Download Standard 1: Governance for Safety and Quality in Health Service

National Safety and Quality
Health Service Standards
DRAFT
Guide for use in
Day Procedure Services
October 2011
Australian Commission on Safety and Quality in Health Care
1
National Safety and Quality Health Service Standards Guide for use in Day Procedure
Services October 2011
© Commonwealth of Australia 2011
This work is copyright. It may be reproduced in whole or in part for study or training purposes
subject to the inclusion of an acknowledgement of the source. Requests and inquiries
concerning reproduction and rights for purposes other than those indicated above requires the
written permission of the Australian Commission on Safety and Quality in Health Care, GPO
Box 5480 Sydney NSW 2001 or [email protected]
Suggested citation:
Australian Commission on Safety and Quality in Health Care (2011), National Safety and
Quality Health Service Standards Guide for use in Day Procedure Services, ACSQHC, Sydney.
Acknowledgments:
This document was prepared by the staff of the Australian Commission on Safety and Quality in
Health Care (ACSQHC) in collaboration with the Day Procedure Services Working Group. These
individuals have freely given their time, expertise and documentation to support the development
of this guide. The involvement and willingness of all concerned to share their experience and
expertise is greatly appreciated.
Australian Commission on Safety and Quality in Health Care
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Contents
Introduction ..................................................................................................................................................5
Standard 1: Governance for Safety and Quality in Health Service Organisations ...............................9
Criterion: Governance and quality improvement systems ..................................................................... 10
Criterion: Clinical practice ...................................................................................................................... 15
Criterion: Performance and skills management ..................................................................................... 17
Criterion: Incident and complaints management.................................................................................... 20
Criterion: Patient rights and engagement .............................................................................................. 23
Standard 2: Partnering with Consumers ................................................................................................ 26
Criterion: Consumer partnership in service planning ............................................................................. 27
Criterion: Consumer partnership in designing care................................................................................ 30
Criterion: Consumer partnership in service measurement and evaluation ............................................ 31
Standard 3: Preventing and Controlling Healthcare Associated Infections ...................................... 33
Criterion: Governance and systems for infection prevention, control and surveillance ......................... 34
Criterion: Infection prevention and control strategies ............................................................................ 38
Criterion: Managing patients with infections or colonisations ................................................................ 42
Criterion: Antimicrobial stewardship ....................................................................................................... 45
Criterion: Cleaning, disinfection and sterilisation ................................................................................... 47
Criterion: Communicating with patients and carers ............................................................................... 49
Standard 4: Medication Safety ................................................................................................................ 50
Criterion: Governance and systems for medication safety .................................................................... 51
Criterion: Documentation of patient information ..................................................................................... 56
Criterion: Medication management processes ....................................................................................... 58
Criterion: Continuity of medication management ................................................................................... 62
Criterion: Communicating with patients and carers ............................................................................... 63
Standard 5: Patient Identification and Procedure Matching ................................................................ 65
Criterion: Identification of individual patients .......................................................................................... 66
Criterion: Processes to transfer care ..................................................................................................... 69
Criterion: Processes to match patients and their care ........................................................................... 70
Standard 6: Clinical Handover ................................................................................................................ 72
Criterion: Governance and leadership for effective clinical handover.................................................... 73
Criterion: Clinical handover processes .................................................................................................. 74
Criterion: Patient and carer involvement in clinical handover ................................................................ 77
Standard 7: Blood and Blood Products ................................................................................................. 78
Criterion: Governance and systems for blood and blood product prescribing and clinical use ............. 79
Criterion: Documenting patient information ............................................................................................ 83
Criterion: Managing blood and blood product safety ............................................................................. 85
Australian Commission on Safety and Quality in Health Care
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Criterion: Communicating with patients and carers ........................................................................ 86
Standards 8: Preventing and Managing Pressure Injuries .................................................................. 88
Criterion: Governance and systems for the prevention and management of pressure injuries ............. 89
Criterion: Preventing pressure injuries ................................................................................................... 92
Criterion: Managing pressure injuries .................................................................................................... 95
Criterion: Communicating with patients and carers ............................................................................... 96
Standard 9: Recognising and Responding to Clinical Deterioration in Acute Health Care ............. 97
Criterion: Establishing recognition and response systems .................................................................... 98
Criterion: Recognising clinical deterioration and escalating care ........................................................ 101
Criterion: Responding to clinical deterioration ..................................................................................... 104
Criterion: Communicating with patients and carers ............................................................................. 106
Standard 10: Preventing Falls and Harm from Falls ........................................................................... 109
Criterion: Governance and systems for preventing falls ...................................................................... 110
Criterion: Screening and assessing risks of falls and harm from falling .............................................. 113
Criterion: Preventing falls and harm from falling .................................................................................. 115
Criterion: Communicating with patients and carers ............................................................................. 116
Action Plan Template ............................................................................................................................. 116
Action Plan Template ............................................................................................................................. 117
Glossary .................................................................................................................................................. 118
References .............................................................................................................................................. 124
Appendix 1 - Decision Support Tool for determining the level of performance to meet the NSQHS
Standards ................................................................................................................................................ 127
Appendix 2 - Summary table of items and actions in the NSQHS Standards to be audited or
reviewed by health services .................................................................................................................. 130
Appendix 3 - NSQHS Standards actions that require workforce training ........................................ 135
Appendix 4 - Summary table of not applicable actions for health service organisations to be
accredited against the NSQHS Standards ........................................................................................... 136
Appendix 5 - Steps in determining not applicable actions ................................................................ 138
Australian Commission on Safety and Quality in Health Care
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Introduction
This guide has been developed to assist health service organisations meet the requirements of
the National Safety and Quality Health Service (NSQHS) Standards.
It provides an overview of the NSQHS Standards and their purpose, examples of evidence a
health service organisation could use to demonstrate how they are meeting the NSQHS
Standards, and additional information and resources and to support the implementation of the
NSQHS Standards.
About the NSQHS Standards
The NSQHS Standards were developed by the Australian Commission on Safety and Quality in
Health Care (the Commission) following extensive consultation and collaboration with a wide
range of stakeholders, including jurisdictions, technical experts, health professionals and
consumers.
The NSQHS Standards aim to drive the implementation and use of safety and quality systems
and to improve the quality of health service provision in Australia. The NSQHS Standards focus
on areas that are essential to improving patient safety and quality of care and include:
1. Governance for Safety and Quality in Health Service Organisations
2. Partnering with Consumers
3. Preventing and Controlling Healthcare Associated Infections
4. Medication Safety
5. Patient Identification and Procedure Matching
6. Clinical Handover
7. Blood and Blood Products
8. Preventing and Managing Pressure Injuries
9. Recognising and Responding to Clinical Deterioration in Acute Health Care
10. Preventing Falls and Harm from Falls.
The first two Standards, ‘Governance for Safety and Quality in Health Service Organisations’
and ‘Partnering with Consumers’, set the overarching requirements for effective implementation
of the remaining eight Standards, which address specific clinical areas of patient care.
The NSQHS Standards provide a nationally consistent statement of the level of care consumers
should be able to expect from health services.
The NSQHS Standards were selected because they address areas where:

the impact is on a large number of patients

there is a known gap between the current situation and best practice outcomes, and

improvement strategies exist that are evidence-based and achievable.
Australian Commission on Safety and Quality in Health Care
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The Commission developed the NSQHS Standards to be applied across all settings of care.
Health service organisations, such as hospitals and day procedure services, will be accredited
against the NSQHS Standards. Other health services may choose to use the NSQHS
Standards as part of their internal quality systems.
Structure and Content of the NSQHS Standards
Each NSQHS Standard includes a:

description of the Standard

statement of intent

statement on the context in which the Standard must be applied

list of key criteria, and

series of items and actions relevant to each criterion.
Core and Developmental Actions
The NSQHS Standards apply to a wide variety of health services. Because of the variable size,
structure, and complexity of health service delivery models, a degree of flexibility is required in
the application of the NSQHS Standards.
To achieve this flexibility, each action within the Standards is designated as either:

core: which are critical for safety and quality, and which must be met in order to meet the
Standard, or

developmental: which are aspirational targets. Health service organisations will not be
required to achieve developmental actions in order to meet the Standard.
Core actions are considered fundamental to safe practice. All core actions must be met before a
health service can achieve an accreditation award against the NSQHS Standards.
Developmental actions identify areas where health services can focus activities or investments
that improve patient safety and quality. Health services do not need to meet development
actions to achieve an accreditation award. A review of all core and developmental items will
occur in 2015.
Ratings
The Commission has recommended that health service organisations meet the requirements of
the NSQHS Standards. Assessment will be against a three point rating scale:

Not Met (NM) – the actions required have not been achieved.

Satisfactorily Met (SM) – the actions required have been achieved.

Met with Merit (MM) – in addition to achieving the actions required, measures of good
quality and a higher level of achievement are evident. This would mean a culture of safety,
evaluation and improvement is evident throughout the organisation in relation to the action
or Standard under review.
This rating system is used to rate individual actions within a Standard and to rate the Standard
overall.
Australian Commission on Safety and Quality in Health Care
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Individual accrediting agencies may choose to apply additional items, such as partially met in
the rating scale when carrying out assessments. Health services can discuss this with their
accrediting agency.
Not Applicable
In exceptional circumstances, a criterion, item or action may be rated as ‘not applicable’. ‘Not
applicable’ items are those which are inappropriate in a specific service context and/or for which
assessment would be meaningless. If an item is rated as ‘not applicable’ an explanation must
be provided for this decision to the accrediting agency. Appendix 5 describes the proposed
process to apply for ‘not applicable’ actions.
About this Guide
Each Standard is presented in a separate section which details:

the criteria, items and actions to meet each Standard

examples of evidence that a health service organisation may use to demonstrate an action
is being met, and

a self assessment tool.
The evidence provided includes examples that can be used to demonstrate that an item is being
met – but it is not a checklist. Furthermore, the examples or suggestions provided do not
represent an exhaustive ‘list’ of possible evidence. The service type, size, nature and location
will influence the types of evidence that are appropriate and available. Please note, however,
that organisations must provide sufficient evidence that each core item is being addressed in
order to meet the NSQHS Standards.
The self assessment section (in column five) provides an opportunity for the health service
organisation to review performance against the actions required and determine if current
systems and processes meet the requirements. Self assessment is an important component of
an accreditation process as it allows services to identify areas or issues that require attention
prior to assessment by an external accrediting body.
An action plan template is provided on page 118 to assist practices to plan the changes needed
to meet the NSQHS Standards. It also provides space to identify the potential risks and barriers
to the actions; the strategies to be used to overcome these; the person responsible for the
action; and the expected timeframes for completion.
Additional information that may assist in understanding and clarifying the NSQHS Standards
has been included for some actions and this is identified within the table with the symbol (i).
A list of resources and tools for the implementation of safer systems is also included at the end
of the section for each Standard.
Australian Commission on Safety and Quality in Health Care
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Key for symbols used in the Guide for Day Procedure Services
C
D
N/A
indicates that the action is core and therefore must be met
indicates that the action is developmental
indicates that the action is not applicable
(i)
indicates there is additional information to assist in interpretation of the
Standards. Additional information specific to a particular action is included
immediately below the relevant action
self assessment – ‘met with merit’.
self assessment – ‘satisfactorily met’.
- add to action plan
self assessment – ‘not met’ and add action to action plan
template provided on page 118.
Australian Commission on Safety and Quality in Health Care
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Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
Standard 1: Governance for Safety and Quality in Health Service Organisations
Health service organisation leaders implement governance systems to set, monitor and improve the performance of the organisation and
communicate the importance of the patient experience and quality management to all members of the workforce. Clinicians and other members of
the workforce use the governance systems.
The intention of this Standard is to:
Create integrated governance systems that maintain and improve the reliability and quality of patient care, as well as improve patient outcomes.
Context
This Standard provides the safety and quality governance framework for health service organisations. It is expected that this Standard will apply to
the implementation of all other Standards in conjunction with Standard 2, ‘Partnering with Consumers’.
Criteria to achieve the Governance for Safety and Quality in Health Service Organisations Standard:
Governance and quality improvement systems
Clinical practice
Performance and skills management
Incident and complaints management
Patient rights and engagement
Australian Commission on Safety and Quality in Health Care
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Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
Criterion: Governance and quality improvement systems
There are integrated systems of governance to actively manage patient safety and quality risks.
C/D
C
C
This criterion will be
achieved by:
Actions required
1.1 Implementing a
governance system that
sets out the policies,
procedures and/or
protocols for:

establishing and
maintaining a clinical
governance framework

identifying safety and
quality risks

collecting and
reviewing performance
data

implementing
prevention strategies
based on data analysis

analysing reported
incidents

implementing
performance
management
procedures

ensuring compliance
with legislative
requirements and
relevant industry
standards

communicating with
and informing the
clinical and non-clinical
workforce

undertaking regular
clinical audits with
legislative
requirements and
relevant industry
1.1.1 An organisation-wide
management system is in place
for the development,
implementation and regular
review of policies, procedures
and/or protocols
Examples of evidence that can be used to demonstrate an action is being met.
This is not a checklist. Use only those examples that show that you have met the
Standards
 Policies, procedures and/or protocols are in place for items listed in 1.1
 Agenda papers, meeting minutes and /or reports of relevant committees that
oversee the development and review of policies, procedures and/or protocols
 A register of completed reviews of policies, procedures and/or protocols, including
the date of review and any changes made
 Bylaws outlining mandatory criteria for meetings
Self
assessment
- add to
action plan
(i) Policies, procedures and/or protocols should be based on best practice and identify legislative
requirements. They should include:
 nationally agreed definitions where available
 the date the policy was implemented and the scheduled review date
 links to relevant resource materials and/or references
 amendments approved following either incident, national changes in policy or policy review
 mechanisms for checking compliance
 an approval for use in the organisation
 are accessible to the workforce
1.1.2 The impact on patient
safety and quality of care is
considered in business decision
making
Australian Commission on Safety and Quality in Health Care
 Business plans outlining the potential impact on patient safety and quality of care
 Agenda papers, meeting minutes and/or reports of relevant committees (such as
finance and audit committees or strategic planning committees)
- add to
action plan
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Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
C/D
This criterion will be
achieved by:
Actions required
Examples of evidence that can be used to demonstrate an action is being met.
This is not a checklist. Use only those examples that show that you have met the
Standards
Self
assessment
standards
C
1.2 The board, chief
executive officer and/or
other higher level of
governance within a health
service organisation taking
responsibility for patient
safety and quality of care
governance
C
C
1.2.2 Action is taken to improve
the safety and quality of patient
care
1.3 Assigning workforce
roles, responsibilities and
accountabilities to
individuals for:


C
1.2.1 Regular reports on safety
and quality indicators and other
safety and quality performance
data are monitored by the
executive level of governance
1.3.1 Workforce are aware of
their delegated safety and
quality roles and responsibilities
patient safety and
quality in their delivery
of health care
the management of
safety and quality
specified in each of
these Standards
1.3.2 Individuals with delegated
responsibilities are supported to
understand and perform their
roles and responsibilities, in
particular to meet the
requirements of these
Standards
Australian Commission on Safety and Quality in Health Care
 Committee terms of reference outline the senior executive responsibilities for
governance of patient safety and quality of care
 Agenda papers, meeting minutes and/or reports from relevant committee(s)
include safety and quality indicators and data
 Safety and quality information presented to the senior executive and/or relevant
committees
 Data that reports trends in safety and quality issues are recorded, such as in
meeting minutes or annual reports
 Risk register or log that includes actions to address identified risks
 Agenda papers, meeting minutes and/or reports of relevant committee(s) that
detail improvement actions taken
 Quality improvement plan includes actions to address issues identified
 Examples of improvement activities that have been implemented and evaluated
 Communication material developed for the workforce and/or patients
 Policies, procedures and/or protocols outline the delegated safety and quality
roles and responsibilities for the workforce
 Descriptions of delegated safety and quality roles and responsibilities included in
position descriptions, the workforce duty statements and/or employment contracts
 Orientation and ongoing training resources on safety and quality roles and
responsibilities across clinical areas
 Records of attendance at training by the workforce
 Organisational structure chart that outlines relevant reporting lines
 Agenda papers, meetings minutes and/or reports from the workforce meetings
 Written communication to the workforce about roles and responsibilities
 Results of the workforce surveys regarding safety and quality roles and
responsibilities
 Descriptions of delegated safety and quality roles and responsibilities included in
position descriptions, the workforce duty statements and/or employment contracts
 Orientation and ongoing training resources are provided to meet the requirements
of the NSQHS Standards
 Records of attendance at training by the workforce
 Performance appraisals that include feedback to the workforce on delegated
safety and quality roles and responsibilities.
 Results of the workforce surveys regarding safety and quality roles and
responsibilities
11
- add to
action plan
SM
- add to
action plan
- add to
action plan
- add to
action plan
Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
C/D
This criterion will be
achieved by:
Actions required
Examples of evidence that can be used to demonstrate an action is being met.
This is not a checklist. Use only those examples that show that you have met the
Standards
Self
assessment
(i) Appendix 3 summarises the actions in the NSQHS Standards that require workforce training
C
D
D
1.3.3 Agency or locum
workforce are aware of their
designated roles and
responsibilities
1.4 Implementing training in
the assigned safety and
quality roles and
responsibilities
1.4.1 Orientation and ongoing
training programs provide the
workforce with the skill and
information needed to fulfil their
safety and quality roles and
responsibilities
1.4.2 Annual mandatory training
programs to meet the
requirements of these
Standards
 Policies, procedures and/or protocols that address the roles and responsibilities
of locum and agency workforce
 Contracts with locum and agency workforce specify designated roles and
responsibilities
 Position descriptions, workforce duty statements and/or employment contracts for
locum and agency workforce specify designated roles and responsibilities
 Orientation and ongoing training resources for locum and agency staff
 Attendance records of training for locum and agency staff
 Orientation and ongoing training resources regarding safety and quality roles and
responsibilities for the workforce
 Records of attendance at training by the workforce
 Results of workforce surveys regarding safety and quality roles and
responsibilities
 Information on current legislative and regulatory requirements and guidelines
accessible to all staff
 Schedule of annual mandatory education and training sessions which includes
the requirements of the NSQHS Standards
 Orientation and ongoing training resources to address the requirements of the
NSQHS Standards
 Attendance records of mandatory training sessions
 Evaluation survey or report on training programs on staff safety and quality roles
and responsibilities
- add to
action plan
- add to
action plan
- add to
action plan
(i) Appendix 3 summarises the actions in the NSQHS Standards that require workforce training
D
1.4.3 Locum and agency
workforce have the necessary
information, training and
orientation to the workplace to
fulfil their safety and quality
roles and responsibilities
Australian Commission on Safety and Quality in Health Care
 Policies, procedures and/or protocols readily accessible to locum and agency
staff
 Observational audits show that internal communication systems that provide
access to information about safety and quality information (for example Intranet,
memos) are accessible to the locum and agency staff
 Orientation and ongoing training resources for locum and agency workforce
regarding their safety and quality roles and responsibilities
 Attendance records of training for locum and agency staff
 Skills appraisals and/or record of competencies of locum and agency workforce
 Record of locum and agency workforce credentials (qualifications)
12
- add to
action plan
Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
C/D
This criterion will be
achieved by:
Actions required
Examples of evidence that can be used to demonstrate an action is being met.
This is not a checklist. Use only those examples that show that you have met the
Standards
Self
assessment
(i) Locum and agency workforce may also include clinical, clerical, and/or trades people. They may
include physiotherapy, clinical records coder, security or medical practitioners
D
C
1.4.4 Competency-based
training is provided to the
clinical workforce to improve
safety and quality
1.5 Establishing an
organisation-wide risk
management system that
incorporates identification,
assessment, rating,
controls and monitoring for
patient safety and quality
regularly monitored
C
C
1.5.1 An organisation-wide risk
register is used and regularly
monitored
1.5.2 Actions are taken to
minimise risks to patient safety
and quality of care
1.6 Establishing an
organisation-wide quality
management system that
monitors and reports on the
safety and quality of patient
care and informs changes
in practice
1.6.1 An organisation-wide
quality management system is
used and regularly monitored
Australian Commission on Safety and Quality in Health Care
 Schedule of training for the workforce
 Orientation and ongoing training resources for locum and agency workforce
regarding their safety and quality roles and responsibilities
 Attendance records and/or results of competency based training for staff
 Evaluation of competency-based training courses
 Policies, procedures and/or protocols for implementing and monitoring the risk
management system
 Agenda papers, meeting minutes and/or reports of relevant committees that
oversee the risk management system
 Risk register or log that includes actions to address identified risks
 Orientation and ongoing training resources regarding the organisation’s risk
management system
 Records of attendance at training by the workforce





