government; 2005.

Consumer and Community Participation Program. Consumer and community participation toolkit. Brisbane; Queensland Health; 2002.

National Resource Centre for Consumer Participation in Health. An introduction to consumer participation: Fact Sheet 1. Melbourne VIC; La Trobe University; 2002.

SA Health. Community and consumer participation: principles. Adelaide SA; Government of South Australia. Accessed from http://www.safetyandquality.sa.gov.au/Default.aspx?tabid=105 on 10 September 2010.

SA Health. Consumer and community participation guideline. Adelaide SA; Government of South Australia; 2006.

Further readingHealth Issues Centre and Northern Health Community Participation Program. Good practice in consumer, carer and community participation from Victorian health services: Case study. Community Participation Week. Melbourne VIC; La Trobe University; 2009.

Australian Council for Safety and Quality in Health Care. Partnerships for health in action: Promoting consumer and community involvement in health care improvement. Canberra ACT; Australian Government; 2005.

Consumer and Community Participation Implementation Group and NSW Health. Partners in health. Sharing information and making decisions together. Sydney; NSW Government; 2001.

Sydney West Area Health Service. Consumer and community engagement framework for Sydney West Area Health Service. Penrith; NSW Health; 2007

Gregory J. A framework of consumer engagement in Australian health policy. Health Issues 2007; 91(Winter): 22-27.

Bruce N. Facilitating consumer participation: Lessons to be learnt from breast health consumers? Health Issues 2007; 91(Winter): 16-18.

Lloyd C, Tse S and Deane FP. Community participation and social inclusion: How practitioners can make a difference. Australian e-Journal for the Advancement of Mental Health (AeJAMH) 2006; 5(3): 1-10. Accessed from http://www.qldalliance.org.au/resources/items/2009/09/294410-upload-00001.pdf on 10 September 2010.

Mooney GH and Blackwell SH. Whose health service is it anyway? Community values in healthcare. Med J Aust 2004; 180(2): 76-78.

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Criterion LA – Awareness sA – ImplementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 1.6.2

Consumers / patients are informed of their rights and responsibilities.

a) A consumer / patient rights and responsibilities document exists.

b) A confidentiality and privacy policy / guideline is in place.

c) The organisation provides information on how consumers / patients and carers when relevant, can access advocacy and support services.

d) The procedure for consumer access to their health records is documented and communicated to consumers / patients and when appropriate, their carers.

a) Consumers / patients and when appropriate, carers receive a copy of the rights and responsibilities document.

b) Staff discuss rights and responsibilities with the consumer / patient and when appropriate, their carer.

c) The organisation implements policy and procedures to ensure that personal health-related information is managed in accordance with jurisdictional privacy legislation.

d) Staff and volunteers sign confidentiality agreements.

a) The system to inform consumer / patient rights and responsibilities is evaluated, and improvements to documents and practices are made as required.

a) Documents and practices for consumer / patient rights and responsibilities are compared with external systems, and improvements are made to ensure better practice.

and/or

b) The organisation demonstrates that consumers / patients exercise their rights and understand their responsibilities.

a) The organisation demonstrates it is a leader in ensuring consumers / patients and carers are informed of their rights and responsibilities.

IntentThe intent of this criterion is to assist health service organisations in meeting their responsibilities to inform consumers / patients of both their rights and their responsibilities, in order to achieve the best possible health outcomes.

While the focus of this criterion is upon the rights and responsibilities of the consumer / patient, organisations must be aware that in most instances these rights and responsibilities will extend to family members and/or carers involved in a given episode of care, in particular the rights governing communication, participation and the right to comment upon any aspect of the healthcare experience. This awareness should be demonstrated throughout the organisation’s policies and procedures.

Relationships of 1.6.2 with other criteriaAmong the rights of the consumer / patient are the right to collaborate in the planning and delivery of care (Criterion 1.1.2), to give informed consent to that care (Criterion 1.1.3) and, when required, to have information provided to them in different formats (e.g. in Braille or verbally) or in a language other than English, in printed form or via a trained interpreter

(Criterion 1.6.3). Every consumer / patient has the right to access his or her health record (Criteria 1.1.8 and 2.3.1). Failure of the organisation to meet its obligations with respect to consumer / patient rights may lead to incidents (Criterion 2.1.3) and complaints (Criterion 2.1.4).

Consumer / patient rights and responsibilities Within this criterion, the term consumer refers both to any individual receiving care within the organisation, and to any family member, carer or other support person with an interest and/or a role in that individual’s care. Rights are what the consumer / patient is entitled to demand from his or her healthcare provider and health service organisation, and what the provider and/or organisation is obligated to provide to the consumer / patient and, when appropriate, to his or her carer.

Responsibilities are obligations placed on the consumer / patient when he or she accesses a health service, which are usually defined in terms of honesty, compliance and conduct, and which facilitate the healthcare provider and/or the health service organisation’s provision of safe, high quality health care.

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Criterion LA – Awareness sA – ImplementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 1.6.2

Consumers / patients are informed of their rights and responsibilities.

a) A consumer / patient rights and responsibilities document exists.

b) A confidentiality and privacy policy / guideline is in place.

c) The organisation provides information on how consumers / patients and carers when relevant, can access advocacy and support services.

d) The procedure for consumer access to their health records is documented and communicated to consumers / patients and when appropriate, their carers.

a) Consumers / patients and when appropriate, carers receive a copy of the rights and responsibilities document.

b) Staff discuss rights and responsibilities with the consumer / patient and when appropriate, their carer.

c) The organisation implements policy and procedures to ensure that personal health-related information is managed in accordance with jurisdictional privacy legislation.

d) Staff and volunteers sign confidentiality agreements.

a) The system to inform consumer / patient rights and responsibilities is evaluated, and improvements to documents and practices are made as required.

a) Documents and practices for consumer / patient rights and responsibilities are compared with external systems, and improvements are made to ensure better practice.

and/or

b) The organisation demonstrates that consumers / patients exercise their rights and understand their responsibilities.

a) The organisation demonstrates it is a leader in ensuring consumers / patients and carers are informed of their rights and responsibilities.

The Australian Charter of Healthcare Rights1 was developed by the Australian Commission on Safety and Quality in Health Care (the Commission) and endorsed by all Health Ministers for use in Australia in 2008. The Charter summarises the basic rights that consumers / patients are entitled to receive when accessing health services, as well as outlining the responsibilities of the consumer / patient while receiving health care. The aim of the Charter is to provide a framework for the creation of a genuine partnership between consumers / patients and healthcare providers, in order to achieve the best possible health outcomes.

The Charter has three guiding principles1:

1. Everyone has the right to be able to access health care and this right is essential for the Charter to be meaningful.

2. The Australian Government commits to international agreements about human rights which recognise everyone’s right to have the highest possible standard of physical and mental health care.

3. Australia is a society made up of people with different cultures and ways of life, and the Charter acknowledges and respects these differences.

It is applicable to all health settings anywhere in Australia, including:

• public hospitals

• private hospitals

• multipurpose services

• general practices

• specialist rooms

• day procedure facilities

• community health services

• private allied health facilities

• all sites of domiciliary care.

The Charter summarises the basic rights that consumers / patients are entitled to receive when accessing healthcare services. These rights are:

1. Access

2. Safety

3. Respect

4. Communication

5. Participation

6. Privacy

7. Comment.

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Criterion 1.6.2

Consumers / patients are informed of their rights and responsibilities. (continued)

Implementation of the Australian Charter of Healthcare Rights is mandated at a State / Territory level, and organisations should adopt the Commission’s Charter in toto if they do not have their own Charter of Rights, or make certain that any existing Charter of Rights is in alignment with the official document. Organisations must also have policy / guidelines in place to ensure that the rights and responsibilities of consumers / patients are recognised, that all relevant information is conveyed to consumers / patients in a timely and appropriate manner, and that consumers / patients are given all necessary assistance in the exercise of their rights. Some State / Territory policies may go further and/or into more detail than the Commission’s Charter, and organisations must comply with all relevant legislative requirements. Information on the Australian Charter of Healthcare Rights, as well as various related brochures, posters and information sheets, are available on the Commission’s website (http://www.safetyandquality.gov.au/).

The organisation must be aware of, and make provision for, those circumstances under which the rights of the consumer / patient are transferred to a family member or carer, for example, in the event that the consumer / patient is a minor, or is in an insensate condition. Conversely, there are circumstances under which the rights of the consumer / patient and/or their carer(s) are superseded by the requirements of legislation, including under various provisions of the Mental Health Act. The organisation must ensure that it is aware of all such legislative responsibilities that apply within its jurisdiction.

Prompt points

¼ Does the organisation have its own Charter of Rights, or has it implemented the Australian Charter of Healthcare Rights? If it has its own Charter, how has it ensured that it aligns with all aspects of the Australian Charter?

¼ How is the Charter of Healthcare Rights referenced in the organisation’s policies and procedures, and its management of complaints?

¼ What other policies / guidelines, if any, have been drawn upon in the organisation’s drafting of its rights and responsibilities documentation?

Informing consumers / patients of their rights and responsibilitiesInforming consumers / patients of their rights and responsibilities is one of the organisation’s own responsibilities. A copy or a summary of the organisation’s Charter of Rights should be displayed at reception, in waiting areas, and in consulting rooms and wards. A copy should be included in any information packs sent to elective consumers / patients prior to admission, and given to anyone receiving domiciliary care on the first visit. Where relevant, information about the Charter and its provisions should be displayed upon the organisation’s website. Translated copies of the Charter should be made available, in a range of languages drawn from the organisation’s knowledge of the community it serves, and in Braille and/or audio-format where appropriate; many of these are available to download from the Commission’s website. Consumers / patients should also be made aware that professional interpreters are available to help with understanding the organisation’s Charter, and of how to access this service if it is required or desired.

To support open, respectful and transparent communication, the organisation must ensure that staff are well-versed in the provisions of its Charter of Rights, aware that they must be prepared to discuss rights and responsibilities with consumers / patients, be able and willing to answer any questions that arise, and facilitate consumer / patient access to interpreters and/or advocates as required or desired. The provision of information via documentation and direct explanation should be noted in the consumer / patient’s health record. The consumer / patient’s understanding of the information can be determined during discussion, or via survey.

There are various ways in which the organisation can educate and train its staff in the practical implementation of its Charter of Rights. A copy of the organisation’s Charter should be included in the employment package for new staff, and sessions on the implications and content of such a Charter should be included in orientation and ‘refresher’ education courses for all staff.

Dissemination of information about the organisation’s Charter of Rights and the rights and responsibilities of the consumer / patient should not be confined to the organisation itself. The Charter and related documents can be distributed via existing partnerships with community and advocacy groups, and also supplied to related health facilities such as nursing homes and hostels. The provisions of the Charter could also be made the topic of community education sessions or focus groups.

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Prompt points

¼ Where is the organisation’s Charter of Rights displayed within the organisation? Into how many different languages has it been translated?

¼ When does the organisation provide consumers / patients with information about their rights and responsibilities? In what form(s) is this information provided?

¼ How does the organisation ensure that its staff are able to answer questions about and discuss the provisions of its Charter of Rights?

¼ How does the organisation inform its community of the rights and responsibilities of the consumer / patient?

¼ From whom does the organisation seek feedback about its provision of information about consumer / patient rights and responsibilities? How is this feedback documented? How is it used?

Consumer / patient advocacyIt is the right of the consumer / patient to access advocacy services if required or desired, and this should be clearly stated within the organisation’s rights and responsibilities documentation; separate information pamphlets should also be provided. Organisations are not themselves required to provide advocacy services, but they must assist the accessing of such support services by consumers / patients by advising that these services are available if needed through relevant support agencies, such as cancer, mental health or multicultural groups, as well as various consumer groups in each State / Territory. Information on local advocacy services and how to contact them by telephone or via the internet should be provided, and the process should be facilitated by interpreters if necessary.

Organisations should regularly evaluate the means by which they provide information about advocacy services and consumer / patient satisfaction with the process. Seeking feedback from consumers / patients, their family members and/or carers will allow improvements to be made as required.

Prompt points

¼ How does the organisation make consumers / patients aware of the availability of advocacy services?

¼ What changes, if any, have been made to the provision of information about advocacy services as a result of consumer feedback?

Consumer / patient access to health recordsThe right of the consumer / patient to access his or her own health record is guaranteed under the Australian Charter of Healthcare Rights1, the National Privacy Principles2 and privacy legislation3. The organisation must develop a process by which the consumer / patient can obtain this access, and the details of this process should be documented and made available to the consumer / patient in a range of formats and languages, and via the use of an interpreter if necessary.

Prompt points

¼ How would a consumer / patient obtain access to his or her health record? How is this information provided to the consumer / patient?

Privacy and confidentialityThe consumer / patient’s right to privacy, and to have personal disclosures and medical information handled with strict confidentiality, is fundamental to health care and one of the basic rights mandated in the Australian Charter of Healthcare Rights. There is an expectation within the community that personal health information will be treated with the utmost care, and this duty to maintain confidentiality is underpinned by legal and professional standards.

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Criterion 1.6.2

Consumers / patients are informed of their rights and responsibilities. (continued)

Organisations must have privacy and confidentiality policy / guidelines in place that meet the demands of all relevant legislation, codes of professional ethics, and accepted standards. This documentation should specify under what circumstances personal information will be shared, by whom and with whom. All staff, including volunteers, who work within the health system are in a position of trust, where they may gain access to personal health information that is confidential. Staff must be educated about the organisation’s privacy and confidentiality policy / guidelines, and sign confidentiality agreements on commencement of employment. At a State / Territory level, legislation allows for the fining and/or dismissal of health service employees who breach consumer / patient confidentiality.

Prompt points

¼ What legislation / standards / codes has the organisation drawn upon in drafting and implementing its policy / guidelines for matters of privacy and confidentiality?

¼ How are staff made aware of the terms of the privacy and confidentiality policy / guidelines? When are staff confidentiality agreements signed?

Evidence commonly presented

Consider whether the following will help to address criterion 1.6.2

¼ Consumer / patient rights and responsibilities document / pamphlet, in a range of appropriate languages

¼ Staff education and training programs on the provisions of the Charter and their implementation

¼ Documented process for access to health records for consumers / patients

¼ Evidence of dissemination of information on consumer / patient rights and responsibilities outside the organisation

¼ Documented improvements made to the systems for disseminating information on consumer / patient rights and responsibilities

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Performance measurementThis criterion states that: “Consumers / patients are informed of their rights and responsibilities”. The organisation should be able to demonstrate that it has a Charter of Rights in alignment with the Australian Charter of Healthcare Rights, that it educates and trains its staff to understand and to discuss all aspects of its Charter with consumers / patients, and that it provides consumers / patients and its community with information about, and facilitates the understanding of, its Charter.

Some common suggested performance measures are as follows:

Number of consumers / patients who have received information about their rights and responsibilities in a given time period

Total number of consumers / patients seen in a given time period

Number of consumers / patients who have received information about their rights and responsibilities in an appropriate language or format

Total number of consumers / patients who have received information about their rights and responsibilities

Number of consumers / patient receiving a direct explanation of their rights and responsibilities, as noted in their health records

Total number of health records audited

Number of consumers / patients who can explain their rights and responsibilities

Total number of consumers / patients surveyed

Number of long-term consumers / patients receiving a review of rights and responsibilities every X months

Total number of long-term consumers / patients

Comment: organisation to define ‘X’ and ‘long-term’

References1. Australian Commission on Safety and Quality in Health

Care (ACSQHC). Australian charter of healthcare rights (for consumers). Sydney NSW; ACSQHC; 2008.

2. Office of the Federal Privacy Commissioner. National privacy principles. Information sheet. Canberra ACT; Office of the Privacy Commissioner; 2008.

3. Australian Law Reform Commission (ALRC). For your information: Australian privacy law and practice. ALRC Report 108. Sydney NSW; ALRC; 2008.

Further readingAustralian Commission on Safety and Quality in Health Care (ACSQHC). Australian charter of healthcare rights publications. Sydney NSW; ACSQHC. Accessed from http://www.health.gov.au/internet/safety/publishing.nsf/Content/com-pubs_ACHR on 15 September 2010.

World Health Organization (WHO), Genomic Resource Centre. Patients’ rights. Geneva CH; WHO. Accessed from http://www.who.int/genomics/public/patientrights/en/ on 12 November 2009.

Victorian Department of Human Services (DHS), Home and Community Care Program (HACC). Your rights and responsibilities as a HACC service user. Melbourne VIC; DHS; 2009.

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Criterion LA – Awareness sA – ImplementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 1.6.3

The organisation meets the needs of consumers / patients and carers with diverse needs and from diverse backgrounds.

a) The organisation identifies the diverse needs and diverse backgrounds of its consumers / patients and their carers, to improve its cultural competence, awareness and safety.

b) Policy / guidelines are written to ensure that services are provided appropriate to consumers / patients and carers with diverse needs and from diverse backgrounds.

c) The organisation meets legislative requirements that are relevant to consumers / patients and carers with diverse needs and from diverse backgrounds.

a) The organisation collects demographic data in relation to the diverse population it serves.

b) Staff are informed about and have access to information and resources regarding consumers / patients and carers with diverse needs and from diverse backgrounds.

c) Staff are provided with the opportunity for training to enhance their skills in planning and delivery of appropriate services to consumers / patients and carers with diverse needs and from diverse backgrounds.

d) Food, services, care and consideration for spiritual needs are provided in a manner that is appropriate to consumers / patients with diverse needs and from diverse backgrounds.

e) Translated information is developed appropriate to the diverse needs and diverse backgrounds of consumers / patients.

f) Trained interpreters are available and staff / consumers / patients are informed of the availability.

a) The organisation demonstrates partnerships with relevant local organisations, to support the diverse needs and diverse backgrounds of consumers / patients and their carers.

b) Data on utilisation of the service by people with diverse needs and from diverse backgrounds are collected, and maintained to monitor access, which is improved as required.

c) The organisation evaluates whether consumers / patients and their carers’ diverse needs are met, and strategies for improvement are implemented as required.

a) Where indicated, the organisation demonstrates active partnerships with relevant Aboriginal and Torres Strait Islander communities to support the development of culturally appropriate and responsive services.

and/or

b) Performance indicators for diverse needs and diverse backgrounds are measured, and compared internally and externally, and improvements are made to ensure better practice.

and/or

c) The organisation develops innovative processes for service delivery, consultation and participation, to meet requirements of consumers / patients with diverse needs and from diverse backgrounds.

a) The organisation demonstrates it is a leader in its systems for participation strategies for consumers / patients and carers with diverse needs and from diverse backgrounds.

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Criterion LA – Awareness sA – ImplementationLA plus the following

MA – evaluationSA plus the following

eA – excellenceMA plus the following

oA – LeadershipEA plus the following

Criterion 1.6.3

The organisation meets the needs of consumers / patients and carers with diverse needs and from diverse backgrounds.

a) The organisation identifies the diverse needs and diverse backgrounds of its consumers / patients and their carers, to improve its cultural competence, awareness and safety.

b) Policy / guidelines are written to ensure that services are provided appropriate to consumers / patients and carers with diverse needs and from diverse backgrounds.

c) The organisation meets legislative requirements that are relevant to consumers / patients and carers with diverse needs and from diverse backgrounds.

a) The organisation collects demographic data in relation to the diverse population it serves.

b) Staff are informed about and have access to information and resources regarding consumers / patients and carers with diverse needs and from diverse backgrounds.

c) Staff are provided with the opportunity for training to enhance their skills in planning and delivery of appropriate services to consumers / patients and carers with diverse needs and from diverse backgrounds.

d) Food, services, care and consideration for spiritual needs are provided in a manner that is appropriate to consumers / patients with diverse needs and from diverse backgrounds.

e) Translated information is developed appropriate to the diverse needs and diverse backgrounds of consumers / patients.

f) Trained interpreters are available and staff / consumers / patients are informed of the availability.

a) The organisation demonstrates partnerships with relevant local organisations, to support the diverse needs and diverse backgrounds of consumers / patients and their carers.

b) Data on utilisation of the service by people with diverse needs and from diverse backgrounds are collected, and maintained to monitor access, which is improved as required.

c) The organisation evaluates whether consumers / patients and their carers’ diverse needs are met, and strategies for improvement are implemented as required.

a) Where indicated, the organisation demonstrates active partnerships with relevant Aboriginal and Torres Strait Islander communities to support the development of culturally appropriate and responsive services.

and/or

b) Performance indicators for diverse needs and diverse backgrounds are measured, and compared internally and externally, and improvements are made to ensure better practice.

and/or

c) The organisation develops innovative processes for service delivery, consultation and participation, to meet requirements of consumers / patients with diverse needs and from diverse backgrounds.

a) The organisation demonstrates it is a leader in its systems for participation strategies for consumers / patients and carers with diverse needs and from diverse backgrounds.