- add to
action plan
- add to
action plan
A register of incident reports, adverse events and near misses
Risk register or log that includes actions to address identified risks
Risk assessment and analysis reports
Organisational risk management plan
Agenda papers, meeting minutes and/or reports from relevant committees include
data analysis for identified risks
 Audits of safety and quality indicators
 Quality improvement plan includes actions based on analysis of risk which are
regularly reviewed
- add to
action plan
 A designated committee or personnel with responsibility for the implementation,
coordination and review of an organisation-wide quality management system
 Audit of compliance with policies, procedures and/or protocols and other
legislation or regulations
 Evaluation reports on the safety and quality management system
 Position description or employment contract that requires participation in quality
management system
 Audit of the organisation’s quality improvement plan
 Feedback provided to workforce on safety and quality issues
- add to
action plan
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Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
C/D
This criterion will be
achieved by:
Actions required
Examples of evidence that can be used to demonstrate an action is being met.
This is not a checklist. Use only those examples that show that you have met the
Standards
Self
assessment
(i) Management tools may include the Plan–Do–Check–Act (PDCA) cycle. The PDCA cycle is also
known as the Plan–Do–Study–Act cycle, Deming’s cycle, Shewhart’s cycle and the Continuous
Improvement cycle
C
1.6.2 Actions are taken to
maximise patient quality of care
Australian Commission on Safety and Quality in Health Care
 Register of incident reports, adverse events and near misses
 Results of patient satisfaction survey and organisational responses recorded
 Results of clinical audits and performance indicators identify areas requiring
action
 Evaluation report or review of strategies implemented
 Re-audits of identified deficiencies or areas requiring action
 Strategies and actions taken in response to identified risks are recorded, such as
in agenda papers, meeting minutes and/or reports of relevant committee(s)
 Quality improvement plan includes actions to address issues identified
 Examples of improvement activities that have been implemented and evaluated
 Information communicated to staff
14
- add to
action plan
Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
Criterion: Clinical practice
Care provided by the clinical workforce is guided by current best practice.
C/D
C
This criterion will be
achieved by:
Actions required
1.7 Developing and/or
applying clinical
guidelines or pathways
that are supported by the
best available evidence
1.7.1 Agreed and documented
clinical guidelines and/or
pathways are available to the
clinical workforce
C
Examples of evidence that can be used to demonstrate an action is being met.
This is not a checklist. Use only those examples that show that you have met
the Standards
 Policies, procedures and/or protocols for access and use of clinical guidelines
and/or pathways
 Observational audit that guidelines and and/or pathways are available in clinical
areas (hard copy or electronic)
 List of web addresses for accessing electronic copies of clinical guidelines and/or
pathways
Self
assessment
- add to
action plan
 Audits of adherence to available clinical guidelines and/or pathways
1.7.2 The use of agreed clinical
guidelines by the clinical
workforce is monitored
- add to
action plan
C
C
1.8 Adopting processes to
support the early
identification, early
intervention and
appropriate management
of patients at increased
risk of harm
1.8.1 Mechanisms are in place
to identify patients at increased
risk of harm




1.8.2 Early action is taken to
reduce the risks for at-risk
patients
Australian Commission on Safety and Quality in Health Care
Patient clinical record shows that risk assessments are completed during
admission, on admission and during an ongoing care
Organisational risk profile that details the most likely risks and their potential impact
Register of incident reports, adverse events and near misses includes actions to
address issues identified
Data on complaints and consumer feedback
 Supervision policies, procedures and/or protocols designed to reduce risk
 Instructions about which the workforce can perform procedures identified as being
at most risk
 Risk profile that includes an evaluation of risks and methods of eliminating or
reducing identifiable risks
 Risk management and action plans for identified risks
 Emergency plans for identified risks
 Analysis of the causes of adverse events and near miss incidents and the actions
taken to address the identified risks
 Documented early recognition and response system
 Orientation and ongoing training resources and training attendance records that
address the identified risks
15
- add to
action plan
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action plan
Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
C/D
This criterion will be
achieved by:
C
Actions required
Examples of evidence that can be used to demonstrate an action is being met.
This is not a checklist. Use only those examples that show that you have met
the Standards
1.8.3 Systems exist to escalate
the level of care when there is
an unexpected deterioration in
health status






Policies, procedures and/or protocols regarding escalation of care
Observation that signs, posters and/or stickers on how to call for assistance are
clearly displayed in areas where care is provided
Orientation and ongoing education resources related to escalation of care
Records of attendance at training by the workforce
Record of operational and mechanical call device testing
Incident reports about escalation of care
Self
assessment
- add to
action plan
Link to Standard 9
C
1.9 Using an integrated
patient clinical record that
identifies all aspects of
the patient’s care
1.9.1 Accurate, integrated and
readily accessible patient
clinical records are available to
the clinical workforce at the
point of care
 Policies, procedures and/or protocols for ensuring patient clinical records are
available at the point of care when a patient is transferred within the organisation
and between organisations
 Policies, procedures and/or protocols for obtaining patient clinical records from
storage and other areas of the organisation
 Audits of the accuracy, integration and currency of patient clinical records which
meets best practice
 Observational audits of the availability of patient clinical records to the clinical
workforce at the point of care
- add to
action plan
(i) Patient clinical record is also known as patient medical record, client’s notes, clinical notes, progress
notes, and/or procedure records
C
1.9.2 The design of the patient
clinical record allows for
systematic audit of the
contents against the
requirements of these
Standards
Australian Commission on Safety and Quality in Health Care
 A schedule of audits of the patient clinical record against the requirements of the
NSQSH Standards is developed and maintained
 Completed audits of patient clinical records
- add to
action plan
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Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
Criterion: Performance and skills management
Managers and the clinical workforce have the right qualifications, skills and approach to provide safe, high quality health care.
C/D
C
This criterion will be
achieved by:
Actions required
1.10 Implementing a
system that
determines and
regularly reviews the
roles, responsibilities,
accountabilities and
scope of practice for
the clinical workforce
1.10.1 A system is in place to
define and regularly review the
scope of practice for the
clinical workforce
Examples of evidence that can be used to demonstrate an action is being met.
This is not a checklist. Use only those examples that show that you have met the
Standards
 Policies, procedures and/or protocols regarding the scope of practice for the
clinical workforce clinical supervision of students
 Agenda papers, meeting minutes and/or reports from relevant committee(s)
include information on the roles, responsibilities, accountabilities and scope of
practice for the clinical workforce
 Audits of policies, procedures and/or protocols and position descriptions, against
the requirements and/or recommendations of clinical practice and professional
guidelines
 Audits of policies, procedures and/or protocols against scope of practice defined
by credentialing bodies
 Workforce performance appraisal and feedback records show a review of the
scope of practice for clinical workforce
 Peer review reports
 Agenda papers, meeting minutes and/or reports of relevant committee(s) with
responsibilities for determining and reviewing scope of practice
Self
assessment
- add to
action plan
(i) The policy may have appointments and credentialing incorporated, including service framework and
capability, and licensing agreement which lists the organisations available health services
C
1.10.2 Mechanisms are in
place to monitor that the
clinical workforce are working
within their agreed scope of
practice






Register of the workforce qualifications and areas of credentialed practice
Audit of clinical workforce who have a documented performance appraisal
Reports and/or reviews of clinical workforce key performance indictors
Observational audits of clinical practice
Audits of signatures and role designation in patient clinical records
Audit of compliance with policies, procedures and/or protocols
- add to
action plan
(i) Patient clinical record is also known as patient medical record, client notes, clinical notes, progress
notes, and/or procedure records
Australian Commission on Safety and Quality in Health Care
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Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
C/D
C
C
C
This criterion will be
achieved by:
Actions required
Examples of evidence that can be used to demonstrate an action is being met.
This is not a checklist. Use only those examples that show that you have met the
Standards
1.10.3 Organisational clinical
service capability, planning,
and scope of practice is
directly linked to the clinical
service roles of the
organisation
1.10.4 The system for defining
the scope of practice is used
whenever a new clinical
service, procedure or other
technology is introduced
1.10.5 Supervision of the
clinical workforce is provided
whenever it is necessary for
individuals to fulfil their
designated role
 Strategic plan outlines the organisation’s overall objectives and services provided
 Register of workforce qualifications suitable for clinical service roles of the
organisation
 Case mix audit of services provided
 Evaluation of clinical services targets
 Reports from clinical information systems
 Benchmarking reports
 Evaluation of the quality and safety of clinical services
 Annual reports detail the clinical service capability and clinical services provided
 Policies, procedures and/or protocols and bylaws regarding scope of practice
 Planning documents to introduce new services (including staffing, equipment,
procedures, scope of practice applications and approval for licensing)
 Defined competency standards for using new services, procedures and
technology are available to clinical staff
 Education resources for new services, procedures and technologies
 Attendance training records
 Meeting minutes and reports of clinical practice committees or similar groups
 Staff meeting minutes, memos, intranet messages and/or other methods of
communication with the workforce that define the scope of practice for new clinical
services, procedures or other technology
 Descriptions of roles and responsibilities for designated clinical leaders included in
position descriptions, staff duty statements and/or employment contracts
 Documented review of qualifications and competencies for clinical staff
 Individual performance reviews documented for all the clinical workforce
 Observational audits of individuals clinical practice
 Register of workforce qualifications and areas of credentialed practice
 Audit of clinical workforce who have completed performance reviews
Self
assessment
- add to
action plan
- add to
action plan
- add to
action plan
(i) Policies may detail both the clinical workforce requiring supervised practice such, as student nurses,
and the extent of the supervision required
Australian Commission on Safety and Quality in Health Care
18
Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
C/D
C
This criterion will be
achieved by:
Actions required
1.11 Implementing a
performance
development system
for the clinical
workforce that
supports performance
improvement within
their scope of practice
1.11.1 A valid and reliable
performance review process is
in place for the clinical
workforce
C
C
C
C
Examples of evidence that can be used to demonstrate an action is being met.
This is not a checklist. Use only those examples that show that you have met the
Standards
1.11.2 The clinical workforce
participates in regular
performance reviews that
support individual development
and improvement
1.12 Ensuring that
systems are in place
for ongoing safety
and quality education
and training
1.12.1 The clinical and
relevant non-clinical workforce
have access to ongoing safety
and quality education and
training for identified
professional and personal
development
1.13 Seeking regular
feedback from the
workforce to assess
their level of
engagement with,
and understanding of,
the safety and quality
system of the
organisation
1.13.1 Analyse feedback from
the workforce on their
understanding and use of
safety and quality systems
1.13.2 Action is taken to
increase workforce
understanding and use of
safety and quality systems
Australian Commission on Safety and Quality in Health Care
 Policies, procedures and/or protocols on the performance review process for
clinical workforce
 A documented performance development system that meets professional
development guidelines and credentialing requirements
 Audit of compliance with policies, protocols and/or procedures on the performance
review process for clinical workforce
 Audit of clinical workforce with completed performance reviews
 Audit reports based on observational audits of individuals clinical practice
 Peer review reports
Self
assessment
- add to
action plan
 Individual performance reviews documented for all the clinical workforce
 Records of workforce attendance at training and competency consist with
organisational policies and credential requirements
 Observational audits of clinical practice
 Workforce development plans and programs document training needs identified
through individual performance reviews
 Education resources, plans, and attendance records of safety and quality
education provided
 Safety and quality resources and materials readily available to the workforce
- add to
action plan
 Agenda papers, meeting minutes and/or reports of relevant committees
responsible for safety and quality systems
 Records of workforce feedback regarding the use of safety and quality systems
 Analysis of workforce survey results regarding the use of safety and quality
systems
 Evaluations of workforce training
 Workforce communication books
 Succession plans for key safety and quality positions
 Risk register or log that includes actions to address identified risks
 Agenda papers, meeting minutes and/or reports of relevant committee(s) that
detail improvement actions taken
 Quality improvement plan includes actions to address issues identified
 Examples of improvement activities that have been implemented and evaluated
 Communication material developed for the workforce and/or patients
19
- add to
action plan
- add to
action plan
Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
Criterion: Incident and complaints management
Patient safety and quality incidents are recognised, reported and analysed, and this information is used to improve safety systems.
C/D
C
C
C
This criterion will be
achieved by:
Actions required
1.14 Implementing an
incident management
and investigation
system that includes
reporting, investigating
and analysing incidents
(including near misses),
which all result in
corrective actions
1.14.1 Processes are in
place to support the
workforce recognition and
reporting of incidents and
near misses
Examples of evidence that can be used to demonstrate an item is being met.
This is not a checklist, use only those examples to show that you have met the
standards
1.14.2 Systems are in place
to analyse and report on
incidents
1.14.3 Feedback on the
analysis of reported
incidents is provided to the
workforce
 Policies, procedures and/or protocols for reporting, investigating and analysing
incidents and near misses
 Risk assessment, incident and near miss reporting forms
 A current register of incident reports, adverse events and near misses that may
include actions to address identified risks
 Orientation and ongoing training on the recognition, reporting, investigating and
analysing of incidents, adverse events and near misses
 Records of attendance at training by the workforce
 A current register of incident reports, adverse events and near misses that includes
actions to address identified risks
 Data that reports trends in incidents, adverse events and near misses are recorded,
such as in meeting minutes or annual reports
 Agenda papers, meeting minutes and/or reports of relevant committees include
information and data from incident reports
 Safety and quality information presented to the senior executive and/or relevant
committees
 Meeting minutes of relevant committee(s) that contain an analysis of incidents and
near misses are available to workforce
 Material distributed to workforce on incidents and trends
 Incident reports are available to the workforce
 Agenda papers, meeting minutes and reports of workforce meetings include
information on incidents, adverse events and near misses
Self
assessment
- add to
action plan
- add to
action plan
- add to
action plan
(i) Incident reports provided to the workforce may be limited to major incidents and/or aggregated reports of
all incidents that have been reported
C
1.14.4 Action is taken to
reduce risks to patients
identified through the
incident management
system
Australian Commission on Safety and Quality in Health Care
 Same evidence options as 1.13.2
- add to
action plan
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Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
C/D
This criterion will be
achieved by:
C
C
Actions required
This is not a checklist, use only those examples to show that you have met the
standards
1.14.5 Incidents and
analysis of incidents are
reviewed at the highest level
of governance in the
organisation
1.15 Implementing a
complaints
management system
that includes
partnership with
patients and carers
Examples of evidence that can be used to demonstrate an item is being met.
1.15.1 Processes are in
place to support the
workforce to recognise and
report complaints










C
C
C
1.15.2 Systems are in place
to analyse and implement
improvements in response
to complaints
1.15.3 Feedback is provided
to the workforce on the
analysis of reported
complaints
1.15.4 Patient feedback and
complaints are regularly
reviewed at the highest
level of governance in the
organisation


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

Policies, procedures and/or protocols detail processes for recording and reporting
patient and carers complaints (complaints management)
Comments and complaints forms for patients to complete
Secure patient comments and complaints ‘box’, or similar device, in publicly
accessible places
Patient brochure, information sheets, or equivalent, that outline internal and
external complaints mechanisms
Orientation and ongoing training on the complaints management system
Records of attendance at training by the workforce
A current complaints register which includes responses and actions to address
identified issues
Agenda papers, meeting minutes and/or reports of relevant committees or groups
with responsibility for complaints management
Reports or briefings on analysis of complaints
Quality improvement plan includes actions to address issues identified
Examples of improvement activities that have been implemented and evaluated
Complaints data recorded in agenda papers, meeting minutes and/or or reports of
relevant committees
Material provided to workforce on complaints and trends in complaints
- add to
action plan
- add to
action plan
- add to
action plan
- add to
action plan





Australian Commission on Safety and Quality in Health Care
Record or report of evidence-based interventions that have been initiated for
identified risks
Risk assessments and action plans
Strategies and actions taken in response to identified risks are recorded, such as in
agenda papers, meeting minutes and/or reports of relevant committee(s)
Information on incidents presented to the senior executive and/or relevant
committees
Self
assessment
Agenda papers, meeting minutes and/or reports of relevant committees or groups
with responsibility for complaints management
Safety and quality information presented to the senior executive and/or relevant
committees
Data that reports trends in safety and quality issues is included in meeting minutes
or annual reports
Risk management plan that includes strategies for managing complaints
Evaluation reports note the effectiveness of responses and improvements in
service delivery
21
- add to
action plan
Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
C/D
C
C
This criterion will be
achieved by:
Actions required
1.16 Implementing an
open disclosure process
based on the national
open disclosure
standard
1.16.1 An open disclosure
program is in place and is
consistent with the national
open disclosure standard
Examples of evidence that can be used to demonstrate an item is being met.
This is not a checklist, use only those examples to show that you have met the
standards
1.16.2 The clinical workforce
are trained in open
disclosure processes



Policies, procedures and/or protocols consistent with the principles and processes
outlined in the national open disclosure standard
Documented reports on open disclosure processes in the organisation
Information and data on open disclosure presented to the senior executive and/or
relevant committees


Orientation and ongoing training resources on the open disclosure processes
Records of attendance at training by the workforce
Self
assessment
- add to
action plan
- add to
action plan
Australian Commission on Safety and Quality in Health Care
22
Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
Criterion: Patient rights and engagement
Patient rights are respected and their engagement in their care is supported
C/D
C
This criterion will be
achieved by:
Actions Required
1.17 Implementing through
organisational policies and
practices a patient charter of
rights that is consistent with
the current national charter
of healthcare rights
1.17.1 The organisation
has a charter of patient
rights that is consistent
with the current national
charter of healthcare
rights
C
Examples of evidence that can be used to demonstrate an item is being met.
This is not a checklist, use only those examples to show that you have met the
standards
1.17.2 Information on
patient rights is provided
and explained to patients
and carers


Self
assessment
Policies, procedures and/or protocols regarding the implementation and use of a
charter of patients rights
Charter of rights consistent with the Australian Charter of Healthcare Rights
- add to
action plan




A patient charter of rights is displayed in areas accessible to the public
Brochures, information sheets or other documents that explain the charter of rights
are given to patients
Charter of patient rights is available in a range of languages and formats, consistent
with the patient profile
Admission checklist that includes provision and explanation of patient charter of
rights
MM
- add to
action plan
Link with Standard 2
C
C
1.17.3 Systems are in
place to support patients
who are at risk of not
understanding their
healthcare rights
1.18 Implementing
processes to enable
partnership with patients in
decisions about their care,
including informed consent
to treatment
1.18.1 Patients and carers
are partners in the
planning for their
treatment








Australian Commission on Safety and Quality in Health Care
A register of interpreter and other advocacy and support services is available for the
workforce and patients
Patient clinical records reflect assessment of need and support provided
Analysis of consumer feedback regarding healthcare rights
Results of patient and/or carer satisfaction surveys regarding healthcare rights
Patient clinical records include:
o information provided to patient and/or carers about their proposed treatment
o patient and/or carer involvement in pre-operative assessment
o patient and/or carer involvement in discharge planning
o case conference records with patients and/or carers
o completed consent forms
Observational audits of consumers participating in making decisions about their care
Analysis of consumer feedback regarding consumer participation in making
decisions about their care
Results of patient and/or carer satisfaction surveys regarding consumer participation
in making decisions about their care
23
- add to
action plan
- add to
action plan
Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
C/D
C
D
This criterion will be
achieved by:
Actions Required
Examples of evidence that can be used to demonstrate an item is being met.
This is not a checklist, use only those examples to show that you have met the
standards
1.18.2 Mechanisms are in
place to monitor and
improve documentation of
informed consent
1.18.3 Mechanisms are in
place to align the
information provided to
patients with their capacity
to understand


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

Patient information packages or resources about treatments
Translated patient information sheets/resources
A register of interpreter and other advocacy and support services is available for the
workforce and patients
Audits of patient clinical records and informed consent forms
Results of patient and/or carer satisfaction surveys and actions taken to address
issues identified regarding informed consent
Policies, protocols and/or procedures on communicating and providing information
to patients and/or carers
Agenda papers, meeting minutes and/or reports note consumer involvement on
committee(s) responsible for development of patient information materials
Consumers evaluation reports regarding patient information material
Patient information sheets or resources available in a range of languages and
formats, consistent with the patient profile
Results of patient and/or carer satisfaction surveys regarding patient information
material
Self
assessment
- add to
action plan
- add to
action plan
Link with Standard 1.17.3 and Standard 2
D
1.18.4 Patients and carers
are supported to
document clear advanced
care directives and/or
treatment-limiting orders