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Criterion 1.6.3

The organisation meets the needs of consumers / patients and carers with diverse needs and from diverse backgrounds. (continued)

IntentThe Australian population is comprised of many diverse groups, whose needs must be met during the delivery of health care. The intent of this criterion is to ensure that the organisation fulfils its obligation to provide for the diversity of the community it serves.

Relationships of 1.6.3 with other criteriaThe organisation’s responsibility to provide care and services to those consumers / patients with diverse needs, and from diverse backgrounds, must be met in terms of both its physical environment and its communication. Consumers / patients and, in some cases, their carers must be able to access the organisation, and be able to locate the required services (Criterion 3.2.2). They must understand their rights and responsibilities (Criterion 1.6.2), understand and give informed consent to their treatment (Criterion 1.1.3) and, where appropriate, participate in the planning and delivery of their care (Criterion 1.1.2). The organisation, in turn, must understand the community that it is servicing, and supply all necessary information about its services (Criterion 1.2.1).

Policies and proceduresEqual opportunity and freedom from discrimination on the basis of age, race, religion, gender, sexual orientation and disability are legislatively governed in Australia at both Federal and State / Territory levels. Within the healthcare system, this translates to an obligation to create an environment where recognition of diversity is embedded within the culture of the organisation and where all consumers / patients, whatever their individual circumstances, receive equality of care.

Diversity is a broad concept that includes all Australians. It refers to the various qualities that define the individual and exist across society as a whole. It includes characteristics or factors such as age, race, ethnicity, language, gender, sexual orientation, religion, beliefs, family and/or social structure, and ability, including disability; as well as socio-economic level, educational attainment, personality, marital and parental status, general life and work experience, and status within the general community.

Recognising that each person is a unique and complex being is integral to understanding and responding effectively to healthcare needs at an individual, family or community level.

Cultural and linguistic diversity (CALD) pertains to the breadth of cultural and/or linguistic affiliation(s) held by individuals within the community, by virtue of their place of birth, ancestry, ethnic origin, religion, preferred language or language(s) spoken at home, or because of their parents’ identification on a similar basis.1 It is the organisation’s responsibility to develop policy and procedures that fulfil the relevant legislative requirements, and that recognise and provide for the physical, mental, cultural and/or linguistic needs of the consumers / patients accessing its services.

Organisations should develop policies and procedures to address:

• understanding people and their needs

• understanding and analysing changing demographics

• encouraging consumer / patient participation in decision making

• providing relevant and accessible information

• developing an appropriately trained workforce

• meeting the specific needs of different communities.

Prompt points

¼ What legislation did the organisation reference when developing its policies / procedures for delivering health care to those consumers / patients from diverse backgrounds and with diverse needs?

Creating and maintaining a culturally competent workplaceCultural competence refers to the processes and practices implemented by an organisation that foster inclusiveness and establish the progression of learning about diversity and differences and their impact on the way services are delivered, received, accessed and promoted. In the context of health care, cultural competence focuses on the capacity of the organisation to improve health and wellbeing for the individual and the community by integrating culture into the delivery of health services.2 The organisation should strive for the creation of a culturally competent working environment, with culture being integrated

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into the delivery of health services so as to improve health and wellbeing for both the individual and the community.2 In pursuing this aim, it is important to recognise that staff members will bring their own culture to any clinical encounter, and that the health system itself, as an institution, also has a culture of its own. Reflection on practice and upon one’s own culture is an inherent element of cultural competence.

Some cultural groups may have different health needs than others, such as Aboriginal and Torres Strait Islander people. ‘Closing the Gaps’ is a strategy that aims to reduce indigenous disadvantage with respect to life expectancy, child mortality, access to early childhood education, educational achievement and employment outcomes; it was endorsed by the Australian Government in March 2008. There are a number of tools and information on how healthcare organisations can address these issues, available at http://www.healthinfonet.ecu.edu.au/closing-the-gap, as well as a number of other websites.

Those individuals whose personal condition or situation makes it difficult for them fully to participate in their own health care are said to have special needs. The personal condition or situation may be:

• poor literacy, whether from a non-English speaking background or not

• affected by trauma

• affected by medication / drugs

• age (either very young or very old / frail)

• a disability.

There are many different types of disability. A disability can be caused by a genetic condition, an illness or an accident, and may mean that the individual in question has special needs.3 Disability may include:

• intellectual disability

• physical disability

• sensory disability

• acquired brain injury

• neurological impairment

• mental illness

• dual disability / co-morbidity (i.e. one of the above and a psychiatric disability), also known as dual diagnosis; this often refers to a person with a mental illness and a drug or alcohol addiction

• disabilities that are unrelated to ageing

• any combination of the above.

Communication with people with some disabilities may be difficult. Alternative modes of communication may need to be sought for those with vision, speech, language, hearing and cognitive impairments. Care should be taken to focus on the consumer / patient’s overall health, and not just on factors relating to their disability.

Apart from providing a formal interpretation service, the organisation should encourage, and provide the resources and time for staff to undergo further training in order to enhance their ability to provide care for a diverse consumer / patient base. Furthermore, the organisation may wish to consider the recruitment of bilingual staff, which should also be done with reference to the community demographic, with the goal to facilitate effective and responsive care.

Prompt points

¼ How does the organisation foster a greater cultural awareness and better provision of services for culturally and linguistically diverse consumers / patients by its staff?

¼ How does the organisation facilitate communication with special needs consumers / patients?

Meeting the needs of diverse consumers / patientsCulturally and linguistically diverse communities make up a significant proportion of the Australian population. Nevertheless, certain barriers exist that may interfere with the provision of health care to the members of these communities.4 These barriers include:

• different culturally-based concepts of health and illness, which may affect the understanding of treatment and the impact of compliance

• a lack of familiarity with the Australian health system, which may be very different from health services in the country of origin

• a lack of understanding of consumer / patient rights and responsibilities

• a lack of proficiency in the English language, which impacts on the ability to access and communicate with health service providers

• a lack of confidence, which may hinder effective participation in healthcare planning and evaluation

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Criterion 1.6.3

The organisation meets the needs of consumers / patients and carers with diverse needs and from diverse backgrounds. (continued)

• language and cultural barriers, which may prevent the understanding required for informed consent to medical / surgical procedures, and which have serious medico-legal implications

• serious ongoing physical and mental health issues as a result of past trauma, including torture, refugee experiences and/or confinement to prisons or camps.

Accurate and suitably detailed communication between providers and consumers / patients is fundamental to quality health care. Various options exist for providing culturally and linguistically diverse consumers / patients with the required information. Fact sheets in a variety of languages are a first step towards the provision of all relevant documents. The languages into which the text is translated should reflect the demographic served by the organisation. Where the organisation provides services upon a referral basis, broad-based social statistics may be used to guide the development of the fact sheets, which should be re-evaluated and re-issued over time according to data collected within the organisation. The text of the fact sheets should be supported where appropriate by diagrams and schematics, for the benefit of those with deficiencies in language skills. Consumers / patients and families from relevant culturally and linguistically diverse groups should be involved in the development of all such materials.

The provision of an interpreter service promotes access to health services and information for people with limited English proficiency and for the hearing-impaired. The use of interpreters in health care is mandated at a State / Territory level; they are to be used in all situations where communication is essential, including admission, consent, assessment, counselling, discharge, explanation of treatment, associated risks and side effects, health education and medical research, and day-only surgery.5 Interpreters may also assist with meeting the spiritual needs of the consumer / patient. Organisations should not rely upon family members or other non-professional individuals to facilitate communication with consumers / patients with a limited proficiency in English or a hearing impairment, but should arrange for access to accredited interpreters who are trained in medical terminology and issues of confidentiality.

All people, regardless of religious, faith or cultural background, may have pastoral and spiritual needs. As contemporary Australia is multicultural and multifaith, the organisation should have policy and procedures in place regarding spiritual and pastoral care, and provide consumers / patients with access to the appropriate services.

Prompt points

¼ How does the organisation identify the different groups (CALD and/or special needs) for which it needs to provide targeted services?

¼ How are CALD and special needs consumers / patients involved in the decision making process?

¼ How many different language groups are serviced by the organisation’s interpreter service? How did the organisation determine to provide support in these languages?

¼ How often does the organisation reassess the demographic of the community that it serves? How is this carried out?

¼ How does the organisation determine whether the services it provides for its CALD and special needs consumers / patients are appropriate?

¼ With what community groups does the organisation interact in order to best meet the needs of its CALD and special needs consumers / patients?

Evidence commonly presented

Consider whether the following will help to address criterion 1.6.3

¼ Policy that fulfils legislative requirements

¼ Staff training programs

¼ Pre-admission information

¼ Disability and multicultural signage

¼ Availability of information in non-English languages / English for the hearing-impaired

¼ Evidence of access and use of interpreter services by consumers / patients

¼ Evaluation of interpreter services

¼ Evaluation of demographic information

¼ Evidence of community partnerships

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Performance measurementThis criterion states that: “The organisation meets the needs of consumers / patients and carers with diverse needs and from diverse backgrounds”. Healthcare facilities must be able to understand and to meet the diverse needs of the communities they serve. Organisations should be able to demonstrate their knowledge of their community, however defined, and that they are able to fulfil the healthcare and communication needs of the diverse groups that make up their community.