Policies, procedures and/or protocols on advanced care and end of life care that are
consistent with jurisdictional guidelines and directives
Patient information packages or resources about advanced care directives
A register of interpreter and other advocacy and support services that are available
for the workforce and patients
Patient clinical records note information provided to patients on advanced care or
end of life directives
Audit of patient clinical records that contain advanced care directives or end of life
plans
Link with Standard 9.8 if applicable
Australian Commission on Safety and Quality in Health Care
24
- add to
action plan
 N/A
Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
C/D
C
This criterion will be
achieved by:
Actions Required
1.19 Implementing
procedures that protect the
confidentiality of patient
clinical records without
compromising appropriate
clinical workforce access to
patient clinical information
1.19.1 Patient clinical
records are available at
the point of care
C
C
This is not a checklist, use only those examples to show that you have met the
standards
1.19.2 Systems are in
place to restrict
inappropriate access to
and dissemination of
patient clinical information
1.20 Implementing well
designed, valid and reliable
patient experience feedback
mechanisms and using
these to evaluate the health
service performance
Examples of evidence that can be used to demonstrate an item is being met.
1.20.2 Data collected from
patient feedback systems
are used to measure and
improve health service in
the organisation
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
Policies, procedures and/or protocols on retrieving patients clinical records and
protecting patient confidentiality
Observational audits of the workforce accessing electronic or hard copies of patient
clinical records and maintaining confidentiality in clinical areas
Policies, procedures and/or protocols on sharing patient information by telephone,
electronically and other methods, consistent with federal and state or territory
privacy legislation and department and insurers requirements
Code of conduct that includes privacy and confidentiality of patient information
Secure archival storage system
Secure storage system in clinical areas
Workforce confidentiality agreements
Computers that are password protected
Patient clinical records that include consent for transfer of information to other
service providers or national health related register/s
Record of ethics approval for research activities
Data analysis and reports of consumer feedback
Results of patient and/or carer satisfaction surveys
Register of patient comments and complaints
Quality improvement plan includes actions to address issues identified
Strategic, business and quality improvement plans describe how patient and/or
carer feedback was used to evaluate the health service performance
Self
assessment
- add to
action plan
- add to
action plan
- add to
action plan
Additional information and resources
Australian Charter of Healthcare Rights. Australian Commission on Safety and Quality in Health Care: http://www.health.gov.au/internet/safety/publishing.nsf/content/compubs_ACHR
National Safety and Quality Framework. Australian Commission on Safety and Quality in Health Care: www.safetyandquality.gov.au
Open Disclosure Standard: A National Standard for Open Communication in Public and Private Hospitals, following an Adverse Event in Health Care. Australian Council for
Safety and Quality in Health Care, 2005: http://www.health.gov.au/internet/safety/publishing.nsf/Content/C3D94BA657FEE027CA2573E00000B3FA/$File/opendisclfact.pdf
Standard for Credentialing and Defining the Scope of Clinical Practice for Medical Practitioners. Australian Council for Safety and Quality in Health Care:
http://www.health.gov.au/internet/safety/publishing.nsf/Content/a-zpublicationss-u/$File/credentl.pdf
Australian Commission on Safety and Quality in Health Care
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Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
Standard 2: Partnering with Consumers
Leaders of a health service organisation implement systems to support partnering with patients, carers and other consumers to improve the safety
and quality of care. Patients, carers, consumers, clinicians and other members of the workforce use the systems for partnering with consumers.
The intention of this Standard is to:
Create a health service that is responsive to patient, carer and consumer input and needs.
Context
This Standard provides the framework for active partnership with consumers by health service organisations. It is expected that this Standard will
apply in conjunction with Standard 1, ‘Governance for Safety and Quality in Health Service Organisations’, in the implementation of all other
Standards.
Criteria to achieve the Partnering with Consumers Standard:
Consumer partnership in service planning
Consumer partnership in designing care
Consumer partnership in service measurement and evaluation
Australian Commission on Safety and Quality in Health Care
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Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
Criterion: Consumer partnership in service planning
Governance structures are in place to form partnerships with consumers and/or carers.
C/D
D
This criterion will be
achieved by:
Actions required
2.1 Establishing
governance structures
to facilitate
partnership with
consumers and/or
carers
2.1.1 Consumers and/or
carers are involved in the
governance of the health
service organisation
Examples of evidence that can be used to demonstrate an action is being met.
This is not a checklist. Use only those examples that show that you have met the
Standards





Policies, procedures and/or protocols on how to engage consumers and carers in
the governance of the health service organisations are in place
Consumers and carers are represented and supported on boards and/or
committees
Mechanisms used to engage consumer representatives of the local community are
reflected in policy, committee terms of reference and position descriptions
Financial and physical resources are available to support consumer participation
and input at the governance level
Agenda papers, meeting minutes and/or reports of relevant committee(s) show
consumer involvement in governance activities
Self
Assessment
- add to
action plan
(i) Clinical leaders and senior managers will need to draw on a wide range of sources and types of
information when involving consumers in the health service organisation’s processes – formal and informal,
real-time and periodic, quantitative and qualitative, ad hoc and systematic. The key to maximizing the
benefits of consumer input is to triangulate various sources of intelligence.
D
2.1.2 Governance
partnerships are reflective
of the diverse range of
backgrounds in the
population served by the
health service organisation,
including those people that
do not usually provide
feedback
Australian Commission on Safety and Quality in Health Care



Demographic profile of the organisation
Consumer representatives reflect the population profile of the health service
Consumer representation in governance activities reflects diverse population
serviced by health care organisation
- add to
action plan
(i) Consumer engagement strategies should address the diversity in the population service by the health
service organisation . Strategies may include:

mechanisms such as meetings, conferences, forums, working groups, surveys, interviews and morning
tea) to ensure that input is provided by a range of consumers and community members

formal and informal mechanisms to engage consumers in the short and long term

interpreters or advocates for people with special needs

activities that recognise and engage with members of the community who may find it difficult to
participate in traditional governance structures including elderly people, people with disabilities, youth,
the homeless, traumatised individuals, people who as individuals or communities have had previous
negative experiences with health services, for example refugees, some Aboriginal people, Holocaust
survivors.
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Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
C/D
C
C
D
C
This criterion will be
achieved by:
Actions required
2.2 Implementing
policies, procedures
and/or protocols for
partnering with
patients, carers and
consumers in:

strategic and
operational/servic
es planning

decision making
about safety and
quality initiatives

quality
improvement
activities
2.2.1 The health service
organisation establishes
mechanisms for engaging
consumers and/or carers in
the strategic and/or
operational planning for the
organisation
2.3 Facilitating access
to relevant orientation
and training for
consumers and/or
carers partnering with
the organisation
2.3.1 Health service
organisations provide
orientation and ongoing
training for consumers
and/or carers to enable
them to fulfil their
partnership role
2.4 Consulting
consumers on patient
information distributed
by the organisation
2.4.1 Consumers and/or
carers provide feedback on
patient information
publications prepared by
the health service
organisation (for distribution
to patients)
Examples of evidence that can be used to demonstrate an action is being met.
This is not a checklist. Use only those examples that show that you have met the
Standards
2.2.2 Consumers and/or
carers are actively involved
in decision making about
safety and quality
Australian Commission on Safety and Quality in Health Care






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
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

Policies, procedures and/or protocols on involving patients, carers and consumers
in organisational decision making
Documentation and records of processes used to establish a representative body
of patients, carers and consumers who provide input into strategic and/or
operational planning.
Agendas, meeting minutes and/or reports of the relevant committee(s) that show
input form consumers and/or carers into strategic or operational planning
Consultation strategies and reports detailing involvement of consumers in decision
making
Policies, procedures and/or protocols on involving patients, carers and consumers
in organisational decision making about safety and quality
Agendas, meeting minutes and reports of relevant committee meetings reflect
consumer involvement in decision making about safety and quality
Consultation strategies and reports detailing involvement of consumers in decision
making
Information brochure for consumer representatives (which outlines roles and
responsibilities, key policies and so on)
Orientation and ongoing training resources for consumers and/or carers
Records of attendance at training by patients, carers and consumers at training
Consumer evaluation reports of orientation or training sessions
(i) Patients’ or consumers’, and carers’ training may include:

orientation to the service

consumer mentoring

consumer buddy system (consumer to consumer)

briefing and debriefing

science and advocacy training

Reports describe patient, carer and consumer feedback sought and where
feedback has been utilised

Reports of focus groups including consumer input into the identification of barriers
to health information
28
Self
Assessment
- add to
action plan
- add to
action plan
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C/D
C
This criterion will be
achieved by:
Actions required
Examples of evidence that can be used to demonstrate an action is being met.
This is not a checklist. Use only those examples that show that you have met the
Standards
2.4.2 Action is taken to
incorporate consumer
and/or carers’ feedback into
publications prepared by
the health service
organisation for distribution
to patients
Australian Commission on Safety and Quality in Health Care
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Reports describe patient, carer and consumer feedback sought and where
feedback has been utilised
Risk register or log that includes actions to address identified risks
Communication material developed for the workforce and/or patients
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Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
Criterion: Consumer partnership in designing care
Consumers and/or carers are supported by the health service organisation to actively participate in the improvement of the patient experience and
patient health outcomes.
C/D
D
C
D
This criterion will be
achieved by:
Actions required
2.5 Partnering with
consumers and/or carers
to design the way care is
delivered to better meet
patient needs and
preferences
2.5.1 Consumers and/or
carers participate in the
design and redesign of health
services
2.6 Implementing training
for clinical leaders, senior
management and the
workforce on the value of
and ways to facilitate
consumer engagement
and how to create and
sustain partnerships
2.6.1 Clinical leaders, senior
managers and the workforce
access training on patientcentred care and the
engagement of individuals in
their care
Examples of evidence that can be used to demonstrate an action is being met.
This is not a checklist. Use only those examples that show that you have met the
Standards
2.6.2 Consumers and/or
carers are involved in training
the clinical workforce
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Australian Commission on Safety and Quality in Health Care
Consultation strategies and reports that detail active participation and contribution
of patients, carers and consumer, and the modifications made as a result
Project planning and implementation reports detailing patient, carer and consumer
involvement
Programs incorporating or modified following consumer feedback
Ongoing training resources for clinical leaders, senior managers and the workforce
on patient-centred care
Attendance records for workforce training on patient-centred care
Evaluation reports of patient-centred care training program
Records of consumers and/or carers engaged in the development of training
content and material to the clinical workforce
Records of consumers and/or carers engaged in the delivery of training to the
clinical workforce
Record of input from consumers incorporated into training
Record of consumer and/or carer feedback from their participation in clinical
workforce training
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Assessment
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Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
Criterion: Consumer partnership in service measurement and evaluation
Consumers and/or carers receive information on the health service organisation’s performance and contribute to the ongoing monitoring,
measurement and evaluation of performance for continuous quality improvement.
C/D
C
D
D
D
This criterion will be
achieved by:
Actions required
2.7 Informing
consumers and/or
carers about the
organisation’s safety
and quality
performance in a
format that can be
understood and
interpreted
independently
2.7.1 The community and
consumers are provided
with information that is
meaningful and relevant to
the organisation’s safety
and quality performance
2.8 Consumers
and/or carers
participating in the
analysis of safety and
quality performance
information and data,
and the development
and implementation of
action plans
2.8.1 Consumers and/or
carers participate in the
analysis of organisational
safety and quality
performance
2.9 Consumers
and/or carers
participating in the
evaluation of patient
feedback data and
Examples of evidence that can be used to demonstrate an action is being met.
This is not a checklist. Use only those examples that show that you have met the
Standards
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2.8.2 Consumers and/or
carers participate in the
planning and
implementation of quality
improvements
2.9.1 Consumers and/or
carers participate in the
evaluation of patient
feedback data
Australian Commission on Safety and Quality in Health Care
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Agenda papers, meeting minutes and/or reports of relevant committees that involve
consumers in safety and quality projects
Feedback from patients, carers and consumers related to the organisations safety and
quality performance from sources such as surveys, complaints information, feedback
box or from consumers on committees
Annual report and/or newsletters detailing action taken to address identified safety and
quality issues
Safety and quality outcomes information provided to patients in areas such as patient
waiting areas
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Consultation strategies and reports detailing patient, carer and consumer involvement
Project plans and implementation reports detailing patient, carer and consumer
involvement.
Agenda papers, meeting minutes, and/or notes of meetings with patients
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Record of consumer involvement in safety and quality projects
Quality improvement plan includes actions to address issues identified
Examples of improvement activities that have been implemented and evaluated
Self
Assessment
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Agenda papers, meeting minutes and reports of relevant committees record actions
related to patient feedback
Record of consumer input into setting areas of priority and improvement strategies from
patient impression survey data
Consumer recommendations are included in agenda papers, meeting minutes and/or
reports of relevant committees
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C/D
D
This criterion will be
achieved by:
development of action
plans
Actions required
Examples of evidence that can be used to demonstrate an action is being met.
This is not a checklist. Use only those examples that show that you have met the
Standards
2.9.2 Consumers and/or
carers participate in the
implementation of quality
activities relating to patient
feedback data
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Record of consumer input into setting areas of priority and improvement strategies from
patient feedback data
Agenda papers, meeting minutes and reports of relevant committees record actions
related to patient feedback
Self
Assessment
- add to
action plan
Additional information and resources
The Australian Commission on Safety and Quality in Health Care Patient-centred care: Improving quality and safety through partnerships with patients and consumers
http://www.safetyandquality.gov.au/internet/safety/publishing.nsf/Content/PCCC
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Standard 3: Preventing and Controlling Healthcare Associated Infections
Clinical leaders and senior managers of a health service organisation implement systems to prevent and manage healthcare associated infections
and communicate these to all workforce to achieve appropriate outcomes. Clinicians and other members of the workforce use the healthcare
associated infection prevention and control systems.
The intention of this Standard is to:
Prevent patients from acquiring preventable healthcare associated infections and effectively manage infections when they occur by using evidencebased strategies.
Context
It is expected that this Standard will be applied in conjunction with Standard 1, ‘Governance for Safety and Quality in Health Service Organisations’
and Standard 2, ‘Partnering with Consumers’.
Criteria to achieve the Preventing and Controlling Healthcare Associated Infections Standard:
Governance and systems for infection prevention, control and surveillance
Infection prevention and control strategies
Managing patients with infections or colonisations
Antimicrobial stewardship
Cleaning, disinfection and sterilisation
Communicating with patients and carers
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Criterion: Governance and systems for infection prevention, control and surveillance
Effective governance and management systems for healthcare associated infections are implemented and maintained.
C/D
C
This criterion will be
achieved by:
3.1 Developing and
implementing
governance systems for
effective infection
prevention and control
to minimise the risks to
patients of health care
associated infections
Examples of evidence that can be used to demonstrate an action is being met.
Actions required
3.1.1 A risk management
approach is taken when
implementing policies,
procedures and/or protocols for:
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standard infection control
precautions
transmission-based
precautions
aseptic non-touch
technique
safe handling and disposal
of sharps
prevention and
management of
occupational exposure to
blood and body substances
environmental cleaning
and disinfection
antimicrobial prescribing
outbreaks or unusual
clusters of communicable
infection
processing of reusable
medical devices
single-use devices
surveillance and reporting
of data where relevant
reporting of communicable
and notifiable diseases
provision of risk
assessment guidelines to
workforce
exposure-prone
procedures
Australian Commission on Safety and Quality in Health Care
This is not a checklist. Use only those examples that show that you have met the
Standards
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Policies, procedures and/or protocols are in place for items listed in 3.1.1
Policies, procedures and/or protocols
o are based on best practice and identifying legislative requirements, including
Australian Guidelines for the Prevention and Control of Infections in Health
Care (NHMRC 2010) and/or additional jurisdictional protocols
o use nationally agreed definitions for healthcare associated infections (HAI)
o include the date the policy was implemented and scheduled review date
o provide links to relevant resource material
o incorporate amendments approved following incidence, national changes in
policy or policy review
o specify the mechanisms and tools for checking compliance with infection
control policies
A risk assessment tool, such as the AS/NZS 31000:2009 Risk Management
Standards is in use throughout the organisation
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C/D
This criterion will be
achieved by:
C
Examples of evidence that can be used to demonstrate an action is being met.
Actions required
3.1.2 The use of policies,
procedures and/or protocols is
regularly monitored.
This is not a checklist. Use only those examples that show that you have met the
Standards
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Infection control, clinical risk or other relevant committee terms of reference,
agenda papers, meeting minutes and/or reports
Organisational strategic plans that describe the mechanisms for identifying,
escalating and reviewing HAI risks and mechanisms for organisation
consultation
Register or report on review of infection risks or data for interventions to manage
HAI risks
Observational audits and/or reports from data systems
Self
assessment
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Link to Standard 1.2
C
3.1.3 The effectiveness of the
infection prevention and control
systems are regularly reviewed
at the highest level of
governance in the organisation
D
C
3.1.4 Action is taken to improve
the effectiveness of infection
prevention and control policies,
procedures and/or protocols
3.2 Undertaking
surveillance of
healthcare associated
infections
3.2.1 Surveillance systems for
healthcare associated
infections are in place
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Detail of strategies for improvement recorded in, for example, agenda papers,
meeting minutes and/or reports of relevant committees
Education resources and training attendance records
Infrastructure (such as hand basins), instruments (such as sterile packs), and
other equipment (such as solutions) necessary to comply with policy, protocol
and procedures available and accessible to the workforce
Risk register or log that includes actions to address identified risks
Agenda papers, meeting minutes and/or reports of relevant committee(s) that
detail improvement actions taken
Quality improvement plan includes actions to address issues identified
Examples of improvement activities that have been implemented and evaluated
Communication material developed for the workforce and/or patients
Data on healthcare associated infections for Staphylococcus aureus
bacteraemia from any sources that may include central-line associated blood
stream infections multi-resistant organisms, catheter-associated urinary tract
infection or other causes of high risk infection that is appropriate to the
organisation
Surveillance for infections on discharge for specified organisational surgical
procedures
Data collection forms or format
Clinical audits and action plans
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action plan
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action plan
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action plan
(i) Access to infection control personnel and/or microbiologists will differ between metropolitan and rural
areas. Metropolitan health service organisations will have infection control personnel and/or
microbiologists onsite whereas rural health service organisations may be required to access infection
control personnel and/or microbiologists off site, for example from a private pathology service, as a
Australian Commission on Safety and Quality in Health Care
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C/D
This criterion will be
achieved by:
Examples of evidence that can be used to demonstrate an action is being met.
Actions required
This is not a checklist. Use only those examples that show that you have met the
Standards
Self
assessment
resource
C
3.2.2 Healthcare associated
infections surveillance data are
regularly monitored by the
delegated workforce and/or
committees
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C
v
3.3 Developing and
implementing systems
and processes for
reporting, investigating
and analysing health
care associated
infections, and aligning
these systems to the
organisation’s risk
management strategy
3.3.1 Mechanisms to regularly
assess the healthcare
associated infection risks are in
place
3.3.2 Action is taken to reduce
the risks of healthcare
associated infections
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Australian Commission on Safety and Quality in Health Care
Relevant committee papers, including infection control, clinical risk or other
committees with delegated responsibilities for health care associated infection
surveillance
Reports to senior executive committees
Annual reports containing healthcare associated infections surveillance data
Regular reports to owners, regulators, insurers and health departments
Clinical workforce monitoring proformas, review schedules and audit records
Infection prevention plans and strategies, or equivalent documents that are
reviewed and regularly revised in consultation with relevant stakeholders such as
infection control personnel and infectious diseases physicians
Information generated from the surveillance system that may:
o shows trends in healthcare associated infections following improvement
actions
o provide benchmarked data on preventable healthcare associated infections
Guidelines, tools and supports, such as the Australian Guidelines for the
Prevention and Control of Infections in Health Care (NHMRC 2010) that are
accessible to the workforce responsible for assessing HAI risks
Records of healthcare associated infection incidents collected and analysed
Completed risk assessment documents
Terms of reference, agenda papers, meeting minutes and reports of relevant
committees
Current risk management plan and register
Accountabilities for acting on HAI in job descriptions
Description of action/s taken in forums and formats such as, presentations,
posters and reports
Risk register or log that includes actions to address identified risks
Agenda papers, meeting minutes and/or reports of relevant committee(s) that
detail improvement actions taken
Quality improvement plan includes actions to address issues identified
Examples of improvement activities that have been implemented and evaluated
Communication material developed for the workforce and/or patients
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C
C
D
This criterion will be
achieved by:
3.4 Undertaking quality
improvement activities
to reduce healthcare
associated infections
through changes to
practice
Examples of evidence that can be used to demonstrate an action is being met.
Actions required
3.4.1 Quality improvement
activities are implemented to
reduce and prevent healthcare
associated infections
3.4.2 Compliance with changes
in practice are monitored
3.4.3 The effectiveness of
changes to practice are
evaluated
Australian Commission on Safety and Quality in Health Care
This is not a checklist. Use only those examples that show that you have met the
Standards
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A continuous quality improvement plan that shows implementation, regular
review and revision
An amended register or log of implemented improvement activities and
outcomes
Risk register or log that includes actions to address identified risks
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Observational audits and/or reports from data systems
Usage rates of specified products and equipment
Data collected and monitored from pre and post change implementation
Data base of the workforce completion of in-service and other education on
practice changes
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Amended policies, procedures and/or protocols
Evaluation reports and follow up audits
Review of outcomes
Performance indicator trends demonstrating improvements
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Criterion: Infection prevention and control strategies
Strategies for the prevention and control of healthcare associated infections are developed and implemented.
C/D
C
This criterion will be
achieved by:
3.5 Developing,
implementing and
auditing a hand hygiene
program consistent with
the current national
hand hygiene initiative
Examples of evidence that can be used to demonstrate an action is being met.
Actions required
3.5.1 Workforce compliance
with current national hand
hygiene guidelines is
regularly audited
This is not a checklist. Use only those examples that show that you have met the
Standards
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C
3.5.2 Compliance rates from
hand hygiene audits are
regularly reported to the
highest level of governance
in the organisation
C
C
3.5.3 Action is taken to
address non-compliance, or
the inability to comply, with
the requirements of the
current national hand hygiene
guidelines
3.6 Developing,
implementing and
monitoring a risk-based
workforce immunisation
program in accordance
with the current National
Health and Medical
Research Council
Australian immunisation
guidelines
3.6.1 A workforce
immunisation program that
complies with current national
guidelines is in use
Australian Commission on Safety and Quality in Health Care
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Results of audited clinical environments against the 5 Moments for Hand Hygiene
audit tool
Observational audits of hand hygiene
Audits of the amounts of hand hygiene products used
Records of completed hand hygiene education and training consistent with
guidelines such as the Australian Guidelines for the Prevention and Control of
Infections in Health Care (NHMRC 2010)
Analysis of trends in healthcare associated infection rates in the organisation
Hand hygiene plan endorsed by management
Business plan to resource hand hygiene project
Agenda papers, meeting minutes and/or reports for the senior executive and/or
committees or equivalent
Medical advisory committee agenda papers, meeting minutes and/or reports that
include hand hygiene compliance rates
Agenda papers, meeting minutes and/or reports of relevant committees that
include details of hand hygiene strategies and actions
Risk assessment that identifies reasons for hand hygiene non-compliance and
actions
Amended procedures, protocols or work practices that address issues of hand
hygiene non-compliance
Records of education and training on hand hygiene
Review of equipment, supplies and products required to comply with hand hygiene
requirements
Agenda papers, meeting minutes and/or reports of relevant committees
Policies, procedures and/or protocols that are consistent with national guidelines
and jurisdictional legislation and policy directives on immunisation
Register, report or review of vaccinations’ availability and correct storage of
vaccine such as the ‘cold chain’ system
Documents accessible to authorised personnel that:
o identify healthcare workers’ immunisation status at commencement of
employment and throughout their period of employment
o identify subsequent additional vaccination requirements for healthcare workers
o record immunisation refusals and organisational responses to refusals
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C/D
This criterion will be
achieved by:
Examples of evidence that can be used to demonstrate an action is being met.
Actions required
This is not a checklist. Use only those examples that show that you have met the
Standards
Self
assessment
(i) Some health care organisations may outsource their immunisation requirements
C
3.7 Promoting
collaboration with
occupational health and
safety programs to
decrease the risk of
infection or injury to
healthcare workers
3.7.1 Infection prevention and
control consultation related to
occupational health and
safety policies, procedures
and/or protocols are
implemented to address:
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C
3.8 Developing and
implementing a system
for use and
management of
invasive devices based
on the current national
guidelines for
preventing and
controlling infections in
health care
communicable disease
status
occupational
management and
prophylaxis
work restrictions
personal protective
equipment
assessment of risk to
healthcare workers for
occupational allergy
evaluation of new
products and procedures
3.8.1 Compliance with the
system for the use and
management of invasive
devices is monitored
Australian Commission on Safety and Quality in Health Care
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Policies, procedures and/or protocols for the management of occupational
exposures
Policies, procedures and/or protocols that address vaccination refusal
Risk assessments for healthcare workers undertaking exposure prone procedures
Occupational exposure data assessed prior to the introduction of safety devices
and equipment that minimises the risks to healthcare workers and patients
Assessments of skin conditions related to dermatitis or allergy to personal
protective equipment, skin antiseptics or hand hygiene products
Audits of healthcare workers who have completed competency assessments in the
use of personal protective equipment such as gloves, gowns, plastic aprons, face
shields, protective eye wear and masks
Information from monitoring healthcare workers infected or colonised with an
infectious agent
Audits of usage of personal protective equipment
Documented health worker vaccination program consistent with current Australian
immunisation guidelines
Policies, procedures and protocols based on evidence-based guidelines and the
Australian Guidelines for the Prevention and Control of Infections in Health Care
(NHMRC 2010)
Policies, procedures and/or protocols which include a strict single use policy
Infection control, clinical risk or other relevant committee terms of reference,
agenda papers, meeting minutes and/or reports
Organisational strategic plan that identifies, escalates and reviews the risks of
invasive devices and has included consultation across the organisation
Register or reports on invasive device risks and/or interventions to manage these
risks
Observational and clinical audit tools and/or data collection systems
Observational audits on the integrity of critical instruments storage and packaging
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C/D
C
C
This criterion will be
achieved by:
3.9 Implementing
protocols for invasive
device procedures
regularly performed
within the organisation
3.10 Developing and
implementing protocols
for aseptic non-touch
technique
Examples of evidence that can be used to demonstrate an action is being met.
Actions required
3.9.1 Education and
competency-based training in
invasive devices protocols
and use is provided for the
workforce who perform
procedures with invasive
devices
3.10.1 The clinical workforce
is trained in aseptic nontouch technique
This is not a checklist. Use only those examples that show that you have met the
Standards
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C
3.10.2 Compliance with
aseptic non-touch technique
is regularly audited
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3.10.3 Action is taken to
increase compliance with the
aseptic non-touch technique
protocols
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Australian Commission on Safety and Quality in Health Care
Orientation and induction programs on use of invasive devices
Records detailing the numbers or percentage of the workforce who have
undertaken education and training related to the use of invasive devices
Education materials related to use of invasive devices
Education plans for ongoing education and training of the workforce who perform
procedures with invasive devices
Evaluations of education and competency-based training needs
Orientation program resources and training attendance records relating to aseptic
non-touch technique
Education resources and attendance records, and learning packages related to
aseptic non-touch technique
Records detailing the numbers or percentage of the workforce who have
undertaken education and training related to aseptic non-touch technique
Plans for ongoing education and training of the workforce who perform procedures
requiring aseptic non-touch technique
Evaluations of education and competency-based training needs
Policies, procedures and protocols on aseptic non-touch techniques consistent with
relevant policies and guidelines, including the Australian Guidelines for the
Prevention and Control of Infections in Health Care (NHMRC 2010)
Infection control, clinical risk or other relevant committee terms of reference,
agenda papers, meeting minutes and/or reports
Organisational plans or reports detailing routine measures to audit compliance
Register or reports on reviews of aseptic non-touch technique across the
organisation
Observational audits and/or reports from data systems
Educational resources and training attendance records relating to aseptic nontouch techniques
Audits of accessibility of infrastructure, instruments and other equipment necessary
to comply with policies, procedures and/or protocol
Risk register or log that includes actions to address identified risks
Agenda papers, meeting minutes and/or reports of relevant committee(s) that detail
improvement actions taken
Quality improvement plan includes actions to address issues identified
Examples of improvement activities that have been implemented and evaluated
Communication material developed for the workforce and/or patients
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assessment
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Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
C/D
This criterion will be
achieved by:
Examples of evidence that can be used to demonstrate an action is being met.
Actions required
This is not a checklist. Use only those examples that show that you have met the
Standards
Self
assessment
(i) Additional information on aseptic non-touch technique (ANTT) is found in the NHMRC guidelines,
section B1.7.2:
http://www.nhmrc.gov.au/_files_nhmrc/file/publications/synopses/CD33_InfectionControlGuidelines2010.pdf
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Criterion: Managing patients with infections or colonisations
Patients presenting with, or acquiring an infection or colonisation during their care are identified promptly and receive the necessary management
and treatment.
C/D
This criterion will be
achieved by:
C
3.11 Implementing
systems for using
standard precautions
and transmissionbased precautions
Examples of evidence that can be used to demonstrate an action is being met.
Actions required
3.11.1 Standard
precautions and
transmission-based
precautions consistent
with the current national
guidelines are in use
This is not a checklist. Use only those examples that show that you have met the
Standards
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C
3.11.2 Compliance with
standard precautions is
monitored
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C
C
3.11.3 Action is taken to
improve compliance with
standard precautions
3.11.4 Compliance with
transmission-based
precautions is monitored
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Australian Commission on Safety and Quality in Health Care
Policies, procedures and protocols based on current national guidelines, including
the Australian Guidelines for the Prevention and Control of Infections in Health Care
(NHMRC 2010)
Observational audits of workplace practices, for example, environmental and hand
hygiene practices, and personal protection equipment usage
Education resources and training attendance records on systems for using standard
precautions and transmission- based precautions
Observation of accessible personal protective equipment
Standard and transmission based precaution signage available and accessible to the
health workforce
Infection control, clinical risk or other relevant committee terms of reference, agenda
papers, meeting minutes and/or reports
Organisational strategic plans that review compliance and include consultation
across the organisation
Register or reports on review of compliance with standard precautions
Observational audits and/or reports from data systems and surveillance programs
Risk register or log that includes actions to address identified risks
Agenda papers, meeting minutes and/or reports of relevant committee(s) that detail
improvement actions taken
Quality improvement plan includes actions to address issues identified
Examples of improvement activities that have been implemented and evaluated
Communication material developed for the workforce and/or patients
Provision of infrastructure, instruments, and other equipment necessary to comply
with policies, procedures and/or protocols
Infection control, clinical risk or other relevant committee terms of reference, agenda
papers, meeting minutes and/or reports
Organisational strategic plans that review compliance that has included consultation
across the organisation
Register or reports on review of compliance with transmission-based precautions
Observational audits and/or reports from data systems
Education resources and training attendance records associated with transmissionbased precautions
42
Self
assessment
- add to
action plan
- add to
action plan
- add to
action plan
- add to
action plan
Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
C/D
This criterion will be
achieved by:
C
D
Examples of evidence that can be used to demonstrate an action is being met.
Actions required
3.11.5 Action is taken to
improve compliance with
transmission-based
precautions
3.12 Assessing the
need for patient
placement based on the
risk of infection
transmission
3.12.1 A risk analysis is
undertaken to consider
the need for
transmission-based
precautions including:





C
3.13 Developing and
implementing protocols
relating to the
admission, receipt and
transfer of patients with
an infection
accommodation
based on the means
of transmission
environmental
controls through air
flow
transportation within
and outside the
facility
cleaning procedures
equipment
requirements
3.13.1 Mechanisms are
in use for checking for
pre-existing healthcare
associated infection or
communicable disease
on presentation for care
Australian Commission on Safety and Quality in Health Care
This is not a checklist. Use only those examples that show that you have met the
Standards

Self
assessment
Same evidence options as 3.11.3
- add to
action plan












Policies procedures and protocols based on risk assessment, analysis and risk
management processes
Risk assessment reports, register or log
Laboratory-based data reports
Patient clinical records and case notes
Infection control, clinical risk or other relevant committee terms of reference, agenda
papers, meeting minutes and/or reports
Audits of risk assessment practices against guidelines and policies
Policies, procedures and/or protocols addressing identification of pre-existing
healthcare associated infection or communicable disease
Infection control, clinical risk or other relevant committee terms of reference, agenda
papers, meeting minutes and/or reports
Policies, procedures and/or protocols addressing receipt and transfer of patients with
infections
Audits of patient histories
Number of requests for medical records of previous admissions
Audits of screening for healthcare associated infections or communicable diseases in
accordance with local/state screening policies
43
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action plan
- add to
action plan
Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
C/D
This criterion will be
achieved by:
C
Examples of evidence that can be used to demonstrate an action is being met.
Actions required
3.13.2 A process for
communicating a
patient’s infectious status
is in place whenever
responsibility for care is
transferred between
service providers or
facilities
Australian Commission on Safety and Quality in Health Care
This is not a checklist. Use only those examples that show that you have met the
Standards




Policies, procedures and/or protocols related to transfer of care
Handover sheets, discharge forms or similar documents stating infectious status
Electronic flagging of medical notes and discharge summaries
Transfer policy and transfer form
44
Self
assessment
- add to
action plan
Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
Criterion: Antimicrobial stewardship
Safe and appropriate antimicrobial prescribing is a strategic goal of the clinical governance system.
C/D
This criterion will be
achieved by:
C
3.14 Developing,
implementing and regularly
reviewing the effectiveness
of the antimicrobial
stewardship system
Examples of evidence that can be used to demonstrate an action is being met.
Actions required
3.14.1 An antimicrobial
stewardship program is in
place
This is not a checklist. Use only those examples that show that you have met the
Standards






C
C
3.14.2 The clinical
workforce prescribing
antimicrobials have
access to current
endorsed therapeutic
guidelines on antibiotic
usage
3.14.3 Monitoring of
antimicrobial usage and
resistance is undertaken
Australian Commission on Safety and Quality in Health Care


Organisation-wide antimicrobial prescribing policies, guidelines and tools that are
consistent with guidelines such as Therapeutic Guidelines: Antibiotic
Agenda papers, meeting minutes and/or reports of relevant committees
Reports and recommendations from a antimicrobial management team
Educational resources and training attendance records associated with addressing
antimicrobial usage, development of resistance, and judicious prescribing
Audits of antimicrobial usage, particularly in high antimicrobial usage areas
Restriction, approval or review systems to guide the use of broad spectrum
antimicrobials
Referral to specialist infection disease practitioner and/or microbiologist
Access by clinical workforce prescribing antimicrobials to current endorsed
therapeutic guidelines on antibiotic usage (Therapeutic Guidelines: Antibiotic)
Self
assessment
- add to
action plan
- add to
action plan

Prescribing guidelines, policies procedures and/or protocols

Agenda papers, meeting minutes and reports of relevant committees

Medication audits

Records of antibiotic consumption

Reviews of antibiotic usage and feedback to prescribers

Laboratory-based data including analysis of antimicrobial resistance
(i) This may not be applicable for some day surgeries. Examples may include:

specialist proceduralist scope of practice

laboratory surveillance and antimicrobial medication resistance

prescribing behaviour practices and prescribing guidelines

standing orders for antimicrobial medication and prescribing
45
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action plan
Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
C/D
This criterion will be
achieved by:
C
Examples of evidence that can be used to demonstrate an action is being met.
Actions required
3.14.4 Action is taken to
improve the effectiveness
of antimicrobial
stewardship
Australian Commission on Safety and Quality in Health Care
This is not a checklist. Use only those examples that show that you have met the
Standards

Self
assessment
Same evidence options as 3.11.3
- add to
action plan
46
Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
Criterion: Cleaning, disinfection and sterilisation
Healthcare facilities and the associated environment are clean and hygienic. Reprocessing of equipment and instrumentation meets current best
practice guidelines.
C/D
C
Examples of evidence that can be used to demonstrate an action is being met.
This criterion will be
achieved by:
Actions required
3.15 Using risk
management principles
to implement systems
that maintain a clean
and hygienic
environment for patients
and healthcare workers
3.15.1 Policies, procedures
and/or protocols for
environmental cleaning that
address the principles of
infection prevention and
control are implemented,
including:






C
maintenance of building
facilities
cleaning resources and
services
risk assessment for
cleaning and disinfection
based on transmissionbased precautions and
the infectious agent
involved
waste management
within the clinical
environment
laundry/linen
transportation cleaning
and storage
appropriate use of
personal protective
equipment
3.15.2 Policies, procedures
and/or protocols for
environmental cleaning are
regularly reviewed
Australian Commission on Safety and Quality in Health Care
This is not a checklist. Use only those examples that show that you have met the
Standards













Environmental cleaning policies, procedures and protocols consistent with current
guidelines such as the Australian Guidelines for the Prevention and Control of
Infections in Health Care (NHMRC 2010)
Maintenance schedules for infrastructure
Cleaning schedules
Risk assessments
Audits of the collection, transport and storage of linen
Waste management plan
Material safety data sheets or chemical register of cleaning resources utilised
Observational audits of the use of personal protection equipment
Service schedules for infection prevention and control equipment
Documentation and/or data related to routine review of policies, procedures and
protocols may include:
Agenda papers, meeting minutes and/or reports of relevant committees
Completed reviews
Schedule of reviews
47
Self
assessment
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action plan
- add to
action plan
Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
C/D
This criterion will be
achieved by:
C
D
C
C
Examples of evidence that can be used to demonstrate an action is being met.
Actions required
3.15.3 An established
environmental cleaning
schedule is in place and
environmental cleaning
audits are undertaken
regularly
3.16 Reprocessing
reusable medical
equipment, instruments
and devices in
accordance with
relevant national or
international standards
and manufacturers’
instructions
3.16.1 Compliance with
relevant national or
international standards and
manufacturer’s instructions
for cleaning, disinfection and
sterilisation of reusable
instruments and devices is
regularly monitored
3.17 Implementing
systems to enable the
identification of patients
on whom the reusable
medical devices have
been used
3.17.1 A traceability system
that identifies patients who
have a procedure using
sterile reusable medical
instruments and devices is in
place
3.18 Ensuring workforce
who decontaminate
reusable medical
devices undertake
competency-based
training in these
practices
3.18.1 Action is taken to
maximise coverage of the
relevant workforce trained in
a competency-based
program to decontaminate
reusable medical devices
Australian Commission on Safety and Quality in Health Care
This is not a checklist. Use only those examples that show that you have met the
Standards




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






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
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




Cleaning schedules that are consistent with current guidelines such as the
Australian Guidelines for the Prevention and Control of Infections in Health Care
(NHMRC 2010)
Agenda papers, meeting minutes and/or reports of relevant committees
Environmental cleaning audit results
Work instructions and job descriptions
Audits of compliance with cleaning schedule
Agenda papers, meeting minutes and/or reports of relevant committees
Records of sterilisation verifying reprocessing is consistent with legislation
Maintenance schedules for sterilising equipment
Audits of monitoring systems for sterilisers
Risk assessments where there are deviations in the requirements of relevant
standards and the manufacturer’s instructions
Observational audits of cleaning, disinfection and sterilisation processes
Audit results for sterile stock integrity and supply
Agenda papers, meeting minutes and/or reports of relevant committees
Register or record of patients who have, or have had, procedures using reusable
instruments and devices
Audits of medical records (patient clinical records and case notes or records
regarding the use of reusable medical instruments and devices)
Agenda papers, meeting minutes and/or reports of relevant committees that detail
improvement actions
Education and training outlines or materials and attendance data
Schedule of competency based training and targets
Numbers or proportion of workforce who has completed orientation programs and
ongoing education and training
Relevant current standards and guidelines such as the Australian Guidelines for
the Prevention and Control of Infections in Health Care (NHMRC 2010) are
accessible to the relevant workforce
48
Self
assessment
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action plan
- add to
action plan
- add to
action plan
- add to
action plan
Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
Criterion: Communicating with patients and carers
Information on healthcare associated infections is provided to patients, carers, consumers and service providers.
C/D
C
Examples of evidence that can be used to demonstrate an action is being met.
This criterion will be
achieved by:
Actions required
3.19 Ensuring
consumer specific
information on the
management and
reduction of healthcare
associated infections is
available at the point of
care
3.19.1 Information on the
organisation’s corporate
and clinical infection risks
and initiatives
implemented to minimise
patient infection risks is
provided to patients
and/or carers
This is not a checklist. Use only those examples that show that you have met the
Standards








Communication materials used for patient education
Patient education materials translated into languages other than English
Risk alert information and materials provided to patients and their carers, for example
respiratory precautions
Public health risk alert material placed on public display in areas such as reception
and waiting areas
Publication of information on infection rates and risks that are accessible to the public
Web site information available to the public
Information provided to visiting medical specialist for distribution to patients
Information included in pre-admission information dedicated to infection control
practices
Self
assessment
- add to
action plan
(i) National Health and Medical Research Council (NHMRC) has an example of consumer fact sheets at:
www.nhmrc.gov.au
D
3.19.2 Patient infection
prevention and control
information is evaluated to
determine if it meets the
needs of the target
audience





Results of patient satisfaction survey on patient infection prevention and control
information
Documented comments and complaints received from patients and carers
Reports on the evaluation of patient information
Terms of reference, agenda papers, meeting minutes and reports of relevant
committees
Consumer representation on relevant focus groups, committees or working parties
- add to
action plan
Additional information and resources
Healthcare Associated Infection (HAI) Program, Commission on Safety and Quality in Health Care (ACSQHC)
http://www.safetyandquality.gov.au/internet/safety/publishing.nsf/Content/PriorityProgram-03
Additional information in relation to Hand Hygiene may be found on the Hand Hygiene Australia website: www.hha.org.au
National Health and Medical Research Council, Australian Guidelines for the Prevention and Control of Infections in Health Care. NHMRC, 2010: www.nhmrc.gov.au
National Health and Medical Research Council, Australian Guidelines for the Prevention and Control of Infection in Healthcare, Consultation Draft, 7January
2010:.www.nhmrc.gov.au
Therapeutic Guidelines: Antibiotic is located by the following link: www.tga.org.au
Cleaning schedules guidelines are found in: Australian Guidelines for the Prevention and Control of Infections in Health Care: Section B5.1 (NHMRC) 2010. www.nhmrc.gov.au
Australian Commission on Safety and Quality in Health Care
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Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
Standard 4: Medication Safety
Clinical leaders and senior managers of a health service organisation implement systems to reduce the occurrence of medication incidents, and
improve the safety and quality of medicine use. Clinicians and other members of the workforce use the systems to safely manage medicines.
The intention of this Standard is to:
Ensure competent clinicians safely prescribe, dispense and administer appropriate medicines to informed patients and carers.
Context
It is expected that this Standard will be applied in conjunction with Standard 1 ‘Governance for Safety and Quality in Health Service Organisations’
and Standard 2 ‘Partnering with Consumers’.
Criteria to achieve the Medication Safety Standard:
Governance and systems for medication safety
Documentation of patient information
Medication management processes
Continuity of medication management
Australian Commission on Safety and Quality in Health Care
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Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
Criterion: Governance and systems for medication safety
Health service organisations have mechanisms for the safe prescribing, dispensing, supplying, administering, storing, manufacturing,
compounding and monitoring of the effects of medicines.
C/D
C
C
This criterion will be
achieved by:
Actions required
4.1 Developing and
implementing governance
arrangements and
organisational policies,
procedures and/or
protocols for medication
safety, which are
consistent with national
and jurisdictional
legislative requirements,
policies and guidelines
4.1.1 Governance
arrangements are in place to
support the development,
implementation and
maintenance of
organisation-wide
medication safety systems
Examples of evidence that can be used to demonstrate an action is being met.
This is not a checklist. Use only those examples that show that you have met the
Standards
4.1.2 Policies, procedures
and/or protocols are in place
that are consistent with
legislative requirements,
national, jurisdictional and
professional guidelines
Australian Commission on Safety and Quality in Health Care
 Policies, procedures, protocols and/or guidelines for safe management and quality
use of medicines
 Agenda papers, meeting minutes and/or reports of relevant committee(s) such as
management committee or governance committee
 Strategic and operational plans detaining the development, implementation and
maintenance of organisational wide medication safety systems
 Responsibility organisation wide medication safety systems at all levels of the
organisation designated for board or owners, senior executive or senior
managers, unit or facility managers and clinicians
 Information used to identify patient safety and quality medication risks
 Quality improvement plan outlines designated responsibilities and timeframes for
completion of improvement actions
 Orientation and ongoing training resources for the workforce on their roles,
responsibilities and accountabilities for the medication management system
 Records of attendance at training by the workforce on the medication
management systems and medication safety
 A mechanism for dissemination of medication safety alerts
 Observational audit of the workforce access to online and hard copy resources
such as MIMS, therapeutic guidelines, pharmacy manual and guidelines for
administration of injectable medicines
Link to Standard 1