Some common suggested performance measures are:

Number of staff who have participated in cultural awareness training

Total number of staff invited to participate in cultural awareness training

Comment: it is recommended that data for different staff groups be collected

Number of FTE indigenous and/or multicultural staff employed in the organisation

Total number of FTE staff employed in the organisation

Comment: FTE = full time equivalent

Number of CALD consumers / patients accessing interpretive services (printed, verbal)

Total number of CALD consumers / patients

Comment: CALD = culturally and linguistically diverse

Number of languages used in community resources

Total number of CALD groups accessing the service

Number of special needs consumers / patient admitted to or seen by the organisation

Total number of consumers / patients admitted to or seen by the organisation

Number of consumers / patients from specific CALD and/or special needs groups

Target benchmark for consumers / patients from specific CALD and/or special needs groups

Comment: ‘target benchmark’ is the number of consumers / patients that the organisation was required to service, or the target that the organisation hopes to achieve

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Criterion 1.6.3

The organisation meets the needs of consumers / patients and carers with diverse needs and from diverse backgrounds. (continued)

References1. Ethnic Disability Advocacy Centre (EDAC). National

disability strategy: focusing on CALD people with disabilities. Perth WA; EDAC; 2008.

2. Stewart S. Cultural competence in health care. Sydney NSW; Diversity Health Institute, SWAHS; 2006.

3. Victorian Department of Human Services. State disability plan 2002–2012: Part 1. Melbourne; Victorian Government; 2002.

4. Centre for Culture Ethnicity and Health (CEH). Consumer participation and culturally and linguistically diverse communities. Melbourne VIC; CEH; 2005.

5. NSW Health. Policy Directive: Interpreters – standard procedures for working with health care interpreters. Sydney; NSW Health; 2006.

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definitions in this glossary are for use in the context of the ACHs eQuIP5 standards, criteria, elements and guidelines.

access the various pathways and processes via which the consumer / patient may enter the health system and obtain required services

accessibility the ability of consumers / patients or potential consumers / patients to obtain required or available services when needed within an appropriate time1

accountability responsibility and requirement to answer for tasks or activities. This responsibility may not be delegated and should be transparent1

accreditation a public recognition by a healthcare accreditation body of the achievement of accreditation standards by a healthcare organisation, demonstrated through an independent external peer assessment of that organisation’s level of performance in relation to the standards1

advance care plan / directive

instructions that consent to, or refuse, the future use of specified medical treatments. It becomes effective in situations where the consumer / patient no longer has the capacity to make treatment decisions2

AC60: Advanced Completion in 60 days survey

in the context of EQuIP5:

an opportunity for an organisation to promptly address outstanding issues to achieve an acceptable level of performance within 60 days from an EQuIP survey date.

May be offered to an organisation in up to four criteria in order to address:

• High Priority Recommendations (HPRs), and/or

• an SA rating in mandatory criteria, and/or

• an SA rating in non-mandatory criteria

admission the point in the care journey at which an organisation acknowledges a consumer / patient as a client, and accepts responsibility for his or her care3; in some contexts, the term ‘registration’ may be used rather than admission. The point at which admission is considered to have occurred, and the processes by which it happens, vary considerably according to the nature of an organisation.

In the first instance, admission refers to the administrative process by which an individual’s details are entered into the organisation’s systems so that the care journey may begin. However, it is important to recognise that, depending upon the nature and sector of the organisation, admission does not necessarily require the provision of accommodation, or access to a specific facility.

adverse event an incident that results in harm to a consumer / patient, where harm includes disease, injury, suffering, disability and death4

adverse reaction unexpected harm arising from a justified treatment5

agreement a mutually agreed arrangement describing the scope for cooperative ventures between parties and documenting relevant responsibilities

analysis presentation of the essential features into simple elements, such as a summary, outline or identification of the essence of an issue

antimicrobial a chemical substance that inhibits or destroys bacteria, fungi or parasites.4 These include antibiotics, antivirals and disinfectants

appropriate service that is consistent with a consumer / patient’s expressed requirements and is provided in accordance with current best practice1

in the context of EQuIP5: is suitable, or fitting, to do

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appropriateness doing what is necessary, and not doing what is not necessary. Occurs when consumers / patients receive appropriate and necessary care, interventions and services in the most appropriate setting

artificial nutritional support

parenteral and/or enteral nutrition therapy6

(parenteral nutrition: intravenous administration of nutrients into a central or peripheral vein. Enteral nutrition: feeding provided through the gastrointestinal tract via a tube, catheter, or stoma that delivers nutrients distal to the oral cavity)6

as required when required by obligation

assessment a process by which the characteristics and needs of consumers / patients, groups or situations are evaluated or determined so that they can be addressed. Assessment forms the basis of a plan for services or action.1 While assessment may be known by different names and occurs in a broad variety of contexts, such as triage in an emergency department, comprehensive assessment by an Aged Care Assessment Service, or screening and intake by a community health or outreach service, the process remains consistent and as defined above

‘at-risk’ consumer / patient

a consumer / patient characterised by a high risk or susceptibility to a disease7 or event, e.g. falls

Australian standards national standards developed by Standards Australia

benchmarking the continuous measurement of a process, product, or service compared to those of the toughest competitor, to those considered industry leaders, or to similar activities in the organisation, in order to find and implement ways to improve it. One of the foundations of both total quality management and continuous quality improvement. Internal benchmarking occurs when similar processes within the same organisation are compared. Competitive benchmarking occurs when an organisation's processes are compared with best practices within the industry. Functional benchmarking refers to benchmarking a similar function or process, such as scheduling, in another industry6

best practice an approach that has been shown to produce superior results, selected by a systematic process, and judged as exemplary, or demonstrated as successful. It is then adapted to fit a particular organisation1

blood homologous and autologous whole blood, blood including red blood cells, platelets, fresh frozen plasma, cryoprecipitate and cryo-depleted plasma4

blood component fresh blood components including red cells, platelets, fresh frozen plasma, cryoprecipitate and cryodepleted plasma8

blood products plasma derivatives and recombinant products

business plan the current action plan for achieving organisation goals1

by-laws rules, regulations or legislation adopted by the organisation for the regulation of both its internal and external affairs

carbon emissions generally an abbreviation of emissions of greenhouse gases. Greenhouse gases are a number of different gases that all have the ability to influence the global energy balance of the Earth; the greenhouse effect9

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care plan the documentation of items agreed to in a care planning process. This should include:

• date of development

• participants in development of care plan

• consumer / patient-stated and agreed issues or problems

• consumer / patient-stated and agreed goals

• agreed actions and the name of person or service responsible for each action

• timeframe for attaining goals and actions

• planned review date

• consumer / patient acknowledgement of the care plan (signed or verbal)

• actual review date10

carers / support persons people who provide unpaid care and support to family members and friends who have a disability, mental illness, chronic condition, terminal illness or who are frail.11 Carers include parents and guardians caring for children4.

in the context of EQuIP5:

a carer / support person is any person elected by a consumer / patient to accompany or assist the consumer / patient during an episode of care

change management the process of managing the effective implementation of organisational strategies, ensuring that permanent changes in goals, behaviours, relationships, processes and systems are achieved to the organisation’s advantage. It is the key competence required for managing all strategic initiatives

clinical audit a systematic independent examination and review to determine whether actual activities and results comply with planned arrangements1

clinical classification the process of translating data, such as for diseases, conditions, injuries and interventions, from a consumer / patient record into a coded format using a relevant classification system

clinical governance the system by which the governing body, managers and clinicians share responsibility and are held accountable for consumer / patient care, minimising risks to consumers / patients and for continuously monitoring and improving the quality of clinical care12

clinical handover the transfer of professional responsibility and accountability for some or all aspects of care for a consumer / patient, or group of consumers / patients, to another person or professional group on a temporary or permanent basis.4, 13 The efficient and effective transfer of high quality clinical information from one healthcare provider to another facilitates safe transfer of care14

clinical indicator a measure of the clinical management and/or outcome of care that should screen, flag or draw attention to a specific clinical issue. Clinical indicators identify the rate of occurrence of an event and are used to assess, compare and determine the potential to improve care. They assist in assessing whether or not a standard in consumer / patient care is being met by indicating potential problems that might need addressing15

clinical pathway sometimes called a care map, a consumer / patient management tool that organises, sequences and times the major care activities and interventions of the entire interdisciplinary team for a consumer / patient with a particular diagnosis or need for a procedure16

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clinician a healthcare provider, trained as a health professional. Clinicians include registered and non-registered practitioners, or a team of health professionals providing health care who spend the majority of their time providing direct clinical care.4 The term encompasses medical practitioners, nurses, dentists, paramedics and allied health professionals such as physiotherapists, occupational therapists, speech pathologists, dieticians, radiographers, social workers, psychologists, pharmacists and all others in active clinical practice17, but excludes clinicians-in-training and junior practitioners who must work under supervision18

code of practice a published document that sets out commonly agreed sets of guidelines and informs all parties of responsibilities and expectations under the code. Codes of practice can be19:

• voluntary agreements where a group of companies or an industry sector agree to abide by a particular code

• quasi-regulation where the code may be developed by industry in cooperation with government

• co-regulation where the code describes required performance or behaviour, or specifies acceptable means of meeting broader performance-based obligations, and where there are penalties for non-compliance with the code

community a group of people who share a common interest or background (e.g. cultural, social, political, economic, health), which may also be, but is not necessarily, geographic20

competence a guarantee that an individual’s knowledge and skills are appropriate to the service provided and an assurance that the knowledge and skill levels are regularly evaluated1

complaint expression of a problem, an issue, or dissatisfaction with services that may be verbal or in writing1

conditional survey in the context of EQuIP5:

an additional survey that is undertaken one year following an Organisation-Wide Survey or a Periodic Review, during which issues were identified as needing to be addressed rapidly. A recommendation for a Conditional Survey is made for issues for which a 60-day framework is too short to achieve the level of change required, and provides the organisation with an opportunity to address issues that require some time and resources in order to achieve an acceptable level of performance.