Policies, procedures, protocols and/or guidelines related to safe management
and quality use of medicines

Policies, procedures, protocols and/or guidelines are accessible to the clinical
workforce, managers and the senior executive

Actions taken to implement policies, procedures and/or protocols throughout the
organisation such as distribution list for policies, procedures and/or protocols

Observational audit of the accessibility and use of policy documents by the
workforce

Audits of compliance with medication management policies
51
Self
assessment
- add to
action plan
- add to
action plan
Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
C/D
This criterion will be
achieved by:
Actions required
Examples of evidence that can be used to demonstrate an action is being met.
This is not a checklist. Use only those examples that show that you have met the
Standards
Self
assessment
Link to Standards 1.1.1, 1.3.1 and 1.3.2
(i) The policy framework for medication management should apply across the whole organisation and
cover the steps and process and medication management cycles outlined in the Australian
Pharmaceutical Advisory Council’s Guiding Principles to achieve continuity in medication management.
Examples of subject areas could include (but are not limited to):

governance arrangements for the medication management system including the evaluation and
introduction of new medicines

roles, responsibilities and accountabilities for clinical and organisational medication management
activities

procedures for safe prescribing, dispensing, supplying, administering, storing, manufacturing,
compounding and monitoring of the effects of medicines

procedures for managing high risk medicines including a list of high risk or alert medicines

procedures for labelling injectable medicines, fluids and lines

list of approved abbreviations used in prescribing and administering of medicines

list of medicine approved for use in the facility

procedure for procuring medicines

procedures for reporting medication incidents and adverse drug reactions

orientation and ongoing training requirements for all clinical the workforce medication management
system and medication safety

evaluation, audit and feedback
Australian Commission on Safety and Quality in Health Care
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Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
C/D
C
This criterion will be
achieved by:
Actions required
4.2 Undertaking a regular,
comprehensive
assessment of medication
use systems to identify
risks to patient safety and
implementing system
changes to address the
identified risks
4.2.1 The medication
management system is
regularly assessed
Examples of evidence that can be used to demonstrate an action is being met.
This is not a checklist. Use only those examples that show that you have met the
Standards
Self
assessment

Completed risk assessments of:
o systems for managing medicines in the organisation
o processes for handling high risk medicines and’ action plans

Separate risk assessments, registers and/or action plans completed for each unit
or service area

Audits of compliance with policies, procedures and/or protocols on medication
management systems
 Risk register or log that includes actions to address identified risks

Data from the incident reporting system

Agenda papers, meeting minutes and/or reports of relevant committee(s) such
as drug and therapeutics committee, clinical governance committee or senior
executive committee that include medication incident reports

Safety and quality presentations delivered to the executive and/or management
committees

Reports on the implementation of recommendations from National and State or
Territory medication safety alerts
Link to Standard 4.4.1
- add to
action plan
(i) Risk assessment tools may include:

self assessment tools such as the Self Assessment of Medication Safety in Australian Hospitals, Self
Assessment of Antithrombotic Therapy in Australian Hospitals

Failure Mode Effect and Analysis procedure to identify risks when implementing practice changes,
systems redesign

audits in areas where there is a risk to patient safety such as: prescribing, dispensing and
administration of chemotherapy and other high risk medications
C
4.2.2 Action is taken to
reduce the risks identified in
the medication management
system
Australian Commission on Safety and Quality in Health Care





Risk register or log that includes actions to address identified risks
Agenda papers, meeting minutes and/or reports of relevant committee(s) that
detail improvement actions taken
Quality improvement plan includes actions to address issues identified
Examples of improvement activities that have been implemented and evaluated
Communication material developed for the workforce and/or patients such as
memos and patient information leaflets
53
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action plan
Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
C/D
C
C
C
This criterion will be
achieved by:
Actions required
4.3 Authorising the
relevant clinical workforce
to prescribe, dispense and
administer medications
4.3.1 A system is in place to
verify that the clinical
workforce have medication
authorities appropriate to
their scope of practice
Examples of evidence that can be used to demonstrate an action is being met.
This is not a checklist. Use only those examples that show that you have met the
Standards
4.3.2 The use of the
medications authorisation
system is regularly
monitored
4.3.3 Action is taken to
increase the effectiveness of
the medication authority
system
Australian Commission on Safety and Quality in Health Care
Self
assessment
 Policies, procedures and/or protocols detailing roles responsibilities and
accountabilities of clinical workforce for medication management processes
 Delegations detaining clinic positions that have the authority to prescribe dispense
or administer medicines
- add to
 A list of individual workforce members with authority to prescribe medicines
action plan
 Position descriptions detailing responsibilities, accountabilities and scope of
practice of the workforce in medication management
 Orientation and ongoing training resources for the clinical workforce who
prescribe, dispense and administer medications
 Record of attendance at training by the clinical workforce on the medication
system
(i) Policy, procedures and/or protocols for authorising clinical workforce to prescribe, dispense and
administer medicines could include:
 prescribing policy
 medicines that enrolled nurses may administer and conditions on their practice.
 standing orders for registered nurses to administer medicines
 list of nurse initiated medicines
 attendance at orientation and ongoing training sessions on the facility’s medication management
system and safe medication management
 Audits verifying that practitioners prescribing, supplying and administering
medicines are authorised to do so.
 Regular audits of schedule 8 registers
 Agenda papers, meeting minutes and/or reports of relevant committee(s)
- add to
reporting on the analysis of medication incidents
action plan
 Same evidence options as 4.2.2
- add to
action plan
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Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
C/D
C
This criterion will be
achieved by:
Actions required
4.4 Using a robust
organisation-wide system
of reporting, investigating
and managing change to
respond to medication
incidents
4.4.1 Medication incidents
are regularly monitored,
reported and investigated
C
Examples of evidence that can be used to demonstrate an action is being met.
This is not a checklist. Use only those examples that show that you have met the
Standards
4.4.2 Action is taken to
reduce the risk of adverse
medication incidents
 Policies, procedures and/or protocols for reporting and managing medication
incidents and adverse medication incidents
 Incident reporting management system, such as a register or log, that documents
analysis and review of medication incidents
 Agenda papers, meetings minutes and/or reports that demonstrate adverse
medication incidents are routinely reviewed
 Documented adverse medication incidents investigated
 Reports of root cause analyses of medication errors resulting in patient harm
 Audits of patient clinical records and case notes that demonstrate reporting and
investigation of adverse medication incidents, for example using trigger tools to
identify adverse medicines events
 Audit of compliance with policies, procedures and/or protocols
Self
assessment
- add to
action plan
 Same evidence options as 4.2.2
- add to
action plan
C
C
4.5 Undertaking quality
improvement activities to
improve the safety of
medicines use
4.5.1 The performance of
the medication management
system is regularly assessed
4.5.2 Quality improvement
activities are undertaken to
reduce the risk of patient
harm and increase the
quality and effectiveness of
medicines use
Australian Commission on Safety and Quality in Health Care
 Results of activities such as monitoring quality use of medicines indicators and
other performance measures of medication safety.
 Regular (annual) auditing of the National Inpatient Medication Chart to monitor
standard of documentation of prescribing and administering of medicines.
 Agenda papers, meeting minutes or reports of relevant committees that show
reports of audits and/or results
- add to
action plan
(i) Performance measures for monitoring safety and quality of medicines use could include:
 drug use evaluation studies
 use of clinical indicators such as the Clinical Indicators for Quality Use of Medicines in Australian
Hospitals
 audit of National Inpatient Medication Chart using national audit tool
 Agenda papers, meeting minutes and/or reports of relevant committee(s) that
detail improvement actions taken
 Quality improvement plan includes actions to address issues identified
 Examples of improvement activities that have been implemented and evaluated
- add to
 Communication material developed for the workforce and/or patients regarding
action plan
changes implemented as result of medication safety audits
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Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
Criterion: Documentation of patient information
The clinical workforce accurately records a patient’s medication history and this history is available throughout the episode of care.
C/D
C
This criterion will be
achieved by:
Actions required
4.6 The clinical workforce
taking an accurate
medication history when a
patient presents to a
health service
organisation, or as early
as possible in the episode
of care, which is then
available at the point of
care
4.6.1 A best possible
medication history is
documented for each
patient
C
C
This is not a checklist. Use only those examples that show that you have met the
Standards
4.6.2 The medication
history and current clinical
information is available at
the point of care
4.7 The clinical workforce
documenting the patient’s
previously known adverse
drug reactions on initial
presentation and updating
this if an adverse reaction
to a medicine occurs
during the episode of care
Examples of evidence that can be used to demonstrate an action is being met.
4.7.1 Known medication
allergies and adverse drug
reactions are documented
in the patient clinical
record
Australian Commission on Safety and Quality in Health Care
Self
assessment
 Policies, procedures and/or protocols for obtaining and documenting a best possible
medication history including prescription, over the counter and complementary
medicines
 Admission form includes section for medication history
- add to
 Patient clinical records include medication history documentation and a record of
action plan
medicines the patient was taking prior to admission (including prescription, over the
counter and complementary medicines)
(i) Policy for obtaining and recording best possible medication history could include:
 roles and responsibilities for the clinical workforce
 medication risk assessment
 required documentation: specifying record content, how and where to document the medication history
 detail of previous adverse drug reaction
 Policies, procedures and/or protocols for accessing medication history on admission
and clinical information at the point of care
 Observation of patient clinical records accessible at point of patient care
- add to
action plan
Link to Standard 1.9.1
 Policies, procedures and/or protocols for documenting, managing and reporting
adverse drug reactions
 Policies, procedures and/or protocols for checking adverse drug reaction history prior
to prescribing, dispensing or administering medicines
- add to
 Audit of patient’s clinical records whose known adverse drug reactions are
action plan
documented on the current medication chart
 Audit of patient’s clinical records and case notes shows information on new adverse
drug reactions and allergies is recorded, such as completed adverse drug reaction
form, alert in record
 Audit of electronic medicines management systems for prescribing, dispensing and
administering medicines include adverse drug reaction alert systems
(i) Examples of performance measures for this action may include:
 Indicators from Clinical Indicators for Quality Use of Medicines in Australian Hospitals
 Results form audit of the National Inpatient Medication Chart Audit, for examples, the number of patients
administered a medication to which they have had an allergy or previous adverse drug reaction
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C/D
This criterion will be
achieved by:
C
4.7.3 Adverse drug
reactions are reported
within the organisation
and to the Therapeutic
Goods Administration
4.8 The clinical workforce
reviewing the patient’s
current medication orders
against their medication
history and prescriber’s
medication plan, and
reconciling any
discrepancies
Examples of evidence that can be used to demonstrate an action is being met.
This is not a checklist. Use only those examples that show that you have met the
Standards
4.7.2 Action is taken to
reduce the risk of adverse
reactions
C
D
Actions required
4.8.1 Current medicines
are documented and
reconciled at admission
and transfer of care
between healthcare
settings
 Policies, procedures and/or protocols for documenting, managing and reporting of
adverse drug reactions
 Record of the clinical workforce attending education on adverse drug reaction
documentation and reporting
 Audit of patient clinical records and case notes identifies patients who were
administered a medication to which they have had an allergy or previous adverse drug
reaction
 Audit of patient clinical record confirms the adverse drug reaction (ADR) information
was given to patients with a new ADR and that a copy was communicated to the
primary care clinician
 Register of adverse drug reactions includes actions to address the identified risks
 Review of the workforce feedback on adverse drug reactions
 Agenda papers, meeting minutes or reports of relevant committees includes reports on
adverse drug reactions
 Quality improvement plan includes actions to address issues identified
 Examples of improvement activities that have been implemented and evaluated such
as change to policy and/or procedure, feedback to the workforce
 Policies, procedures and/or protocols reporting adverse drug reactions within the
organisations and to the Therapeutic Goods Administration
 Agenda papers, meeting minutes and/or reports of relevant committee(s) include
actions taken to address adverse drug reaction risks
 Register of adverse drug reactions includes actions to address the identified risks
 Record of adverse drug reaction and/or reports submitted to Therapeutic Goods
Administration
 Policies, procedures and/or protocols on reconciling the medication orders with the
medication history on admission, transfer and discharge to another health setting
 Audit of patients’ clinical records in relation to current medicines reconciliation on
admission, transfer and/or discharge
 Audit of patient clinical records includes review of discharge prescriptions
Link to Standard 4.2.2, 4.6.1 and 4.12.4
(i) Examples of performance measures for this action may include:
 Indicators from Clinical Indicators for Quality Use of Medicines in Australian Hospitals
Australian Commission on Safety and Quality in Health Care
57
Self
assessment
- add to
action plan
- add to
action plan
- add to
action plan
Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
Criterion: Medication management processes
The clinical workforce is supported for the prescribing, dispensing, administering, storing, manufacturing, compounding and monitoring of
medicines.
C/D
C
C
C
This criterion will be
achieved by:
Actions required
4.9 Ensuring that
current and accurate
medicines information
and decision support
tools are readily
available to the clinical
workforce when
making clinical
decisions related to
medicines use
4.9.1 Information and
decision support tools for
medicines are available to
the clinical workforce at the
point of care
Examples of evidence that can be used to demonstrate an action is being met.
This is not a checklist. Use only those examples that show that you have met the
Standards
4.9.2 The use of the
information and decision
support tools are regularly
reviewed
4.9.3 Action is taken to
improve the availability and
effectiveness of information
and decision support tools
Australian Commission on Safety and Quality in Health Care
 Current version of medicines reference texts available in patient care areas (hard copy
or electronic)
 Records of clinical workforce access to medicines information systems
 Clinical decision support tools (manual and/or electronic) accessed by staff
Self
assessment
- add to
action plan
(i) Clinical decision support tools may include:
 medicines information texts such as Australian Medicines Handbook, Therapeutic Guidelines, Intravenous
Drug Administration Guidelines
 facility protocols, guidelines, medicines information tools (such as dosing cards, pocket references)
 inbuilt clinical decision support in electronic medication management systems including alerts for allergies,
drug interactions, access to protocols, medicines information
 Risk assessment of medicines information system such as using the drug information
domain in Medication Safety Self Assessment in Australian Hospitals
 Agenda papers, meeting minutes and/or reports of relevant committee(s) responsible
for implementing and maintaining information resources and clinical decision support
- add to
tools
action plan
 Workforce feedback and suggestions on decision support tools
(i) Review of use of electronic decision support tools used for prescribing, dispensing and administering
medicines could include:
 reports on functions used
 acceptance of or bypassing of alerts for allergies, drug interactions, contraindications
 Same evidence options as 4.2.2
- add to
action plan
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C
C
C
C
C
4.10 Ensuring that
medicines are
distributed and stored
securely, safely and in
accordance with the
manufacturer’s
directions, legislation,
jurisdictional orders
and operational
directives
4.10.1 Risks associated
with secure storage and
safe distribution of
medicines are regularly
reviewed
4.10.2 Action is taken to
reduce the risks associated
with storage and distribution
of medicines
4.10.3 The storage of
temperature-sensitive
medicines is monitored
4.10.4 A system that is
consistent with legislative
and jurisdictional
requirements for the
disposal of unused,
unwanted or expired
medications is in place
4.10.5 The system for
disposal of unused,
unwanted or expired
medications is regularly
monitored
Australian Commission on Safety and Quality in Health Care
 Policies, procedures protocols and/or guidelines for safe distribution and storage of
medicines.
 Completed risk assessment of system for distributing and storing medicines
 Audits of compliance with policies, procedures and/or protocols
 Same evidence options as 4.2.2’
 Documented use of ‘Tall Man’ Lettering’ system to reduce errors from look alike sound
alike medicines names.
 Observational audit of separation of products with similar packaging.
 Policies, procedures, protocols and/or guidelines for monitoring temperature of
refrigerators and freezers used to store medicines and vaccines throughout the facility
 Record of daily checks and scheduled maintenance of the medicines and vaccines
refrigerator(s)
 Audit of compliance with processes for daily checks of medicines and vaccines
refrigerators
 Document of temperature reading devices in fridges/alarm settings review, and contact
processes
 An alarm system and documentation of the response mechanism to activated alarms
 Risk register or log that includes actions to address identified risks
 Policies, procedures and/or protocols on the disposal of unused, unwanted or expired
medicines that align with legislative and jurisdictional requirements including Schedule
8 medicines, chemotherapy and hazardous substances
 Orientation and ongoing education resources related to the disposal of unused,
unwanted or expired medications
 Record of attendance at training by the workforce
 Observation of workforce access to infrastructure and equipment necessary to comply
with policy, protocol and procedures
- add to
action plan
- add to
action plan
- add to
action plan
- add to
action plan
 Audits of compliance with policies, procedures and/or protocols
 Risk register or log that includes actions to address identified risks
- add to
action plan
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C
C
4.10.6 Action is taken to
increase compliance with
the system for storage,
distribution and disposal of
medications
4.11 Identifying highrisk medicines in the
organisation and
ensuring they are
stored, prescribed,
dispensed and
administered safely
4.11.1 The risks for storing,
prescribing, dispensing and
administration of high-risk
medicines are regularly
reviewed
 Same evidence options as 4.2.2
 Documented use of ‘Tall Man’ Lettering’ system to reduce errors from look alike sound
alike medicines names.
 Observational audit of separation of products with similar packaging
 Policies, procedures and/or protocols for storing, prescribing, dispensing,
administering and monitoring high risk medicines
 Guidelines for prescribing, dispensing, administering and monitoring specific high
risks medicines such as anticoagulants, chemotherapy, opioids, insulin are available to
the clinical workforce
 A list of high risk medicines as a subset of medicines used in the facility
 Information on actions to be taken in response to medication incidents and near
misses available in the pharmacy and clinical areas
 Audit of compliance with specific storage requirements for high risk medicines such as
concentrated injectables (potassium, electrolytes), opioids
 Audit of compliance with procedures for labelling injectable medicines, fluids and lines
 Completed risk assessment of management of high risk medicines
 Risk register or log that includes actions to address identified risks
 Incident reports that identify trends and implementing actions and strategies
implemented
 Physical security that restricts access to high risk medicines
 Audit of compliance with protocol, procedures and guidelines for prescribing,
dispensing, administering and monitoring specific high risks medicines such as
anticoagulants, chemotherapy, opioids, insulin
Link with Standard 4.10.1 and Standard 5
- add to
action plan
- add to
action plan
(i) Risk assessment tools may include:
 Medication Safety Self Assessment in Australian Hospitals of drug standardisation, storage and
distributions domain
 Medication Safety Self Assessment for Antithrombotic Therapy
Quality improvement tools include indicators for safe and effective use of medicines in the Indicators for
Quality Use of Medicines in Australian Hospitals, for example
 Audit of storage of potassium ampoules
 Audit of prescribing of cytotoxic chemotherapy treatment guided by a hospital approved chemotherapy
treatment protocol
Australian Commission on Safety and Quality in Health Care
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C
4.11.2 Action is taken to
reduce the risks of storing,
prescribing, dispensing and
administering high-risk
medicines
Australian Commission on Safety and Quality in Health Care
 Same evidence options as 4.2.2
- add to
action plan
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Criterion: Continuity of medication management
The clinician provides a complete list of a patient’s medicines to the receiving clinician and patient when handing over care or changing medicines.
C/D
This criterion will be
achieved by:
Actions required
Examples of evidence that can be used to demonstrate an action is being
met.
Self
assessment
This is not a checklist. Use only those examples that show that you have met the
Standards
C
C
C
C
4.12 Ensuring a current
comprehensive list of
medicines, and the
reason(s) for any change,
is provided to the
receiving clinician and the
patient during any clinical
handovers
4.12.1 A system is in use that
generates and distributes a
current and comprehensive
list of medicines and
explanation of changes in
medicines
4.12.2 A current
comprehensive list of
medicines is provided to the
patient and/or carer when
concluding an episode of
care
4.12.3 A current
comprehensive list of
medicines is provided to the
receiving clinician during
clinical handover
4.12.4 Action is taken to
increase the proportion of
patients and receiving
clinicians that are provided
with a current comprehensive
list of medicines during
clinical handover
Australian Commission on Safety and Quality in Health Care
 Policies, procedures and/or protocols related to the medicines information
required for transfer and discharge communication documents.
 Patient clinical record that contains a medicines list and explanation of changes
used at handover of care such as transfer or discharge summary
 Audit of use of policies, procedures and/or protocols related to the medicines
information required for transfer and discharge communication documentation.
- add to
action plan
 Audit of patient clinical records to identify patients provided with a current
comprehensive list of medicines on discharge when medicines changed during
the episode of care
- add to
action plan
 Patient clinical record that shows a current list of medicines, including reasons
for changes, was provided to the receiving clinician
 Documented feedback from receiving clinicians
 Audit of patient clinical records to identify the proportion of transfer and/or
discharge summaries that contain a current comprehensive list of medicines,
medication therapy changes and explanations for changes when medicines
changed during the episode of care
- add to
action plan
Link with Standard 6
 Same evidence options as 4.2.2
- add to
action plan
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Criterion: Communicating with patients and carers
The clinical workforce informs patients about their options, risks and responsibilities for an agreed medication management plan.
C/D
C
This criterion will be
achieved by:
Actions required
4.13 The clinical workforce
informing patients and
carers about medication
treatment options, benefits
and associated risks
4.13.1 The clinical workforce
provides patients with
patient-specific medicine
information, including
medication treatment
options, benefits and
associated risks
C
C
D
Examples of evidence that can be used to demonstrate an action is being met.
This is not a checklist. Use only those examples that show that you have met the
Standards
4.13.2 Information that is
designed for distribution to
patients is readily available
to the clinical workforce
4.14 Developing a
medication management
plan in partnership with
patients and carers
4.14.1 An agreed medication
management plan is
documented and available in
the patient’s clinical record
4.15 Providing current
medicines information to
patients in a format that
meets their needs
whenever new medicines
are prescribed or dispensed
4.15.1 Information on
medicines is provided to
patients and carers in a
format that is understood
and meaningful
Australian Commission on Safety and Quality in Health Care
 Policies, procedures and/or protocols define the roles and responsibilities of the
clinical workforce in informing patients and carers about medication treatment
options, benefits and associated risks.
 Patient clinical records that shows patient-specific information was provided to
patients
 Records of patient education provided such as information on chemotherapy to
oncology or haematology patients
Link with Standard 2
 Materials used in patient education such as brochures, fact sheets, posters
 Observation that patient specific medicines information is available in the
workplace.
 Patients clinical record that shows patient-specific medicines information such as
consumer medicines information was provided
Self
assessment
- add to
action plan
- add to
action plan
Link with Standard 2
 Patients clinical record shows that written information was provided on
medications to be continued by patient post discharge
- add to
action plan
 Patients clinical record shows that information was provided to the patient and/or
carer when medicine was supplied on discharge
 Results of patient experience survey on medicines information provided
- add to
action plan
Link with Standard 2
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Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
D
4.15.2 Action is taken in
response to patient feedback
to improve medicines
information distributed by the
health service organisation
to patients
 Same evidence options as 4.2.2
- add to
action plan
Additional information and resources
Australian Injectable Dugs Handbook (AIDH) 5th edition, 2011, The Society of Hospital Pharmacists of Australia, Melbourne.
Guiding principles for medication management in the community. Australian Pharmaceutical Advisory Council, Canberra: Commonwealth of Australia 2006.
Guiding principles to achieve continuity in medication management. Australian Pharmaceutical Advisory Council, Commonwealth of Australia. (APAC)
Indicators for Quality Use of Medicines in Australian Hospitals. NSW Therapeutic Advisory Group.
Medication Safety Self Assessment in Australian Hospitals and Medication Safety Self Assessment for Antithrombotic Therapy in Australian Hospitals. Clinical Excellence
Commission and NSW Therapeutic Advisory Group.
Medication Safety Self Assessment for Australian Hospitals. Clinical Excellence Commission and NSW Therapeutic Advisory Group.
National Medicines Policy (2000) www.health.gov.au/internet/publishing.nsf/content/nmp-objectives-policy.htm
Medication Management Plan by the ACSQHC is found by the following link: http://www.health.gov.au/internet/safety/publishing.nsf/Content/compubs_Medication_Management_Plan
Rossi, S (ed), 2011, Australian Medicines Handbook 2011, Australian Medicines Handbook Pty Ltd, Adelaide.
Therapeutic guidelines. Melbourne: Therapeutic Guidelines Limited; 2010. www.tg.org.au
Examples of high risk medications may be found at The Institute for Safe Medication Practices (ISMP): www.ismp.org
Australian Commission on Safety and Quality in Health Care
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Standard 5: Patient Identification and Procedure Matching
Clinical leaders and senior managers of a health service organisation establish systems to ensure the correct identification of patients and correct
matching of patients with their intended treatment. Clinicians and other members of the workforce use the patient identification and procedure
matching systems.
The intention of this Standard is to:
Correctly identify all patients whenever care is provided and correctly match patients to their intended treatment.
Context
It is expected that this Standard will be applied in conjunction with Standard 1, ‘Governance for Safety and Quality in Health Service Organisations’
and Standard 2, ‘Partnering with Consumers’.
Criteria to achieve the Patient Identification and Procedure Matching Standard:
Identification of individual patients
Processes to transfer care
Processes to match patients and their care
Australian Commission on Safety and Quality in Health Care
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Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
Criterion: Identification of individual patients
At least three approved patient identifiers are used when providing care, therapy or services.
C/D
C
This criterion will be
achieved by:
Actions required
5.1 Developing,
implementing and
regularly reviewing the
effectiveness of a
patient identification
system including the
associated policies,
procedures and/or
protocols that:
 define approved
patient identifiers
 require at least three
approved patient
identifiers on
registration or
admission
 require at least three
approved patient
identifiers when care,
therapy or other
services are provided
 require at least three
approved patient
identifiers whenever
clinical handover,
patient transfer or
discharge
documentation is
generated
5.1.1 Use of an
organisation-wide patient
identification system is
regularly monitored
Examples of evidence that can be used to demonstrate an action is being met.
This is not a checklist. Use only those examples that show that you have met the
Standards
Australian Commission on Safety and Quality in Health Care






Policies, procedures and/or protocols that are consistent with the national standard
and require the three patient identifiers to be recorded in the patient clinical records
Documented process that identifies patients with multiple identifiers (for example
more than one medical record number) and then applies a unique identifier for the
health service
Policies, procedures and/or protocols that specify the approved patient identifiers for
all clinical services
Policies, procedures and/or protocols that describe the audits and auditing process
to be undertaken for monitoring compliance with the patient identification policy
Approved or required checklists for various procedures
Audit of patient clinical record for the use of three patient identifiers
Self
assessment
- add to
action plan
Link with Standards 1 and 2
(i)
Patients with multiple identifiers may be an issue with multiple site facilities and after hours admissions
via an Emergency Department where the medical record is not available or has been destroyed.
Examples of approved patient identifier:
 full name (family and given names) stated by the patient
 date of birth stated by the patient
 gender
 home address in full as stated by the patient
 photographic image of the patient attached to the patient file
 appointment day or date and time correctly stated by the patient
 a valid card or document stating the patient’s family name
 the patient’s personal identifier stated by the patient
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Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
C/D
This criterion will be
achieved by:
C
Actions required
Examples of evidence that can be used to demonstrate an action is being met.
This is not a checklist. Use only those examples that show that you have met the
Standards
5.1.2 Action is taken to
improve compliance with
the patient identification
matching system










C
C
5.2 Implementing a
robust organisation-wide
system of reporting,
investigation and
change management to
respond to any patient
care mismatching
events
5.2.1 The system for
reporting, investigating and
analysis of patient care
mismatching events is
regularly monitored





5.2.2 Action is taken to
reduce mismatching events





Australian Commission on Safety and Quality in Health Care
Risk register or log that includes actions to address identified risks
Agenda papers, meeting minutes and/or reports of relevant committees that detail
Improvement actions
Quality improvement plan includes actions to address issues identified
Orientation and ongoing education resources
Training attendance records regarding the organisation’s patient identification and
management protocol
Documented strategies for minimising risks of misidentification, patient identification
and procedure matching
Results of patient feedback regarding patient identification
Record/s of regular reviews of policy, protocols and/or procedures
Examples of improvement activities that have been implemented and evaluated
Communication material developed for the workforce and/or patients
Risk register or log that includes actions to address identified risks
Agenda papers, meetings minutes and/or reports that demonstrate mismatch
incidents are routinely reported to and reviewed by management
Incident reporting management system, register or log of near misses and incidents
of patient mismatching events
Root cause analysis of policy or protocol breaches that result in a serious breach or
sentinel event
Audits of patient clinical records include the reporting and investigation of care
mismatching events
Risk register or log that includes actions to address identified risks
Agenda papers, meeting minutes and/or reports of relevant committee(s) that detail
improvement actions taken
Quality improvement plan includes actions to address issues identified
Examples of improvement activities that have been implemented and evaluated
Communication material developed for the workforce and/or patients
67
Self
assessment
- add to
action plan
- add to
action plan
- add to
action plan
Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
C/D
C
This criterion will be
achieved by:
Actions required
5.3 Ensuring that when
a patient identification
band is used, it meets
the national
specifications for patient
identification bands
5.3.1 Inpatient bands are
used that meet the national
specifications for patient
identification bands
Examples of evidence that can be used to demonstrate an action is being met.
This is not a checklist. Use only those examples that show that you have met the
Standards
Australian Commission on Safety and Quality in Health Care
Self
assessment

Patient identification and procedure matching policies, procedures and/or protocols
comply with Australian Specifications for Patient Identification Bands

Audits of patient identification bands compliance with the Australian Specifications
for Patient Identification Bands

Review of related policies, such as blood administration and medication
administration policies, amended based on audit results of the use of patient bands

Audit of compliance of patient identification bands with Australian specifications
(i)
Australian Standard for Patient Identification Bands found at:
http://www.health.gov.au/internet/safety/publishing.nsf/Content/EAC2DBC0F547
77B5CA2574DE00111B73/$File/Specs-PatID-Band.pdf
68
- add to
action plan
Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
Criterion: Processes to transfer care
A patient’s identity is confirmed using three approved patient identifiers when transferring responsibility for care.
C/D
C
This criterion will be
achieved by:
Actions required
5.4 Developing,
implementing and
regularly reviewing the
effectiveness of the
patient identification and
matching system at
patient handover, transfer
and discharge
5.4.1 A patient
identification and
matching system is
implemented and
regularly reviewed as
part of structured clinical
handover, transfer and
discharge processes
Examples of evidence that can be used to demonstrate an action is being met.
This is not a checklist. Use only those examples that show that you have met the
Standards






Patient handover, transfer and discharge policies, procedures and/or protocols include
the use of three patient identifiers
Schedule of routine policy reviews or review dates on policies
Audit of transfer or discharge summaries of patients transferred to another healthcare
organisation for use of three patient identifiers
Agenda papers, meeting minutes and/or reports of the senior executive and
management teams record audit results of handover sheets, transfer forms and
discharge summaries
Workforce meeting minutes, memos, and reports related to feedback on results of
audits on handover, transfer and discharge sheets, forms and summaries
Annual report that provides results of audits on transfer and discharge processes
Link with Standards 6
Australian Commission on Safety and Quality in Health Care
69
Self
assessment
- add
to action
plan
Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
Criterion: Processes to match patients and their care
Health service organisations have explicit processes to correctly match patients with their intended care.
C/D
C
C
C
This criterion will be
achieved by:
Actions required
5.5 Developing and
implementing a
documented process to
match patients to their
intended procedure,
treatment or investigation
and implementing
consistent national
guidelines for patient
procedure matching
protocol or other relevant
protocols
5.5.1 A documented
process to match patients
and their intended
treatment is in use
Examples of evidence that can be used to demonstrate an action is being met.
This is not a checklist. Use only those examples that show that you have met the Standards



5.5.2 The process to
match patients to any
intended procedure,
treatment or investigation
is regularly monitored
5.5.3 Action is taken to
improve the effectiveness
of the process for
matching patients to their
intended procedure,
treatment or investigation
Australian Commission on Safety and Quality in Health Care




Policies, procedures and/or protocols that document when a specific patient
identification procedure is to be used by the workforce. This may include:
o surgical safety checklist
o handover checklists
o medication management plan
Policies, procedures and/or protocols for procedure matching including ‘time out’ to be
carried out
Register and/or record that shows review dates for policies, procedures or protocols and
the future scheduled review dates
Results of observational or records audits of patient and procedure, treatment and
investigation matching (such as surgical, diagnostics, chemotherapy, renal dialysis,
matching and so on)
Risk register or log that includes actions to address identified risks
Agenda papers, meeting minutes and reports to relevant committees that include an
analysis of incident data and trends
Self
assessment
- add to
action plan
- add to
action plan
Same evidence options as 5.2.2
- add to
action plan
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Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
Additional information and resources
Australian Commission on Safety and Quality in Health Care. Patient Identification Protocols. 2009 [cited 2009]. www.safetyandquality.gov.au
Australian Commission on Safety and Quality in Health Care. Specifications For A Standard National Patient Identification Band.
http://www.safetyandquality.gov.au/internet/safety/publishing.nsf/Content/PatientID-Resources-NatStd_Bands
Australian Standard Handbook HB 222–2006 Australian Health Care Client and Provider Identification Handbook. Standards Australia.
Standards Australia. Australian Standard AS5017-2006 Health Care Client Identification. 2006, Sydney.
Royal Australasian College of Surgeons Surgical Safety Checklist (Australia And New Zealand)
http://www.surgeons.org/media/12661/LST_2009_Surgical_Safety_Check_List_(Australia_and_New_Zealand).pdf
Australian Commission on Safety and Quality in Health Care
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Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
Standard 6: Clinical Handover
Clinical leaders and senior managers of a health service organisation implement documented systems for effective and structured clinical handover.
Clinicians and other members of the workforce use the clinical handover systems.
The intention of this Standard is to:
Ensure there is timely, relevant and structured clinical handover that supports safe patient care.
Context
It is expected that this Standard will be applied in conjunction with Standard 1, ‘Governance for Safety and Quality in Health Service Organisations’
and Standard 2, ‘Partnering with Consumers’.
Criteria to achieve the Clinical Handover Standard:
Governance and leadership for effective clinical handover
Clinical handover processes
Patient and carer involvement in clinical handover
Australian Commission on Safety and Quality in Health Care
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Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
Criterion: Governance and leadership for effective clinical handover
Health service organisations implement effective clinical handover systems.
C/D This criterion will be achieved Actions required
by:
C
C
C
Examples of evidence that can be used to demonstrate an action is being met.
Self assessment
This is not a checklist. Use only those examples that show that you have met the
Standards
 Policies, procedures and/or protocols on clinical handover that are accessible to the
6.1 Developing and
6.1.1 Clinical handover policies,
workforce
implementing an organisational procedures and/or protocols are
 Patient clinical record shows that clinical handover has occurred
system for structured clinical
used by the workforce and
 Discharge summary that details emergency contact information, post procedure
handover that is relevant to the regularly monitored
- add to
instructions, appointment times
healthcare setting and
action plan
 Transfer guidelines and forms for transferring patients to another facility for ongoing
specialities, including:
care or investigation

documented policy,

Audit of patient clinical records
procedures and/or
(i) Policy documents may address clinical handover from area to area and include:
protocols

agreed tools and guides
 process for signing off on a clinical handover when a patient’s care is transferred
 discharge form that details emergency contact information, post procedure instructions, appointment
times
 guidelines and forms for transfer to another facility for ongoing care or investigation
 tools for auditing the clinical pathways and documents
 reporting mechanism and procedures that include reporting on risk reduction measures
 details of the evidence-based approach to be adopted and the validated tool(s) for clinical handover
 patient engagement and/or centred care policy
6.1.2 Action is taken to
maximise the effectiveness of
clinical handover policies,
procedures and/or protocols
6.1.3 Tools and guides are
periodically reviewed










Australian Commission on Safety and Quality in Health Care
Tools that have been validated and/or are based on the national tools for clinical
handover
Observational audit of clinical handover
Educational resources and training attendance records related to clinical handover
- add to
Risk register or log that includes actions to address identified risks
action plan
Agenda papers, meeting minutes and/or reports of relevant committee(s) that detail
improvement actions taken
Quality improvement plan includes actions to address issues identified
Examples of improvement activities that have been implemented and evaluated
Communication material developed for the workforce and/or patients
Schedule of policy, procedures and/or protocols to update in line with best practice
or emerging information
Quality improvement plan that includes details of last review and schedule for future
reviews
- add to
action plan
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Criterion: Clinical handover processes
Health service organisations have documented and structured clinical handover processes in place.
C/D This criterion will be
achieved by:
C
C
Actions required
Examples of evidence that can be used to demonstrate an action is being met.
Self assessment
This is not a checklist. Use only those examples that show that you have met the
Standards
 Clinical handover policies, procedures and/or protocols included in the facility’s
6.2 Establishing and
6.2.1 The workforce has access
orientation guides or manuals
maintaining structured and
to documented structured
 Posting of clinical handover policies, procedures and/or protocols on health service
documented processes for
processes for clinical handover
communication board or web site
clinical handover
that include:
- add to
 Educational resources and training attendance records related to clinical handover
action plan

preparing for handover,
 Patient clinical record shows that clinical handover has occurred
including setting the
 Discharge summary that details emergency contact information, post procedure
location and time while
instructions, appointment times
maintaining continuity of
 Guidelines and forms for transfer to another facility for ongoing care or investigation
patient care
 Tools and resources associated for structured clinical handover process that are

organising relevant
accessible to the workforce such as ISOBAR, ISBAR, SBAR, SHARED
workforce members to
participate

being aware of the clinical
context and patient needs

participating in effective
handover resulting in
transfer of responsibility
and accountability for care
 Reports, investigations and feedback to the workforce on patient incidents involving
6.3 Monitoring and evaluating 6.3.1 Regular evaluation and
clinical handover
the agreed structured clinical monitoring of processes for
 Risk register or log that includes actions to address identified risks
handover processes, including: clinical handover are in place.
 Observational audits of clinical handover

regularly reviewing local
- add to
 Results of patient satisfaction surveys regarding clinical handovers
processes based on
action plan
 Meeting minutes and/or reports of meetings record actions taken and areas for
current best practice in
future improvement
collaboration with

C

clinicians, patients and
carers
undertaking quality
improvement activities and
acting on issues identified 6.3.2 Local processes for
from clinical handover
clinical handover are reviewed
reviews
in collaboration with clinicians,
reporting the results of
patients and carers
clinical handover reviews
Australian Commission on Safety and Quality in Health Care



Audits of clinical handover at patient admission, transfer and discharge and reports
on variation from agreed pathways
Patient feedback data such as focus groups, patient satisfaction surveys
Agenda papers, meeting minutes and/or reports of relevant committees
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Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
C/D This criterion will be
achieved by:
C
at executive level of
governance
C
Actions required
Examples of evidence that can be used to demonstrate an action is being met.
This is not a checklist. Use only those examples that show that you have met the
Standards
 Risk register or log that includes actions to address identified risks
6.3.3 Action is taken to increase
 Agenda papers, meeting minutes and/or reports of relevant committee(s) that detail
the effectiveness of clinical
improvement actions taken
handover
 Quality improvement plan includes actions to address issues identified
 Examples of improvement activities that have been implemented and evaluated
 Communication material developed for the workforce and/or patients
6.3.4 The actions taken and the
outcomes of local clinical
handover reviews are reported
to the executive level of
governance






Self assessment
- add to
action plan
Reports to senior executive on progress and outcomes of actions related to reviews
of clinical handover
Risk register or log that includes actions to address identified risks
Agenda papers, meeting minutes and/or reports of relevant committee(s) that detail
- add to
improvement actions taken
action plan
Quality improvement plan includes actions to address issues identified
Examples of improvement activities that have been implemented and evaluated
Communication material developed for the workforce and/or patients
(i) Executive level of governance may be for a service, facility or broader organisation of a health service,
whichever is the most appropriate to take action on the results
C
6.4 Implementing a robust
organisation-wide system of
reporting, investigation and
change management to
respond to any clinical
handover incidents
6.4.1 Regular reporting,
investigating and monitoring of
clinical handover incidents is in
place






Committee terms of reference outline the senior executive responsibilities for clinical
handover incidents
Agenda papers, meeting minutes and/or reports of relevant committee(s) include
information on clinical handover
- add to
Safety and quality information presented to the senior executive and/or relevant
action plan
committees
Incident reporting forms and processes included in policies, procedures and/or
protocols
Reports on trends in clinical handover incidents
Feedback provided to the workforce and consumers
Link to 1.2.1
(i) An example may include root cause analysis or sentinel event
Australian Commission on Safety and Quality in Health Care
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C/D This criterion will be
achieved by:
Actions required
Examples of evidence that can be used to demonstrate an action is being met.
Self assessment
This is not a checklist. Use only those examples that show that you have met the
Standards
 Orientation documentation addresses clinical handover policy, procedures and/or
6.4.2 Action is taken to reduce
protocols
the risk of an adverse clinical
 Educational resources and attendance records related to clinical handover
handover incident
 Posting of clinical handover policy/guideline on health service communication board
or web site
 Risk register or log that includes actions to address identified risks
 Agenda papers, meeting minutes and/or reports of relevant committee(s) that detail
improvement actions taken
 Quality improvement plan includes actions to address issues identified
 Examples of improvement activities that have been implemented and evaluated
 Communication material developed for the workforce and/or patients
(i) Clinical steps that require handover in a day surgeries procedure service may include:
Admission to clinical nurse, clinical admission nurse to anaesthetic staff member, anaesthetic staff member to
theatre staff, theatre staff to recovery staff, recovery staff to second stage recovery staff, second stage
recovery or discharge staff to responsible patient and/or carer
Australian Commission on Safety and Quality in Health Care
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Criterion: Patient and carer involvement in clinical handover
Health service organisations establish mechanisms to include patients and carers in clinical handover processes.
C/D This criterion will be
achieved by:
D
Actions required
Examples of evidence that can be used to demonstrate an action is being met.
Self assessment
This is not a checklist. Use only those examples that show that you have met the
Standards
 Information for patients and carers on their roles in handover such as access to a
6.5 Developing and
6.5.1 Mechanisms to involve a
patient charter of rights
implementing mechanisms to patient and, where relevant,
 Patient experience survey related to clinical handover
include patients and carers in their carer in clinical handover
 Forms that patients review, sign and receive as a copy related to their clinical
the clinical handover process are in use
NM - add to
management and handover at discharge
that are relevant to the
action plan
healthcare setting
Additional information and resources
Australian Commission on Safety and Quality in Health Care. 2010. The OSSIE guide to clinical handover improvement. Sydney: www.safetyandquality.gov.au
Australian Commission on Safety and Quality in Health Care. 2011. The Implementation Toolkit for Clinical Handover Improvement: www.safetyandquality.gov.au
Australian Day Surgery Nurses Association: www.adsna.info
Australian Commission on Safety and Quality in Health Care
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Standard 7: Blood and Blood Products
Clinical leaders and senior managers of a health service organisation implement systems to ensure the safe, appropriate, efficient and effective use
of blood and blood products. Clinicians and other members of the workforce use the blood and blood product safety systems.
The intention of this Standard is to:
Ensure that the patients who receive blood and blood products do so appropriately and safely.
Context
It is expected that this Standard will be applied in conjunction with Standard 1, ‘Governance for Safety and Quality in Health Service Organisations’
and Standard 2, ‘Partnering with Consumers’.
Criteria to achieve the Blood and Blood Products Standard:
Governance and systems for blood and blood product prescribing and clinical use
Documenting patient information
Managing blood and blood product safety
Communicating with patients and carers
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Criterion: Governance and systems for blood and blood product prescribing and clinical use
Health service organisations have systems in place for the safe and appropriate prescribing and clinical use of blood and blood products.
C/D
C
This criterion will be
achieved by:
Actions required
7.1 Developing
governance systems
for safe and
appropriate
prescription,
administration and
management of blood
and blood products
7.1.1 Blood and blood
product policies, procedures
and/or protocols are
consistent with national
evidence-based guidelines
for pre-transfusion practices,
prescribing and clinical use of
blood and blood products
Examples of evidence that can be used to demonstrate an action is being met.
This is not a checklist. Use only those examples that show that you have met the
Standards





7.1.2 The use of policies,
procedures and/or protocols
is regularly monitored
Australian Commission on Safety and Quality in Health Care
Policies, procedures and/or protocols for safe and appropriate prescription,
prescription, administration and management of blood and blood products that
adhere to national guidelines and best practice, and address areas such as
o prescription, administration and management of blood and blood products
o pre-transfusion and sampling practices such as specimen collection
o processes that relate to laboratory-hospital interface
o consent procedure
o tools for transfusion that are available
o storage and transportation of blood and blood products
Orientation of the workforce including nursing, junior medical officer and consultants
which reflect current national guidelines and criteria relating to blood and blood
products management.
Education resources related to blood components management
Training attendance records.
Evaluation reports of education and training
Self
assessment
- add to
action plan
(i) Examples of areas that could be audited to assess appropriateness and administrative practices:

clinical audit of fresh frozen plasma

clinical audit of red cell use in orthopaedic surgery

audit of blood transfusion policy and administration practices

blood storage and handling survey

Agenda papers, meeting minutes and/or reports of relevant committee(s) that detail
monitoring of the use of policies, procedures and/or protocols, such as a clinical
review group or transfusion committee

Strategic plan where it relates to blood and blood products
- add to

Risk register or log that includes actions to address identified risks
action plan

Documentation on consultation processes in the development and review of policies,
procedures and/or protocols

Clinicians checklist for prescribing blood components to ensure blood products are
only released for transfusion when guidelines have been satisfied

Audits of the use of forms and tools for prescription, request and administration of
blood products

Reports on transfusions provided to clinical units, senior and relevant committee(s)

Reports of vetting of transfusion requests.