A Conditional Survey may be offered to an organisation in up to two criteria in order to address:

• High Priority Recommendations (HPRs), and/or

• an SA rating in mandatory criteria

In addition, a Conditional Survey may be offered to an organisation in order to address:

• LA/SA ratings in from six to eleven non-mandatory criteria

confidentiality guaranteed limits on the use and distribution of information collected from individuals or organisations1

consent, informed a process of communication between a consumer / patient and his or her medical officer that results in the consumer / patient’s authorisation or agreement to undergo a specific medical intervention. This communication should ensure the consumer / patient has an understanding of all the available options and the expected outcomes such as the success rate and/or side effects for each option4

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consent, acknowledgement of

in the absence of a completed consent form, an acknowledgement of consent form should be present in the health record, signed by the consumer / patient and, when appropriate, the treating physician, stating that the proposed treatment, the benefits and risks and any costs involved have been explained to the consumer / patient

consumer / patient a person, however titled, who makes either direct or indirect use of health services; that is, a current or potential user of the health system, and/or their carer(s).21, 22 This encompasses consumers / patients receiving health care from a clinician4, those with specific health needs, or who may at some time have them, and those who have a general interest in the health system and health funding. Many consumers / patients also have an indirect influence upon the health system in the capacity of taxpayers

consumer / patient participation

the process of involving consumers / patients and the community meaningfully in decision making about their own health care, health service planning, policy development, setting of priorities and quality issues in the delivery of services23

continuity of care the ability to provide uninterrupted, coordinated care or services across programs, practitioners, organisations and levels over time20

contract a mutual agreement between two or more competent parties that creates a legally supportable obligation to do or not do something specified

coordinate to bring together in a common, ordered and harmonious action or effort

corporate governance the processes by which the organisation is directed, controlled and held to account. It encompasses the systems, processes and arrangements by which authority, accountability, stewardship, leadership, direction and control are exercised in an organisation.24 It influences how objectives are set and achieved, how risk is monitored and assessed and how performance is optimised25

credentialling the formal process used to verify the qualifications, experience, professional standing and other relevant professional attributes of clinicians for the purpose of forming a view about their competence, performance and professional suitability to provide safe, high quality healthcare services within specific organisational environments26

credentials documentation that an individual’s knowledge, skills, competence and qualifications comply with specific requirements1

criteria specific steps to be taken or activities to be done, to reach a decision or a standard1

cultural competence the processes and practices implemented by an organisation that foster inclusiveness and establish the progression of learning about diversity and differences, and their impact on the way services are delivered, received, accessed and promoted. In the context of health care, cultural competence focuses on the capacity of the organisation to improve health and wellbeing for the individual and the community by integrating culture into the delivery of health services27

culture, organisational the prevailing pattern of beliefs, attitudes, values and behaviours within an organisation28

data unorganised facts from which information can be generated

data collection a store of data captured in an organised way for a specific defined purpose

data integrity accuracy, consistency and completeness of data

data security protection of data from intentional or unintentional destruction, modification or disclosure

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defining the scope of clinical practice

the process that follows on from the credentialling of medical practitioners and other clinicians, which involves delineating the extent of, and limits to, an individual’s clinical practice within a particular organisation, based on that individual’s credentials, competence, performance and professional suitability, and the needs and the capability of the organisation to support the individual’s scope of clinical practice26, 29

delegation the devolution of authority appropriate to individual roles and responsibilities within an organisation for the operation of clinical and non-clinical services. A formal delegation system ensures that clear lines of accountability exist, particularly where temporary delegations are enacted

deteriorating consumer / patient

a consumer / patient whose physiological condition is deteriorating. May apply to any consumers / patients receiving medical, surgical, maternity or mental health care and is determined by observing and documenting changes in their clinical circumstances. This includes both the absolute change in physiological measurements and abnormal observations, as well as the rate of change over time for an individual30

disaster recovery a disaster recovery strategy is a set of pre-determined procedures that provides for substitute operations and a quick return to normal after any disruption

discharge / transfer of care

the release of a consumer / patient from care7 or movement of a consumer / patient from one setting of care to another31

document control system a planned system for controlling the release, change and use of important documents within an organisation, particularly policies and procedures. The system requires each document to have a unique identification, and to show dates of issue, updates and authorisation. Issue of documents in the organisation is controlled and all copies of all documents are readily traceable and obtainable32

diverse background the breadth of social, economic and cultural factors that influence an individual consumer / patient’s experience and perspective. This encompasses culturally and/or linguistically diverse backgrounds

diverse needs the range of consumer / patient needs that may be found within the community that an organisation serves, and which may form a barrier to health care if not addressed by the organisation in meeting its duty of care. Such needs may be cultural, physical, linguistic, economic or health-status related

education systematic instruction and learning activities to develop or bring about change in knowledge, attitudes, values or skills1

effective producing the desired result

effectiveness care, intervention or action that is relevant to the consumer / patient’s needs and based on established standards. This care, intervention or action achieves the desired outcome20

efficiency achieving desired results with the most cost-effective use of resources20

electronic records a record on electronic storage media that is produced, communicated, maintained and/or accessed by means of electronic equipment. An Electronic Health Record (EHR) is a repository of information regarding the health status of a consumer / patient, in computer-processable form33

elements in the context of EQuIP5:

elements identify what should be in place to achieve the criterion at a certain rating level: a description of what is required to achieve the criterion. These provide prompts for improvement and best practice

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employee assistance program

a proven strategy for assisting employees and their families with personal and work-related problems, difficulties and concerns which they may experience from time to time and which can affect work performance

entry a process by which a consumer / patient comes into a healthcare organisation to receive healthcare services

end-of-life care a quality management approach that evaluates the individual holistic needs of a consumer / patient, his or her family and/or carers, and coordinates appropriate care at the end of life. It recognises the interdependent physical, social, emotional, cultural and spiritual aspects of care and includes the combination of broad health and community services that care for a person at the end of his or her life34

environmental sustainability

development that meets the needs of the present without compromising the ability of future generations to meet their own needs. The ability to maintain the balance between resources, such as water, timber and solar energy, and living organisms such as humans, animals and plants35, 36

error unintentionally being wrong in conduct or judgement. Errors may occur by doing the wrong thing (commission) or by failing to do the right thing (omission)37

ethics acknowledged set of principles which guide professional and moral conduct

evaluation assessment of the degree of success in meeting the goals and expected results (outcomes) of the organisation, services, program or consumers / patients1

evidence data and information used to make decisions. Evidence can be derived from research, experimental learning, indicator data, and evaluations. Evidence is used in a systematic way to evaluate options and make decisions1

evidence-based the use of systematically reviewed appraised clinical research findings to aid the delivery of optimum clinical care to consumers / patients38; the transfer of knowledge from research into healthcare practice

external entity a body / establishment external to the organisation

externally based references

reference and research information generated outside the organisation, such as journals, internet information, research databases, library resources, etc.

feedback a communication from a consumer / patient relaying how delivered products, services and information compare with consumer / patient expectations

flexible work practices working arrangements that assist employees to meet personal responsibilities, such as caring for a child or other family member. These may include39:

• changes in hours of work

• changes in patterns of work

• changes in location of work

follow-up processes and actions taken after a service has been completed1

formalised follow-up documented processes and actions taken after a service has been completed

governance the set of relationships and responsibilities established by a healthcare organisation between its executive, workforce and stakeholders (including consumers). It incorporates the set of processes, customs, policy directives, laws, and conventions affecting the way a healthcare organisation is directed, administered or controlled. Governance arrangements specify the mechanisms for monitoring performance4

governing body a body that carries legal accountability and/or scope of organisational responsibility for the services provided, such as an individual owner or a group of senior managers, a governing body of directors, a board, a group of senior managers and/or a chief executive appointed by a government agency

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guidelines principles guiding or directing action.1 Clinical practice guidelines are systematically developed statements to assist practitioner and consumer / patient decisions about appropriate health care for specific circumstances.40 Guidelines in the EQuIP5 Guide provide essential information for the achievement of the EQuIP5 standards

healthcare-associated infections

infections acquired in healthcare facilities (nosocomial infections) and infections that occur as a result of healthcare interventions (iatrogenic infections), and which may manifest after people leave the healthcare facility41

healthcare provider a team or individuals who, in cooperation with the consumer / patient, assume responsibility for all aspects of an episode of care in response to the diagnosis and needs of the consumer / patient

health priority areas identified health areas which contribute significantly to the burden of illness and injury, which have potential for health gains and reduction in the burden of disease. These priorities sit under the overarching framework of the National Chronic Disease Strategy42–44

health record term used to describe many types of data and reports about a consumer / patient stored in different media45

health workforce the workforce that provides health care to consumers / patients; ranging from workers with no formal qualifications providing support services in home-based settings through to highly qualified specialists working in technology intensive super-acute hospital settings

High Priority Recommendation (HPR)

in the context of EQuIP5:

a recommendation where there is an area of high risk identified by the surveying team when:

• consumer / patient care is compromised, and/or

• the safety of consumers / patients and/or staff is jeopardised

The HPR is a trigger for the organisation to address the issue either at an AC60 or at a Conditional Survey

home ward outlier consumer / patient

a consumer / patient who is being treated in an area of the organisation that normally treats a different casemix, for example, a consumer / patient with a medical condition such as diabetes who may be admitted to a surgical ward due to a lack of available medical beds

iatrogenic arising from or associated with health care rather than an underlying disease or injury37

ICD – 10 – AM a system of codes, from a set of defined categories, which are used to categorise activity in a consistent and systemised way: the International Classification of Diseases, 10th Revision, Australian modification

incident an event or circumstance which could have or did lead to unintended and/or unnecessary harm to a person, and/or complaint, loss or damage4

include(s) a list that provides examples and is not limiting

indicator performance measurement tool, screen or flag that is used as a guide to monitor, evaluate, and improve the quality of services. Indicators relate to structure, process and outcomes1