Documentation such as request forms or blood administration forms for ordering or
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Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
C/D
This criterion will be
achieved by:
Actions required
Examples of evidence that can be used to demonstrate an action is being met.
This is not a checklist. Use only those examples that show that you have met the
Standards




C
C
7.1.3 Action is taken to
increase the safety and
appropriateness of
prescribing and clinically
using blood and blood
products
7.2 Undertaking a
regular, comprehensive
assessment of blood
and blood product
systems to identify
risks to patient safety
and take action to
reduce risks
7.2.1 The risks associated
with transfusion practices and
clinical use of blood and
blood products are regularly
assessed
Australian Commission on Safety and Quality in Health Care
Self
assessment
administering blood components that adhere to national guidelines
Risk register or log that incorporates blood and blood product risks
Reports from clinical data systems
Observational audit of accessibility and use of clinical guidelines in clinical areas
Audit of patient clinical records for compliance with policy and procedures
(i) Standardised data items collected that are used to assess ‘appropriateness’ rates include:

blood component given

clinical or laboratory indications

reasons for giving blood component if not in accordance with guidelines

other relevant medical history of condition

number of units required

Audit of patient clinical records that assess compliance with national guidelines such
as the rationale for administering blood and blood products

Observational audit of use of policies, procedures and/or protocols

Feedback of audit provided to clinical groups
- add to

Education resources and training attendance records relating to blood and blood
action plan
products

Peer review and self-audit tools and reports on outcomes

Agenda papers, meeting minutes and/or reports of relevant committee(s) that detail
improvement actions

Quality improvement plan includes actions to address issues identified

Examples of improvement activities that have been implemented and evaluated

Communication material developed for the workforce and/or patients






Forms or processes included in the policies, procedures and/or protocols to assess
blood and blood product risks
Report on incident related to blood and blood products
Audit of compliance with policies, procedures and/or protocols
Risk register or log that includes actions to address identified risks
Process for addressing pathology laboratory documentation that identifies patient
safety risks from the use of blood and blood products
Agenda papers, meetings minutes and/or reports that relate to transfusion practices
are routinely reviewed by management
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C/D
This criterion will be
achieved by:
C
Actions required
Examples of evidence that can be used to demonstrate an action is being met.
This is not a checklist. Use only those examples that show that you have met the
Standards
7.2.2 Action is taken to
reduce the risks associated
with transfusion practices and
the clinical use of blood and
blood products




C
7.3 Ensuring blood and
blood product adverse
events are included in
the incidents
management and
investigation system
7.3.1 Reporting on blood and
blood product incidents is
included in regular incident
reports













C
7.3.2 Adverse blood and
blood product incidents are
reported to and reviewed by
the highest level of
governance in the health
service organisation
Australian Commission on Safety and Quality in Health Care


Patients clinical record that shows patients are informed of the risks and benefits of
transfusion
Education resources and training attendance records related to the prescription and
clinical administration of blood and risk assessment
Agenda papers, meeting minutes and/or reports of relevant committee(s) that detail
improvement actions
Examples of modifications to policies, procedures, protocols or work practices to
address issues of non-compliance
Communication material developed for the workforce and/or patients
Policies, procedures and/or protocols for reporting and managing incidents relating to
use of blood and blood products
A current register for reporting adverse events with transfusion of blood or blood
components and includes actions to address identified risks.
Records of healthcare blood product adverse events
Documented incidents are investigated
Incident reporting management system, such as a register or log, that documents
analysis and review of incidents relating to use of blood and blood product
Agenda papers, meetings minutes and/or reports of relevant committees that
demonstrate incidents relating to use of blood and blood products are routinely
reviewed
Root cause analysis of breaches of policies, procedures and/or protocols resulting in
a serious breach or sentinel event
Audits of patient clinical records that demonstrate reporting and investigation of
incidents relating to use of blood and blood products
Audit of compliance with policies, procedures and/or protocols
Data that reports trends in incidents relating to use of blood and blood products are
recorded, such as in meeting minutes or annual reports
Information relating to use of blood and blood products presented to the senior
executive and/or relevant committees
Peer review processes for transfusion practice such as quality assurance meetings
Agenda papers, meeting minutes and/or reports of relevant committees or groups
with responsibility for management of blood and blood products such as medical
advisory and management committee
Reports of adverse blood and blood product incidents provided to relevant
committees and senior executive
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assessment
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- add to
action plan
- add to
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Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
C/D
This criterion will be
achieved by:
C
C
Actions required
This is not a checklist. Use only those examples that show that you have met the
Standards
7.3.3 Health service
organisations participate in
relevant haemovigilance
activities conducted by the
organisation or at state or
national level
7.4 Undertaking quality
improvement activities
to improve the safe
management of blood
and blood products
Examples of evidence that can be used to demonstrate an action is being met.
7.4.1 Quality improvement
activities are undertaken to
reduce the risks of patient
harm from the clinical
administration of blood and
blood products
Australian Commission on Safety and Quality in Health Care



Policies, procedures and/or protocols identifying all haemovigilance reporting
obligations for the organisation
Schedules of haemovigilance reporting
Reports provided to organisations monitoring haemovigilance
 Risk register or log that includes actions to address identified risks
 Agenda papers, meeting minutes and/or reports of relevant committee(s) that detail
improvement actions taken
 Quality improvement plan includes actions to address issues identified
 Examples of improvement activities that have been implemented and evaluated
 Communication material developed for the workforce and/or patients
82
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assessment
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action plan
- add to
action plan
Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
Criterion: Documenting patient information
The clinical workforce accurately records a patient’s blood and blood product transfusion history and indications for use of blood and blood
products.
C/D
C
C
C
C
This criterion will be
achieved by:
Actions required
This is not a checklist. Use only those examples that show that you have met the
Standards
7.5 As part of the patient 7.5.1 A best possible history
treatment plan, the
clinical workforce
accurately documenting:

relevant medical
conditions

indications for
transfusion

any special product
or transfusion
requirements

known patient
transfusion history

type and volume of
product transfusion

patient response to
transfusion
7.6 The clinical
workforce documenting
any adverse reactions
to blood or blood
products
Examples of evidence that can be used to demonstrate an action is being met.

of blood product usage and

relevant clinical and product

information is documented in

the patient clinical record
7.5.2 The patient clinical

records of transfused
patients are periodically
reviewed to assess the
proportion of records
completed

7.5.3 Action is taken to
increase the proportion of
patient clinical records of
transfused patients with a
complete patient clinical
record

7.6.1 Adverse reactions to
blood or blood products are
documented in the patient
clinical record
Australian Commission on Safety and Quality in Health Care


Policies, procedures and/or protocols provide tools, forms and/or specified process for
taking a history of blood product usage
Audit of patient clinical records for use of tools, forms and specified process
Review of incidents related to poor patient records management
Education material and attendance at training related to patient record taking
Education resources and training attendance records related to patient record taking
and auditing of patient records
Audit of patient clinical record and reports on the proportion of patents with complete
patient history reviewed by relevant committees
Audit of compliance with policies procedures and/or protocols
Agenda papers, meetings minutes and/or reports that relate to transfusion practices
are routinely reviewed by management
Self
assessment
- add to
action plan
- add to
action plan
Audit of patient clinical record shows that clinical records for transfused patients are
complete
- add to
action plan
 Policies, procedures and/or protocols on documentation and reporting of adverse
reactions
 Record of the clinical workforce attending education on adverse reaction documentation
and reporting
 Audit of patient clinical records for information on adverse reactions
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C/D
C
C
This criterion will be
achieved by:
Actions required
Examples of evidence that can be used to demonstrate an action is being met.
This is not a checklist. Use only those examples that show that you have met the
Standards
7.6.2 Action is taken to
reduce the risk of adverse
events from administering
blood or blood products
7.6.3 Adverse events are
reported internally to the
appropriate governance
level and externally and as
appropriate to the pathology
service provider, blood
service or product
manufacturer whenever
appropriate
Australian Commission on Safety and Quality in Health Care
 Posting of policy, procedures and/or guideline on health service communication board
or web site
 Education resources and training attendance records related to appropriate prescribing
and administration of blood products
 Audit results of compliance with policies procedures and/or protocols provided to
clinical workforce and relevant committees
 Risk register or log that includes actions to address identified risks
 Agenda papers, meeting minutes and/or reports of relevant committee(s) include the
outcomes of actions taken in response to identified risks
 Quality improvement plan includes actions to address issues identified
 Examples of improvement activities that have been implemented and evaluated such as
change to policies or /procedures, publication of medicine information bulletin
 Adverse reaction reports included in agenda papers, meeting minutes or reports of
relevant committees
 Agenda papers, meeting minutes and/or reports of relevant committee(s) that detail
improvement actions
 Reports from incident reporting and management systems that have been sent to
external organisations, including pathology service providers and manufacturers
 Communication material developed for the workforce and/or patients
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Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
Criterion: Managing blood and blood product safety
Health service organisations have systems to receive, store, transport and monitor wastage of blood and blood products safely and efficiently.
C/D
C
This criterion will be
achieved by:
Actions required
7.7 Ensuring the
receipt, storage,
collection and
transport of blood and
blood products within
the organisation are
consistent with best
practice and/or
guidelines
7.7.1 Regular review of
the risks associated with
receipt, storage,
collection and transport
of blood and blood
products is undertaken
Examples of evidence that can be used to demonstrate an action is being met.
Self
This is not a checklist. Use only those examples that show that you have met the Standards
assessment









C
C
C
7.7.2 Action is taken to
reduce the risk of
incidents arising from the
use of blood or blood
product control systems
7.8 Minimising
unnecessary wastage
of blood and blood
products
7.8.1 Blood and blood
product wastage is
regularly monitored
Audit of transportation and storage of blood and blood products against with policies,
procedures and/or protocols
Delegation documentation for access to the secure blood fridge
Review of access to secure blood fridge where 24 hour on-site pathology service is not
available
Register of current blood components
Audit of documentation accompanying blood components
Delegation documentation for responding to storage alarms and taking corrective action
Positions descriptions, employment contracts or policies, procedures and/or protocols
specify blood related delegations
Observational audit show that labels and dates are checked each time blood components
are handled
Records of disposal rates of blood products
- add to
action plan
(i) Australian Standard for Medical Refrigeration Equipment – For the Storage of Blood and Blood Products
(AS3864) is a resource which specifies the requirements for refrigerators and used for the storage of blood and
blood products

Same evidence options as 7.4.1
- add to
action plan



Reports from pathology laboratories regularly reviewed and reconciled by a clinical team
Audit of compliance o f usage and disposal against policy
Review of audit results by relevant committees
- add to
action plan
7.8.2 Action is taken to
minimise wastage of
blood and blood products

Same evidence options as 7.4.1
NM - add to
action plan
Australian Commission on Safety and Quality in Health Care
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Criterion: Communicating with patients and carers
Patients and carers are informed about the risks and benefits of using blood and blood products and about the available alternatives when a plan
for treatment is developed.
C/D
This criterion will be
achieved by:
Actions required
Examples of evidence that can be used to demonstrate an action is being
met.
Self assessment
This is not a checklist. Use only those examples that show that you have met the
Standards
C
7.9 The clinical workforce
informing patients and
carers about blood and
blood product treatment
options, and the associated
risks and benefits
C
C
C
7.9.1 Patient information
relating to blood and blood
products, including risks,
benefits and alternatives, is
available for distribution by
the clinical workforce
7.9.2 Plans for care that
include the use of blood
and blood products are
developed in partnership
with patients and carers
7.10 Providing information
to patients about blood and
blood product use and
possible alternatives in a
format that can be
understood by patients and
carers
7.10.1 Information on blood
and blood products is
provided to patients and
carers in a format that is
understood and meaningful
7.11 Implementing an
informed consent process
for all blood and blood
product use
7.11.1 Informed consent is
undertaken and
documented for all
transfusions of blood or
blood products in
accordance with the
informed consent policy of
the health service
organisation
Australian Commission on Safety and Quality in Health Care
 Materials used in patient education such as brochures, fact sheets, posters
 Patient information that is available for distribution by the workforce
- add to
 Patients clinical record shows that patients were provided with patient-specific
action plan
blood information
 Patient experience survey shows that patient information was provided
(i) Consumers’ communication tools and education resources may be found at National Blood Authority,
Red Cross or resources provided by jurisdictions
 Information available to patients and carers on treatment option and use of
blood products
 Patient comment on and sign care plan and receive a copy
 Care plan that patients review, sign and receive as a copy related to the use of
blood and blood products
 Audits of patient clinical record demonstrate shows that patients are involved in
the development of their care plan
 Patient and/or carer experience surveys regarding their involvement in the
development of their care plan
 Materials used in patient education such as brochures, fact sheets, posters
 Patients clinical record shows that patients information is provided
 Patient feedback shows patient satisfaction with information provided
 Reports from consumer focus groups on patient information
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Policies, procedures and/or protocols on informed consent
Standardised consent form
Materials used in patient education include information on consent
Audit of compliance with policy and procedure
Reports from patient feedback on informed consent
Link with Standard 2
86
- add to
action plan
- add to
action plan
- add to
action plan
Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
Additional information and resources
This Standard may not be applicable to some Day Surgeries but should remain for those places who are involved in blood and blood products.
National Health and Medical Research Council, Clinical Practice Guidelines on the Use of Blood Components, Commonwealth Department of Health and Ageing:
www.nhmrc.gov.au
National Blood Authority Australia, Final Report, December 2007, Production Benchmarking and Demand Drivers, Commonwealth of Australia:
http://www.nba.gov.au/bptools/index.html
National Blood Authority Australia, Endorsed by AHMC, April 2008, National Blood Supply Contingency Plan, Commonwealth of Australia.
www.nba.gov.au
Australian Standard for Medical Refrigeration Equipment – For the Storage of Blood and Blood Products (AS3864)
Australian and New Zealand Society of Blood Transfusion Blood Product Reference Guidelines: www.anzsbt.org.au
Australian Red Cross Blood Service (ARCBS): http://www.transfusion.com.au/sites/default/files/BloodFridgeRecord.pdf
Australian Commission on Safety and Quality in Health Care
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Standards 8: Preventing and Managing Pressure Injuries
Clinical leaders and senior managers of the health service organisation implement evidence-based systems to prevent pressure injuries and
manage them when they do occur. Clinicians and other members of the workforce use the pressure injury prevention and management systems.
The intention of this Standard is to:
Prevent patients from developing pressure injuries and effectively managing pressure injuries when they do occur.
Context
It is expected that this Standard will be applied in conjunction with Standard 1, ‘Governance for Safety and Quality in Health Service Organisations’
and Standard 2, ‘Partnering with Consumers’.
Criteria to achieve the Preventing and Managing Pressure Injuries Standard:
Governance and systems for the prevention and management of pressure injuries
Preventing pressure injuries
Managing pressure injuries
Communicating with patients and carers
Australian Commission on Safety and Quality in Health Care
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Criterion: Governance and systems for the prevention and management of pressure injuries
Health service organisations have governance structures and systems in place for the prevention and management of pressure injuries.
C/D
C
This criterion will be
achieved by:
Actions required
8.1 Developing and
implementing policies,
procedures and/or
protocols that are based
on current best practice
guidelines
8.1.1 Policies, procedures
and/or protocols are in use
that are consistent with best
practice guidelines and
incorporate screening and
assessment tools
Examples of evidence that can be used to demonstrate an action is being met.
This is not a checklist. Use only those examples that show that you have met the
Standards
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C
C
C
8.1.2 The use of policies,
procedures and/or protocols
are regularly monitored
8.2 Using a riskassessment framework
and reporting systems to
identify, investigate and
take action to reduce the
frequency and severity of
pressure injuries
Self assessment
8.2.1 An organisation-wide
system for reporting
pressure injuries is in use
8.2.2 Administrative and
clinical data are used to
regularly monitor and
investigate the frequency
Australian Commission on Safety and Quality in Health Care
Policies, procedures and/or protocols that are evidence based and consistent with
best practice guidelines and incorporate screening and assessment tools
Audit of clinical practice and the tools and procedures employed to identify
individuals at risk
Evaluation reports of the organisations’ pressure injury prevention program that
includes the use of policy, procedures and/or protocols and areas that require
modification and education requirements
Reports tracking trends over time may benchmark high performing agencies
- add to
action plan
(i) Evidence-based clinical practice guidelines, such as the Australian Wound Management Association
Clinical Practice Guidelines for Pressure Ulcer Prevention and Management are readily available and
accessible to the clinical workforce: www.awma.com.au

Policies, procedures and/or protocols are available to the workforce

Observation audit of the use of policies, procedures and/or protocols

Patient clinical record reviewed against policies, procedures and/or protocols

Audits, prevalence surveys and/or incident reporting are conducted and findings
- add to
inform organisational prevention and management policies, procedures and/or
action plan
protocols

Agenda papers, meeting minutes and/or reports of relevant committees that detail
improvement actions
(i) A health service where there is a high risk of pressure injuries may routinely undertake a comprehensive
assessment of all patients for pressure injuries. Low risk services may undertake a simple screening
process and only fully assess patients indentified to be at risk of pressure injuries. This would be reflected in
the organisation’s policies, procedures and/or protocols

Incident reporting forms and processes included in policies, procedures and/or
protocols

Reports on pressure injuries and interventions to manage pressure injuries

Education resources and training attendance record related to pressure injury
- add to
reporting systems
action plan

Agenda papers, meeting minutes and/or reports of relevant committees
 Process to extract information and regular reports form administration and clinical
data on pressure injuries
 Quality improvement plans that require routine review of pressure injury incidence,
prevalence and management information
 Agenda papers, meeting minutes and/or reports of relevant committees with
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C/D
This criterion will be
achieved by:
Actions required
Examples of evidence that can be used to demonstrate an action is being met.
This is not a checklist. Use only those examples that show that you have met the
Standards
and severity of pressure
injuries