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infection control management plan

a documented plan that outlines the structure of an infection control program, its overall aims and objectives, associated quality management activities, program evaluation criteria and timeframes for review.46 The document should address the governance of infection control and identify:

• who is at risk and from what

• the hazards involved

• the procedures for minimising risk

• appropriate measures for infection control, based on standard precautions and when required, additional precautions

information management the process of planning, organising, analysing and controlling data and information. The management of information applies to both computer-based and manual systems

information privacy the right of a person to control the use and disclosure of information that reveals his or her identity, health information or health status

information system a system that provides access to information using hardware, software, supplies, policies, procedures and people

information technology (IT)

mechanical and electronic devices designed for the collection, storage, manipulation, presentation and dissemination of information

integrated governance an additional approach that aims to strengthen and streamline healthcare organisation governance arrangements by focusing on quality4 as the driver of change and placing clinical governance at the heart of governance arrangements. Considered a key building block of good governance in health care47

integrity, data the characteristic of data and information being accurate and complete

interoperability the ability of information systems to reliably exchange information without error33

intervention any act performed to prevent harming of a consumer / patient or to improve the mental, emotional or physical function of a consumer / patient48

IT cost management a mechanism to manage IT costs

IT security a tangible set of physical and logical mechanisms used to protect information held in hard copy, computer systems and information, and telecommunication infrastructure from unauthorised access

IT system a group of interacting, interrelated or interdependent elements forming or regarded as forming a collective entity

leadership the ability to provide direction and cope with change. It involves establishing a vision, developing strategies for producing the changes needed to implement the vision, aligning people, and motivating and inspiring people to overcome obstacles1

legibility data or information that is decipherable or readable16

legislation the body of laws made by Parliament. These consist of: acts of parliament; and regulations, ordinances and rules which are also called ‘subordinate’ or ‘delegated’ legislation49

magnet hospital a term coined in the United States from research that sought to understand why certain hospitals were able to attract and retain staff

management setting targets or goals for the future through planning and budgeting, establishing processes for achieving those targets and allocating resources to accomplish those plans. Ensuring that plans are achieved by organising, staffing, controlling and problem solving1

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mandatory criterion in the context of EQuIP5:

one where it is considered that without Marked Achievement (evaluation), the quality of care or the safety of people within the organisation could be at risk

malnutrition a state of nutrition in which a deficiency or excess (or imbalance) of energy, protein, and other nutrients causes measurable adverse effects on tissue / body form (shape, size and composition) and function and clinical outcome50

manual handling / task a task comprised wholly or partly by any activity requiring a person to use any part of their musculoskeletal system in performing their work. These tasks can include51:

• lifting, lowering, pushing, pulling, carrying or otherwise moving, holding or restraining any person, animal or item

• repetitive actions

• sustained work postures

• exposure to vibration

medication error any preventable event that may cause or lead to inappropriate medication use or consumer / patient harm while the medication is in the control of the healthcare professional or consumer / patient4

medication management the processes of dispensing, prescribing, storing, administering and monitoring the effects of medicines4

medico legal requirements

requirements of or relating to both medicine and law7

mission a broad written statement in which an organisation states what it does and why it exists. The mission sets apart one organisation from another1

monitor to check, supervise, observe critically, measure or record the progress of an activity, action or system on a regular basis in order to identify change and/or track change37

morbidity a diseased state or symptom or the incidence of disease; the rate of sickness in a specified community or group7

mortality the number of deaths in a given time or place or the proportion of deaths to a given population7

multidisciplinary care or a service given with input from more than one discipline or profession

National Chronic Disease Strategy

the overarching framework of national direction for improving chronic disease prevention and care across Australia. A nationally agreed agenda to encourage coordinated action in response to the growing impact of chronic disease on the health of Australians and the healthcare system42

near miss an incident that did not cause harm, but had the potential to do so4

needs physical, mental, emotional, social or spiritual requirement for wellbeing. Needs may or may not be perceived or expressed by those in need. They must be distinguished from demands, which are expressed desires, not necessarily needs1

non-clinical information information that is not direct, personal consumer / patient information

non-surgical wounds in the context of EQuIP5:

wounds that may arise following admission to a health service and only whilst the consumer / patient is admitted. This encompasses pressure ulcers, or ulcers that may develop by other means; skin tears, caused by friction and/or tearing; skin infections, etc. This does not include wounds that would be the purpose of the admission, such as burns, wounds related to cancers, radiation injuries etc.

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nutrition care interventions, monitoring, and evaluation designed to facilitate appropriate nutrient intake based upon the integration of information from the nutrition assessment6, 52

nutrition screening the process of identifying consumers / patients with characteristics commonly associated with nutrition problems who may require comprehensive nutrition assessment and may benefit from nutrition intervention50

nutrition assessment a comprehensive approach to gathering pertinent data in order to define nutritional status and identify nutrition-related problems. The assessment often includes consumer / patient history, medical diagnosis and treatment plan, nutrition and medication histories, and nutrition-related physical examination including anthropometry, nutritional biochemistry, psychological, social, and environmental aspects50

objective target that must be reached if the organisation is to achieve its goals. It is the translation of the goals into specific, concrete terms against which results can be measured1

ongoing care the active and supportive management of care for people with chronic or complex conditions as well as the process that follows an admission to a healthcare organisation

open disclosure the open discussion of incidents that resulted in harm to a consumer / patient while receiving health care. The criteria of open disclosure are an expression of regret, a factual explanation of what happened and the potential consequences, and the steps being taken to manage the event and prevent recurrence4

operational plan a short-term plan that details how aspects of a strategic plan will be accomplished

organisation all sites / locations under the governance of, and accountable to, the governing body / owner(s)1

orientation a formal process of informing and training staff on entry into a position or organisation, covering the policies, processes and procedures applicable to that healthcare organisation4

outcome results that may or may not have been intended that occur as a result of a service or intervention

palliative care plan a written statement developed for a consumer / patient who is suffering from a life-limiting illness, with little or no prospect of a cure, and for whom the primary treatment goal is quality of life, which states the nursing and other interventions to be undertaken, the health outcomes to be achieved and the review of care which will occur at regular intervals53

pathway a multidisciplinary plan of care that commences before or on admission and finishes at discharge

patient master index permanent listing or register of health information held by an organisation on consumers / patients who have received or are scheduled to receive services4

performance measure in the context of EQuIP5:

suggested indicators at the end of each criterion in the Guide provided to assist organisations to identify, or ‘flag’, an issue that may need further investigation and to assist in the evaluation of processes. These measures are distinct from clinical indicators, available to organisations through the ACHS Clinical Indicator Program

personal information information or an opinion (including information or an opinion forming part of a database), whether true or not, and whether recorded in a material form or not, about an individual whose identity is apparent, or can reasonably be ascertained, from the information or opinion54

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policy written statement(s) which acts as a guideline and reflects the position and values of the organisation on a given subject.1 All procedures and protocols should be linked to a policy statement4

pressure ulcer a localised injury to the skin and/or underlying tissue, usually over a bony prominence and caused by unrelieved pressure, friction or shear. Pressure ulcers occur most commonly on the sacrum and heel but can develop anywhere on the body. Pressure injury is a synonymous term for pressure ulcer4

prevention and management

a systematic approach adopted by all sections of an organisation to ensure appropriate identification and actions for consumers / patients at risk of an illness or condition

procedure a set of documented instructions conveying the approved and recommended steps for a particular act or sequence of acts

process a series of actions, changes or functions that bring about an end or a result

psycho-social pertaining to a combination of psychological and social factors48

quality activities activities which measure performance, identify opportunities for improvement in the delivery of care and service, and include actions and follow-up

quality framework an overarching approach to quality improvement that promotes integration of risk management with quality improvement strategies and informs decision making and planning55

quality improvement ongoing response to quality assessment data about a service in ways that improve the processes by which services are provided to consumers / patients1

quality use of medicines the judicious, appropriate, safe and effective use of medicines56

records all records within the organisation, clinical and non-clinical

records management field of management responsible for the efficient and systematic control of the creation, receipt, maintenance, use and disposition of records57

record safety the physical safety of records such as from light, humidity, vermin, fire and moisture

record storage the function of storing records for future retrieval and use57

recruitment and selection process used to attract, choose and appoint qualified staff32

referral the process of directing or redirecting a consumer / patient to an appropriate specialist or agency for definitive treatment7

relevant in the context of EQuIP standards:

when something is connected with a matter; when there is a logical connection

research an active, diligent and systematic process of inquiry in order to discover, interpret or revise facts, events, behaviours, or theories, or to make practical applications with the help of such facts, laws or theories

risk the effect of uncertainty on objectives which may be positive and/or negative. Objectives can have different aspects, such as financial, health and safety, and environmental goals and can apply at different levels, such as strategic, organisation-wide, project, product and process. Risk is often expressed in terms of a combination of the consequences of an event and the associated likelihood of occurrence58

risk management coordinated activities to direct and control an organisation with regard to risk, such as activities that identify, control and minimise threats to the ongoing efficiency, effectiveness and success of its operations to deliver desired outcomes4, 58

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risk management framework

a set of components that provide the foundations and organisational arrangements for designing, implementing, monitoring, reviewing and continually improving risk management throughout the organisation. The framework should be embedded within the organisation's overall strategic and operational policies and practices58

root cause analysis (RCA)

a systematic process whereby the factors which contributed to an incident are identified37

sample blood samples collected from a consumer / patient for purposes of blood or blood product / component transfusion / infusion

sampling the collection of a sample from a consumer / patient

scope of clinical practice the extent of an individual medical practitioner’s clinical practice within a particular organisation, based on the individual’s credentials, competence, performance and professional suitability, and the needs and the capability of the organisation to support the medical practitioner’s scope of clinical practice.59 This is delineated after the process of credentialling

self identified Aboriginal or Torres Strait Islander person

a person of Aboriginal or Torres Strait Islander descent who identifies as an Aboriginal or Torres Strait Islander and is accepted as such by the community in which he or she lives60

sentinel event an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof. Serious injury specifically includes loss of limb or function. The phrase "or the risk thereof" includes any process variation for which a recurrence would carry a significant chance of a serious adverse outcome. Such events signal the need for immediate investigation and response6

services products of the organisation delivered to consumers / patients, or units of the organisation that deliver products to consumers / patients1

skillmix the mix of posts, grades or occupations within a unit / organisation. It may also refer to the combinations of activities or skills needed for each job within the organisation61

specialty ward area in the context of EQuIP5:

an area of an organisation that normally treats consumers / patients with a specific casemix, for example, an orthopaedic ward, a paediatric ward, a maternity ward, etc.

staff term which includes employed, visiting, sessional, contracted or volunteer personnel

stakeholder individuals, organisations or groups that have an interest or share in services1

standard a desired and achievable level of performance against which actual performance is measured1

statutory notifications any notification required by an act of parliament

statutory requirements any requirement laid down by an act of parliament

strategic plan a formalised plan that establishes an organisation’s overall objectives and that seeks to position the organisation in terms of its environment1

strategy a long-term plan of action designed to achieve a particular objective

surveillance the ongoing, systematic collection, analysis and interpretation of health-related data essential to the planning, implementation and evaluation of public health practice62, closely integrated with the timely dissemination of these data to those responsible for prevention and control63

survey external peer review which measures the performance of the organisation against an agreed set of standards32

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References1. International Society for Quality in Health Care (ISQua).

The ISQua surveyor training standards programme. Dublin IRL; ISQua; 2009.

2. NSW Health. Guidelines for end-of-life care and decision-making. Sydney; NSW Health; 2005.

3. Queensland Health, Admitted Patient Data Collection (QHAPDC). Queensland Health Admission policy. Appendix F: Criteria for admission. Brisbane; Qld Health. Accessed from http://www.health.qld.gov.au/hic/qhapdc2006/Appendix_F.pdf on 20 August 2010.

4. Australian Commission on Safety and Quality in Health Care. Consultation paper on the draft National Safety and Quality Healthcare Standards, August 2010. Sydney NSW; ACSQHC; 2010.

5. World Health Organization. Final technical report: The conceptual framework for the International Classification for Patient Safety, Version 1.1. Geneva CH; WHO; 2009.

6. Joint Commission on Accreditation of Healthcare Organisations (JCAHO). Sentinel event glossary of terms. Oakbrook Terrace USA; JCAHO. Accessed from http://www.jointcommission.org/SentinelEvents/se_glossary.htm on 9 September 2010.

7. MedlinePlus Medical Dictionary. Medical Dictionary. Merriam-Webster. Accessed from http://www.merriam-webster.com/medlineplus/at%20risk on 12 August 2010.

8. National Blood Authority (NBA). National haemovigilance data dictionary: A guide for formatting haemovigilance data for the Australian national haemovigilance data set. 3rd edn. Canberra ACT; NBA; 2010.

9. Energy Australia. What are carbon emissions? In: University of Sydney Integrated Sustainability Analysis Group. Carbon emissions & you. Sydney NSW; Energy Australia. Accessed from http://www.energysave.energyaustralia.com.au/carbon_emissions__and__you/learn/4.0_key_questions/4.3_carbon_questions/4.4.1_what_are_carbon_emissions on 14 September 2010.

10. Primary Care Partnerships Victoria. Victorian service coordination practice manual. Melbourne; Victorian Department of Human Services; 2009.

11. Australian Commission on Safety and Quality in Health Care (ACSQHC). Consultation Paper on the National Safety and Quality Healthcare Standards (Draft). Sydney NSW; ACSQHC; 2009.

12. Australian Council on Healthcare Standards (ACHS). News in brief: Clinical governance defined. ACHS News, 2004; 12(Spring): 4.

13. Australian Commission on Safety and Quality in Health Care (ACSQHC). Windows into safety and quality in health care 2008. Sydney NSW; ACSQHC; 2008.

14. Sydney South West Area Health Service. Guideline: clinical handover. Sydney; NSW Health; 2007.

system the resources, policies, processes and procedures that are organised, integrated, regulated and administered to accomplish an objective4

tracking creating, capturing and maintaining information about the movement and use of records57

training the development of practical skills that should be related to the professional development needs of the individual and organisation and may be incorporated into professional development programs4

unique identifier universal number or code that uniquely identifies a person or other discrete entity33

validation to make sound, ratify, confirm, substantiate or to give legal force to. Validity deals with the relationship of the data obtained to the purpose for which it accomplishes, or measures what it seeks to measure

values principles and beliefs that guide an organisation and may involve social or ethical issues

vision description of what the organisation would like to be1

waiting list a register which contains essential details about consumers / patients who have been assessed as needing elective care

when required required at the time

where required required in certain circumstances

October 2010  243

15. ACHS Performance and Outcomes Service. ACHS clinical indicator program information 2010. Sydney NSW; Australian Council on Healthcare Standards (ACHS); 2010.

16. Abdelhak M, Grostick S, Hanken MA and Jacobs E. Health information: Management of a strategic resource. 2nd edn. Philadelphia USA; Saunders; 2001.

17. Frommer M, Heinke M and Barton M. Credentialling of cancer clinicians: A guide for Australian healthcare organisations. Sydney NSW; Cancer Council Australia and the Australian Cancer Network; 2005.

18. Australian Health Practitioner Regulation Agency (AHPRA). Registration process. Canberra ACT; AHPRA. Accessed from http://www.ahpra.gov.au/Registration/Registration-Process.aspx on 16 July 2010.

19. South Australian Government and Northern Territory Government. Australian codes of practice database. Accessed from http://codes.bli.net.au/Codes.asp?Section=90 on 10 September 2010.

20. National Health Information Standards and Statistics Committee (NHISSC). National health performance framework. 2nd edn. Canberra ACT; AIHW; 2009.

21. Gregory J. Consumer engagement in Australian health policy: Final report of the AIHPS research project. Melbourne VIC; Australian Institute of Health Policy Studies (AIHPS); 2008.

22. SA Health. Consumer and community participation policy directive. Adelaide; Government of South Australia; 2009.

23. Austin Health. Consumer and community participation. Heidelberg VIC; Austin Health. Accessed from http://www.austin.org.au/Page.aspx?ID=138 on 9 June 2010.

24. UK Department of Health. A first class service, quality in the new NHS. London UK; National Health Service. Accessed from http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4006902 on 1 September 2010.

25. ASX Corporate Governance Council. Corporate governance principles and recommendations. Sydney NSW; Australian Securities Exchange (ASX); 2007.

26. Australian Council for Safety and Quality in Health Care. Standard for credentialling and defining scope of clinical practice. Canberra ACT; Australian Council for Safety and Quality in Health Care; 2004.

27. Stewart S. Cultural competence in health care. Sydney NSW; Diversity Health Institute, SWAHS; 2006.

28. Forster P. Queensland health systems review. Final report Brisbane; Queensland Govt; 2005.

29. Royal Australasian College of Surgeons (RACS). Position paper: Appointments and credentialing committees that define scope of practice. Melbourne VIC; RACS; 2009.

30. Australian Commission on Safety and Quality in Health Care (ACSQHC). National Consensus Statement: essential elements for recognising and responding to clinical deterioration. Sydney NSW; ACSQHC; 2010.

31. Ma E, Coleman E, Fish R et al. Quantifying posthospital care transitions in older patients. J Am Med Dir Assoc 2004; 5(2): 71-74.

32. Shaw CD and ISQua toolkit working group. Toolkit for accreditation programs: Some issues in the design and redesign of external health care assessment and improvement systems. Melbourne VIC; ISQua; 2004.

33. National E-Health Transition Authority (NEHTA). Acronyms, abbreviations & glossary of terms. Sydney NSW; NEHTA; 2005.

34. Palliative Care Australia (PCA). Palliative care – Glossary of terms. Melbourne VIC; PCA; 2008.

35. Green Times, your online green journal and directory. Environmental sustainability. Sydney NSW; Sierra Marketing. Accessed from http://www.greentimes.com.au/glossary/categories/lifestyle/environmental-sustainability.html on 14 September 2010.

36. Qld Dept of Environment and Resource Management. Sustainability. Brisbane; Queensland Government. Accessed from http://www.derm.qld.gov.au/environmental_management/sustainability/ on 14 September 2010.

37. Runciman WB. Shared meanings: preferred terms and definitions for safety and quality concepts. Med J Aust 2006; 184(10 Suppl): S41-S43.

38. Rosenberg W and Donald A. Evidence-based medicine: an approach to clinical problem solving. BMJ 1995; 310(6987): 1122-1126.

39. Fair Work Australia and Fair Work Ombudsman. Fair work online. Canberra ACT, Australian Government. Accessed from http://www.fairwork.gov.au/Pages/default.aspx on 17 March 2010.

40. Field MJ, Lohr KN and the Committee to Advise the Public Health Service on Clinical Practice Guidelines, Institute of Medicine (eds). Clinical practice guidelines: Directions for a new program. Washington DC USA; National Academies Press; 1990.

41. National Health and Medical Research Council (NHMRC). Australian guidelines for the prevention and control of infection in healthcare (Consultation Draft). Canberra ACT; Australian Government; 2010.

42. National Health Priority Action Council (NHPAC). National chronic disease strategy. Canberra ACT; Australian Health Ministers’ Advisory Council (AHMAC); 2005.

43. Australian Institute of Health & Welfare (AIHW). Chronic disease: National chronic disease strategy. Canberra ACT; AIHW. Accessed from http://www.health.gov.au/internet/main/publishing.nsf/Content/pq-ncds-strat on 17 August 2010.

44. Australian Institute of Health & Welfare (AIHW). National Health Priority Area FAQs. Canberra ACT; Australian Government. Accessed from http://www.aihw.gov.au/nhpa/faqs.cfm#NHPA_what on 10 September 2010.

45. United Medical Protection (UMP). Medico-legal handbook: A guide to legal issues in medical practice. Sydney NSW; UMP; 2003.

46. Queensland Communicable Diseases Unit. Infection control guidelines – extract. 2nd edn. Brisbane; Queensland Health; 2001.

seCtIon 6Glossary

244  The ACHS EQuIP5 Guide  Book 1  Accreditation, Standards and Guidelines  Clinical Function

47. National Health Service (NHS). Integrated governance handbook: A handbook for executives and non-executives in healthcare organisations. London UK; Department of Health; 2006.

48. Harris PG, Nagy S and Vardaxis N (eds). Mosby’s dictionary of medicine, nursing and health professions. Sydney NSW; Mosby Elsevier; 2010.

49. Law Reform Commission NSW (NSW LRC). Discussion Paper 30 (1993) – Review of the Anti-Discrimination Act 1977 (NSW). Lawlink NSW. Sydney NSW; NSW LRC. Accessed from http://www.lawlink.nsw.gov.au/lrc.nsf/pages/DP30TOR on 16 September 2010.

50. Dietitians Association of Australia. Evidence based practice guidelines for the nutritional management of malnutrition in adult patients across the continuum of care. Nutr Diet 2009; 66(Suppl.): S1-S34.

51. Australian Safety and Compensation Council (ASCC). National standard for manual tasks. Canberra ACT; ASCC; 2007.

52. American Society for Parenteral and Enteral Nutriton (ASPEN). Definition of terms. Silver Spring USA; ASPEN. Updated: November 2009. Accessed from http://www.nutritioncare.org/lcontent.aspx?id=546 on 14 September 2010.

53. Palliative Care Australia (PCA). Standards for providing quality palliative care for all Australians. Canberra ACT; PCA; 2005.

54. Privacy Act (1988)(Cth.)

55. Australian Council on Healthcare Standards (ACHS). Risk management and quality improvement handbook. Sydney NSW: ACHS; 2007. Accessed from http://www.achs.org.au/RiskMgmtQIHandbook/ on 27 July 2010.

56. Australian Council for Safety and Quality in Health Care. The national strategy for quality use of medicines. Canberra ACT; Department of Health and Ageing; 2002.

57. AS ISO 15489.1:2002 Records management: General.

58. AS/NZS ISO 31000:2010 Risk management — Principles and guidelines.

59. Queensland Health. Credentialing and defining the scope of clinical practice for medical practitioners in Queensland: A policy and resource handbook. Brisbane; Queensland Government; 2009.

60. ‘The Commonwealth Definition’, High Court judgement in the case of Commonwealth v Tasmania (1983) 46 ALR 625.

61. Buchan J and Dal Poz MR. Skill mix in the health care workforce: reviewing the evidence. Bull World Health Organ 2002; 80: 575-580.

62. World Health Organization (WHO). Public health surveillance. Geneva CH; WHO. Accessed from http://www.who.int/immunization_monitoring/burden/routine_surveillance/en/index.html on 2 September 2010.

63. Thacker S and Berkelman R. Public health surveillance in the United States. Epidemiol Rev 1988; 10: 164-190.

October 2010  245

A

ACHS Australian Council on Healthcare Standards

ADG Australian Dangerous Goods

AEC Animal Ethics Committee

AHMC Australian Health Ministers’ Conference

AHRQ Agency for Healthcare Research and Quality

ALARA As Low As Reasonably Possible

ANZCMHN Australian and New Zealand College of Mental Health Nurses

ANZICS Australian and New Zealand Intensive Care Society

ANZSBT Australian and New Zealand Society of Blood Transfusion

APAC Australian Pharmaceutical Advisory Council

ARCBS Australian Red Cross Blood Service

ASERNIP-S Australian Safety and Efficacy Register of New Interventional Procedures–Surgical

ARPANSA Australian Radiation Protection and Nuclear Safety Agency

AS/NZS Australian and New Zealand Standard

B

C

CABG Coronary Artery Bypass Graft(s)

CCTV Closed Circuit Television

CEO Chief Executive Officer

CI Clinical Indicator

CIAP Clinical Information Access Program

CJD Creutzfeldt-Jakob Disease

CPD Continuing Professional Development

CPI Clinical Practice Improvement

CQI Continuous Quality Improvement

CPR Cardiopulmonary Resuscitation

CSM Customer Services Manager

D

DNA Deoxyribonucleic Acid

DRG Diagnosis Related Group

E

EA Excellent Achievement (EQuIP Rating)

EAP Employee Assistance Program

ED Emergency Department

EEO Equal Employment Opportunities

EPA Environmental Protection Authority

EQuIP Evaluation and Quality Improvement Program

seCtIon 6EQuIP5 Acronyms

seCtIon 6EQuIP5 Acronyms

246  The ACHS EQuIP5 Guide  Book 1  Accreditation, Standards and Guidelines  Clinical Function

F

FTE Full Time Equivalent

G

g / L Haemoglobin is measured in grams (g) per litre (L)

GP General Practitioner

H

HACC Health and Ageing Home and Community Care

Hb Haemoglobin

HIV Human Immunodeficiency Virus

HREC Human Research Ethics Committee

HRM Human Resources Management

HSANZ Haematology Society of Australia & New Zealand

I

I&CT Information and Communication Technology

ICMP Infection Control Management Plan

ICU Intensive Care Unit

IM Information Management

ISO International Organization for Standardization

IT Information Technology

J

JMO Junior Medical Officer

K

KPI Key Performance Indicator

L

LA Little Achievement (EQuIP Rating)

LMCA Left Main Coronary Artery

M

MA Marked Achievement (EQuIP Rating)

MET Medical Emergency Team

MSDS Material Safety Data Sheets

N

NA Not Applicable

NATA National Association of Testing Authorities

NBA National Blood Authority

NCDDD National Cardiovascular Disease and Diabetes Register

NEHTA National E-Health Transition Authority

NFR Not For Resuscitation

NHMRC National Health and Medical Research Council

NHPA National Health Priority Areas

NICS National Institute of Clinical Studies

NOHSC National Occupational Health and Safety Commission

October 2010  247

NPAAC National Pathology Accreditation Advisory Council

NPP National Privacy Principles

NPS National Prescribing Service

NSQHS (STANDARDS)

National Safety and Quality Health Service (Standards)

O

OA Outstanding Achievement (EQuIP Rating)

OH&S Occupational Health and Safety

OWS Organisation-Wide Survey (ACHS EQuIP survey)

P

PBS Pharmaceutical Benefits Scheme

PDCA Plan, Do, Check, Act

PDSA Plan, Do, Study, Act

POS Performance Outcomes Service (ACHS)

PR Periodic Review (ACHS EQuIP survey)

Q

QA Quality Assurance

QI Quality Improvement

QUM Quality Use of Medicine

R

RACP Royal Australasian College of Physicians

RACS Royal Australasian College of Surgeons

RAND Corporation, the name of which was derived from a contraction of the term research and development

RANZCA Royal Australian and New Zealand College of Anaesthetists

RCA Root Cause Analysis

RCBS Red Cross Blood Service

RCNA Royal College of Nursing, Australia

S

SA Some Achievement (EQuIP Rating)

SHPA Society of Hospital Pharmacists of Australia

SIDS Sudden Infant Death Syndrome

T

TQM Total Quality Management

U

UCLA University of California, Los Angeles

V

VA Veterans’ Affairs

VMO Visiting Medical Officer

VTE Venous Thromboembolism

WXYZ

WHO World Health Organization

248  The ACHS EQuIP5 Guide  Book 1  Accreditation, Standards and Guidelines  Clinical Function

Contact and Information

Inquiries regarding EQuIP5, other ACHS accreditation programs and program education and support, should be directed to:

The Australian Council on Healthcare Standards (ACHS) 5 Macarthur Street Ultimo NSW 2007 Australia

+61 2 9281 9955

+61 2 9211 9633

achs@achs.org.au

www.achs.org.au

strive for excellence | framework for maintaining quality care and service | focus on the customer | developing strong leadership | striving for best practice | standards | criterion | guidelines | safety, quality performance | strive for excellence | framework for maintaining quality care and service | focus on the customer | developing strong leadership | striving for best practice | standards | criterion | guidelines | safety, quality performance | strive for excellence | framework for maintaining quality care and service | focus on the customer | developing strong leadership | striving for best practice | standards | criterion | guidelines | safety, quality performance | strive for excellence | framework for maintaining quality care and service | focus on the customer | developing strong leadership | striving for best practice | standards | criterion | guidelines | safety, quality performance | strive for excellence | framework for maintaining quality care and service | focus on the customer | developing strong leadership | striving for best practice | standards | criterion | guidelines | safety, quality performance | strive for excellence | framework for maintaining quality care and service | focus on the customer | developing strong leadership | striving for best practice | standards | criterion | guidelines | safety, quality performance | strive for excellence | framework for maintaining quality care and service | focus on the customer | developing strong leadership | striving for best practice | standards | criterion | guidelines | safety, quality performance | strive for excellence | framework for maintaining quality care and service | focus on the customer | developing strong leadership | striving for best practice | standards | criterion | guidelines | safety, quality performance | strive for excellence | framework for maintaining quality care and service | focus on the customer | developing strong leadership | striving for best practice | standards | criterion | guidelines | safety, quality performance | strive for excellence | framework for maintaining quality care and service | focus on the customer | developing strong leadership | striving for best practice | standards | criterion | guidelines | safety, quality performance | strive for excellence | framework for maintaining quality care and service | focus on the customer | developing strong leadership | striving for best practice | standards | criterion | guidelines | safety, quality performance | strive for excellence | framework for maintaining quality care and service | focus on the customer | developing strong leadership | striving for best practice | standards | criterion | guidelines | safety, quality performance | strive for excellence | framework for maintaining quality care and service | focus on the customer | developing strong leadership | striving for best practice | standards | criterion | guidelines | safety, quality performance | strive for excellence | framework for maintaining quality care and service | focus on the customer | developing strong leadership | striving for best practice | standards | criterion | guidelines | safety, quality performance | strive for excellence | framework for maintaining quality care and service | focus on the customer | developing strong leadership | striving for best practice | standards | criterion | guidelines | safety, quality performance | strive

Safety Quality Performance