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C
C
Self assessment
8.2.3 Information on
pressure injuries is regularly
reported to the highest level
of governance in the health
service organisation
8.2.4 Action is taken to
reduce the frequency and
severity of pressure injuries
Australian Commission on Safety and Quality in Health Care
(i)
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delegated responsibilities for pressure injuries such as clinical risk committees and
the senior executive
Reports on trends in pressure injuries
External reports to owners, regulators, insurers and departments
Feedback to clinical workforce on incidence and prevalence, monitoring proformas,
trends, changes to policy, procedure and/or protocols and review schedules
Pressure injury data collected may include:
number of pressure injuries
stage of pressure injuries
pressure injury prevention strategies in place at time of injury
management strategies implemented
Agenda papers, meeting minutes and/or reports of relevant committees includes
information and data on pressure injuries
Pressure injury prevalence and/or incidence reports are routinely tabled at senior
executive and clinical governance meetings within the organisation
 Pressure injury prevention plans describe consultation with relevant stakeholders
 Data used to track trends over time and changes from actions taken
 Reports benchmarking performance in the management of preventable pressure
injuries against high performing services
 Education resources and training attendance records on changes to policies,
procedures and/or protocols following review of pressure injury incidents
 Risk register or log that includes actions to address identified risks
 Agenda papers, meeting minutes and/or reports of relevant committee(s) that detail
improvement actions taken
 Quality improvement plan includes actions to address issues identified
 Examples of improvement activities that have been implemented and evaluated
 Communication material developed for the workforce and/or patients
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action plan
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action plan
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action plan
Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
C/D
This criterion will be
achieved by:
Actions required
Examples of evidence that can be used to demonstrate an action is being met.
Self assessment
This is not a checklist. Use only those examples that show that you have met the
Standards
(i) Educational topics to prevent and manage pressure injuries may include:

manual handling to prevent shear and friction

aetiology and risk factors for pressure injuries

application of risk assessment tools

skin assessment

selection and/or use of support surfaces

development and implementation of an individualised program of skin care

repositioning to decrease risk of tissue breakdown

documentation pressure injuries assessment and management

incident reporting
C
C
8.3 Undertaking quality
improvement activities to
address safety risks and
monitor the system that
prevent and manage
pressure injuries
8.3.1 Quality improvement
activities are undertaken to
prevent pressure injuries
and/or improve the
management of pressure
injuries
8.4 Providing or
facilitating access to
equipment and devices to
implement effective
prevention strategies and
best practice
management plans
8.4.1 Equipment and
devices are available to
effectively implement
prevention strategies for
patients at risk and plans for
the management of patients
with pressure injuries
Australian Commission on Safety and Quality in Health Care
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Risk register or log that includes actions to address identified risks
Amended policies, procedures and/or protocols and guidelines
Observational audits of use of screening assessment tools
Report on usage rates of specified products and equipment
Data collected pre and post interventions
Agenda papers, meeting minutes and/or reports of relevant committee(s) that
details improvement actions
 Quality improvement plan includes actions to address issues identified
 Examples of improvement activities that have been implemented and evaluated
 Communication material developed for the workforce and/or patients
 Agenda papers, meeting minutes and/or reports of relevant committee responsible
for evaluating the efficacy of products, equipment and devices
 Inventories of equipment and audits of clinical use
 Maintenance log of equipment and devices
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Criterion: Preventing pressure injuries
Patients are screened on presentation and pressure injury prevention strategies are implemented when clinically indicated.
C/D
C
This criterion will be
achieved by:
Actions required
8.5 Identifying risk factors
for pressure injuries using
an agreed screening tool
for all presenting patients
within timeframes set by
best practice guidelines
8.5.1 An agreed tool to
screen for pressure injury
risk is used by the clinical
workforce to identify
patients at risk of a pressure
injury
Examples of evidence that can be used to demonstrate an action is being met.
This is not a checklist. Use only those examples that show that you have met the
Standards




Pre admission assessment tool
Orientation and ongoing education resources on the use of pressure injury
screening for the relevant clinical workforce
Schedule of training and attendance records for relevant clinical workforce
Audit of patient clinical record for use of screening assessment
Self
assessment
- add to
action plan
(i) Policies, procedures and/or protocols should include criteria that assist the clinical work force determine
the need to screening and or assessment. This will be risk based.
C
C
C
8.6 Conducting a
comprehensive skin
inspection in timeframes
set by best practice
guidelines on patients with
a high risk of developing
pressure injuries at
presentation, regularly as
8.5.2 The use of the
screening tool is monitored
to identify the proportion of
at-risk patients that are
screened for pressure
injuries on presentation


8.5.3 Action is taken to
maximise the proportion of
patients who are screened
for pressure injury on
presentation


8.6.1 Comprehensive skin
inspections are undertaken
using an agreed
assessment tool and
documented in the patient
clinical record for patients
at risk of pressure injuries



Australian Commission on Safety and Quality in Health Care
Audit of patient clinical record for compliance with screening requirement
Observational audit of the use of screening tool
M - add to
action plan



Risk register or log that includes actions to address identified risks
Agenda papers, meeting minutes and/or reports of relevant committee(s) that detail
improvement actions taken
Quality improvement plan includes actions to address issues identified
Examples of improvement activities that have been implemented and evaluated
Communication material developed for the workforce and/or patients
Assessment tool is included in policies, procedures and/or protocols
Report on use of assessment tool provided to clinical workforce
Audit of patient clinical record for completed assessment tool and timing of
assessments
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C/D
C
This criterion will be
achieved by:
clinically indicated during
a patient’s admission, and
before discharge
C
C
C
D
Actions required
This is not a checklist. Use only those examples that show that you have met the
Standards
8.6.2 Patient clinical
records, transfer and
discharge documentation
are periodically audited to
identify at-risk patients with
documented skin
assessments
8.6.3 Action is taken to
increase the proportion of
skin assessments
documented on patients at
risk of pressure injuries
8.7 Implementing and
monitoring pressure injury
prevention plans including
review when clinically
indicated
Examples of evidence that can be used to demonstrate an action is being met.
8.7.1 Prevention plans for
all patients at risk of a
pressure injury are
consistent with best
practice guidelines and are
documented in the patient
clinical record
8.7.2 The effectiveness
and appropriateness of
pressure injury prevention
plans are regularly
reviewed
8.7.3 Patient clinical
records are monitored to
determine the proportion of
at-risk patients that have
an implemented pressure
injury prevention plan
Australian Commission on Safety and Quality in Health Care
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Policies, procedures and/or protocols specify the nature and frequency of patient
clinical record audits
Audit of patient clinical record that shows at risk patients with documented skin
assessments
Agenda papers, meeting minutes and/or reports of relevant committees include
information relating to the audit of patient clinical records
Report to clinical workforce on audit
Provision of infrastructure, instruments, and other equipment necessary to comply
with policy, protocol and procedures are accessible to the workforce
Risk register or log that includes actions to address identified risks
Agenda papers, meeting minutes and/or reports of relevant committee(s) that detail
improvement actions taken
Quality improvement plan includes actions to address issues identified
Examples of improvement activities that have been implemented and evaluated
Communication material developed for the workforce and/or patients
Policies, procedures and/or protocols reference sources and are consistent with
national guidelines
Log of availability and use of pressure injury prevention devices
Audit of patient clinical records for compliance with policies, procedures and/or
protocols
Patient clinical record for review of an individual’s pressure injury prevention plan
Reports on the prevalence and/or incidence of pressure injury within the
organisation
Documented review of policies, procedures and/or protocols
Agenda papers, meeting minutes and/or reports of relevant committee(s)
Self
assessment
- add to
action plan
- add to
action plan
- add to
action plan
- add to
action plan
Audit of patient clinical record identifies patients with documented injury prevention
plans
Report on patients with completed pressure injury prevention plans
- add to
action plan
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C/D
D
This criterion will be
achieved by:
Actions required
Examples of evidence that can be used to demonstrate an action is being met.
This is not a checklist. Use only those examples that show that you have met the
Standards
8.7.4 Action is taken to
increase the proportion of
patients at risk of pressure
injuries who have an
implemented prevention
plan
Australian Commission on Safety and Quality in Health Care

Self
assessment
Same evidence options as 8.5.3
- add to
action plan
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Criterion: Managing pressure injuries
Patients who have pressure injuries are managed according to best practice guidelines.
C/D
C
C
C
C
This criterion will be
achieved by:
Actions required
8.8 Implementing best
practice management
and ongoing monitoring
as clinically indicated
8.8.1 An evidence-based
wound management
system is in place within
the health service
organisation
Examples of evidence that can be used to demonstrate an action is being met.
This is not a checklist. Use only those examples that show that you have met the
Standards
8.8.2 Management plans
for patients with pressure
injury management plans
are consistent with best
practice and documented
in the patient clinical record
8.8.3 Patient clinical
records are monitored to
determine compliance with
evidence-based pressure
injury management plans
8.8.4 Action is taken to
increase compliance with
evidence-based pressure
injury management plans
Australian Commission on Safety and Quality in Health Care
Self
assessment
 Policies, procedures and/or protocols describe the evidence-based wound
management system to be used
 Agenda papers, meeting minutes and/or reports of relevant committee(s) with
responsibilities for implementing and monitoring the wound management system
- add to
 Education resources and training attendance data managing pressure injuries
action plan
 Observational audit that evidence-based guidelines are accessed by the clinical
workforce
 Reports from clinical data systems
 Audits of patient clinical records
(i) Evidence-based clinical practice guidelines are the Australian Wound Management Association: Clinical
Practice Guidelines for Pressure Ulcer Prevention and Management; and standards such as the Australian
Wound Management Association Standards for Wound Management

Policies, procedures and/or protocols outline the pressure injury management plan
documentation requirements for individuals at risk of pressure injury

A management plan form that specifies the care required, requires the designation of
responsibilities for care, and states the frequency of turning, equipment needs, need
- add to
for referrals and expected outcomes
action plan

Audit of patient clinical records for completed pressure injury management plans
- add to
action plan

Same evidence options as 8.5.3
- add to
action plan
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Criterion: Communicating with patients and carers
Patients and carers are informed of the risks, prevention strategies and management of pressure injuries.
C/D
D
D
This criterion will be
achieved by:
Actions required
8.9 Informing patients
with a high risk of
pressure injury, and
their carers, about the
risks, prevention
strategies and
management of
pressure injuries
8.9.1 Patient information on
prevention and management
of pressure injuries is
provided to patients and
carers in a format that is
understood and is
meaningful
8.10 Developing a
plan of management
in partnership with
patients and carers
8.10.1 Pressure injury
management plans are
developed in partnership
with patients and carers
Examples of evidence that can be used to demonstrate an action is being met.
This is not a checklist. Use only those examples that show that you have met the
Standards









Materials used in patient education such as brochures, fact sheets, posters
Patient information that is available for distribution by the clinical workforce in a range
of formats and language
Audit of patient clinical records for patients provided with information on prevention
and management of pressure injuries
Report on available patient feedback on information provided
Information and leaflets for patients and/or carers on managing pressure injuries
Patient comments on and signs pressure injury management plan and receives a
copy
Observational audits of consumers participating in making decisions about their care
Audits of patient clinical record demonstrate the clinical workforce and patients have
collaborated in the development of pressure injury treatment plans and discharge
summaries if the individual remains at risk following discharge
Results of patient and/or carer satisfaction surveys regarding re pressure injury
management plan
Self
assessment
- add to
action plan
- add to
action plan
Link to Standard 1.18.1 and Standard 2
Additional information and resources
Australian Wound Management Association Clinical Practice Guidelines for the Prediction and Prevention of Injuries 2011:
http//www.awma.com.au/publications/publications.php#clinical
Australian Wound Management Association Standards for Wound Management 2010: www.awma.com.au
Joanna Briggs Institute, Best Practice Evidence based information sheets for Health Professionals, Pressure Injuries – prevention of pressure related damage. Volume 12,
Issue 2, 2008, ISSN: 1329-1874: www.joannabriggs.edu.au
Joanna Briggs Institute, Best Practice Evidence based information sheets for Health Professionals, Pressure Ulcers – management of pressure related tissue damage. Volume
12, Issue 3, 2008, ISSN: 1329-1874: www.joannabriggs.edu.au
Agency for Healthcare Research and Quality, Preventing Pressure Ulcers in Hospitals A Toolkit for Improving Quality of Care. www.ahrq.gov/research/ltc/pressureulcertoolkit/
Australian Commission on Safety and Quality in Health Care
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Standard 9: Recognising and Responding to Clinical Deterioration in Acute Health Care
Health service organisations establish and maintain systems for recognising and responding to clinical deterioration. Clinicians and other members
of the workforce use the recognition and response systems.
The intention of this Standard is to:
Ensure a patient’s deterioration is recognised promptly, and appropriate action is taken. #
Context
It is expected that this Standard will be applied in conjunction with Standard 1, ‘Governance for Safety and Quality in Health Service Organisations’
and ‘Standard 2 Partnering with Consumers’.
Criteria to achieve the Recognising and Responding to Clinical Deterioration in Acute Health Care Standard:
Establishing recognition and response systems
Recognising clinical deterioration and escalating care
Responding to clinical deterioration
Communicating with patients and carers
# This Standard does not apply to psychiatric deterioration associated with mental disorders.
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Criterion: Establishing recognition and response systems
Organisation-wide systems consistent with the National Consensus Statement are used to support and promote recognition of, and response to,
patients whose condition deteriorates in an acute health care facility.
C/D
C
C
This criterion will be
achieved by:
Actions required
9.1 Developing,
implementing and
regularly reviewing the
effectiveness of
governance arrangements
and the policies,
procedures and/or
protocols that are
consistent with the
requirements of the
National Consensus
Statement
9.1.1 Governance
arrangements are in place
to support the
development,
implementation and
maintenance of
organisation-wide
recognition and response
systems
Examples of evidence that can be used to demonstrate an action is being met.
This is not a checklist. Use only those examples that show that you have met the
Standards
9.1.2 Policies, procedures
and/or protocols for the
organisation are
implemented in areas
such as:

measurement and
documentation of
observations

escalation of care

establishment of a
rapid response
system

communication about
clinical deterioration



Committee terms of reference, agenda papers, meeting minutes and/or reports of
relevant committee
Position descriptions for workforce with responsibility for developing, implementing,
sustaining and monitoring recognition and response systems
Reports on actions arising from review and evaluation of recognition and response
systems
- add to
action
Link to Standard 1



Policies, procedures and/or protocols that are consistent with the requirements of the
National Consensus Statement and that cover items listed in 9.1.2
Examples of actions taken to implement policies throughout the organisation
Observational and documentation audit of compliance to policies, procedures and/or
protocols
- add to
action
(i) The recognition and response policy framework should apply across the whole organisation. The policy
should address:

governance arrangements for overseeing the performance of recognition and response systems

roles and responsibilities for key clinical and organisational support activities

resources for the recognition and response systems, such as equipment and staff

processes to support prompt and effective recognition of and response to clinical deterioration apply
across the organisation, including identification of any areas where variations to these arrangements
apply

evaluation, audit and feedback processes and tools

arrangements with external organisations that may be part of the rapid response system
Link with Standard 1
Australian Commission on Safety and Quality in Health Care
Self
assessment
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C/D
C
C
This criterion will be
achieved by:
Actions required
9.2 Collecting information
about the recognition and
response systems,
providing feedback to the
clinical workforce, and
tracking outcomes and
changes in performance
over time
9.2.1 Feedback is actively
sought from the clinical
workforce on the
responsiveness of the
recognition and response
systems
Examples of evidence that can be used to demonstrate an action is being met.
This is not a checklist. Use only those examples that show that you have met the
Standards
9.2.2 Deaths or cardiac
arrests for a patient
without an agreed
treatment-limiting order
(such as not for
resuscitation or do not
resuscitate) are reviewed
to identify the use of the
recognition and response
systems, and any failures
in these systems
9.2.3 Data collected about
recognition and response
systems are provided to
the clinical workforce as
soon as practicable

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
Report on surveys of the workforce perceptions of recognition and response systems
Feedback mechanisms for the workforce to provide for individual calls for emergency
assistance such as debriefing of the workforce involved in individual events, peer
review processes
Reports of review of specific event by relevant committee such as Medical Advisory
Committee
Policies, procedures and/or protocols describe processes for mortality reviews
Records of death reviews and reviews of cardiac arrests
Mechanism for recording deaths, a mortality review process, and outcomes of
reviews
Performance data from routine collections from the recognition and response
systems provided to the clinical workforce
Reports or documents containing data about recognition and response systems
provided to the clinical workforce
Self
assessment
- add to
action
- add to
action
- add to
action
(i) Data about the performance of recognition and response systems should be collected. This should be
reviewed against the planned operation of the system and the effectiveness of the system in improving the
recognition of and response to clinical deterioration (outcome measures). Data items that could be collected
include:

Process measures:
o existence of required policies procedures and/or protocols, such as an escalation protocol
o proportion of observation charts completed correctly
o number of calls for emergency assistance
o number of calls for emergency assistance within 24 hours of admission to the ward
o number of calls for emergency assistance with 24 hours post surgery
o details of each call for emergency assistance, including antecedents to the call, such as whether
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C/D
This criterion will be
achieved by:
Actions required
Examples of evidence that can be used to demonstrate an action is being met.
This is not a checklist. Use only those examples that show that you have met the
Standards

Self
assessment
calling criteria were triggered with no action taken
Outcome measures:
o number of cardiac arrests
o number of deaths, including deaths where the patient does not have a treatment-limiting order
o outcomes of calls for emergency assistance
o number of unplanned admissions to intensive care
o number of transfers to units or facilities with a higher level of care
Further information is available from Implementation Guide for the National Consensus Statement:
Essential Elements for Recognising and Responding to Clinical Deterioration
C
9.2.4 Action is taken to
improve the
responsiveness and
effectiveness of the
recognition and response
systems
Australian Commission on Safety and Quality in Health Care
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
Risk register or log that includes actions to address identified risks
Agenda papers, meeting minutes and/or reports of relevant committee(s) that detail
improvement actions taken
Quality improvement plan includes actions to address issues identified
Examples of improvement activities that have been implemented and evaluated
Communication material developed for the workforce and/or patients
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Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
Criterion: Recognising clinical deterioration and escalating care
Patients whose condition is deteriorating are recognised and appropriate action is taken to escalate care.
C/D
This criterion will be
achieved by:
Actions required
Examples of evidence that can be used to demonstrate an action is being
met.
Self assessment
This is not a checklist. Use only those examples that show that you have met the
Standards
D
9.3 Implementing
mechanism(s) for
recording
physiological
observations that
incorporates triggers
to escalate care when
deterioration occurs
9.3.1 When using a general observation
chart, ensure that it:

is designed according to human
factors principles

includes the capacity to record
information about respiratory rate,
oxygen saturation, heart rate, blood
pressure, temperature and level of
consciousness graphically over
time

includes thresholds for each
physiological parameter or
combination of parameters that
indicate abnormality

specifies the physiological
abnormalities and other factors that
trigger the escalation of care

includes actions required when
care is escalated
Australian Commission on Safety and Quality in Health Care


Policies, procedures and/or protocols describe the observation chart to be
used and reference resources
Patient clinical record shows the use of a general observation chart
- add to
action plan
(i) ‘Human factors’ is the study of the interactions among humans and other elements of a system, and
the profession that applies theory, principles, data and methods to design in order to optimise human
well-being and overall system performance. In this context, an observation and response chart that is
designed according to human factors principles is designed to optimise the recognition of clinical
deterioration, and to prompt an appropriate and timely response.
Key characteristics of observation and response charts that have been designed according to human
factors principles include:

Having observations listed in order of importance in detecting deterioration and in logical groups.
Because there is good evidence regarding respiratory rate as predictor for clinical deterioration, it
should be listed as the first observation to be recorded.

Ensuring that when values for an observation is categorised into discrete ranges, that these
categories are mutually exclusive.

Only including information in the main observation recording part of the chart that is critical for
recognising clinical deterioration, and responding to it appropriately. Generally this will only
include space for recording key observations graphically, the response to be taken when
deterioration is identified, and whether there are any modifications to the normal physiological
ranges for the patient.

Ensuring that the space on the chart for recording observations is close to the information about
the responses that need to be made when deterioration is identified. This reduces the potential for
cognitive and memory load and errors occurring.

Design elements that support ease of use of the chart. These include:
o recording observations as separate graphs, rather than overlaying them on the same area of
the chart
o consistent use of abbreviations, labels, fonts and formatting
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C/D
This criterion will be
achieved by:
Actions required
Examples of evidence that can be used to demonstrate an action is being
met.
Self assessment
This is not a checklist. Use only those examples that show that you have met the
Standards

C
9.3.2 Mechanisms for recording
physiological observations are regularly
audited to determine the proportion of
patients that have complete sets of
observations recorded in agreement
with their monitoring plan
9.3.3 Action is taken to increase the
proportion of patients with complete
sets of recorded observations, as
specified in the patient’s monitoring plan
C
For more information see the Developers Guide to Observation and Response Charts.

Policies, procedures and/or protocols that describe the frequency and
processes for auditing observations charts

Feedback to the clinical workforce on audits of observations charts

Results of audits of observations charts. This could be included as part of
- add to
regular documentation audit
action plan






C
9.4 Developing and
implementing
mechanisms to
escalate care and call
for emergency
assistance where
9.4.1 Mechanisms are in place to
escalate care and call for emergency
assistance
Australian Commission on Safety and Quality in Health Care
o font sizes and spaces for recording observations and writing text sufficient to allow easy use
o features to support accurate recording of observations such as dual scales within the table for
recording observations, and appropriate use of thicker horizontal and vertical lines
Using colour in a meaningful way to support the recognition of deterioration. The density of
colours should relate to the extent to which a patient’s observations are outside normal ranges.
This supports of the charts by users who have red–green colour blindness.




Orientation and ongoing education resources and attendance records
regarding importance of taking observations
Risk register or log that includes actions to address identified risks
Agenda papers, meeting minutes and/or reports of relevant committees that
detail improvement actions taken
Quality improvement plan includes actions to address issues identified
Examples of improvement activities that have been implemented and
evaluated
Communication material developed for the workforce and/or patients
Policies, procedures and/or protocols describe the process for escalation of
care
Observation of mechanisms such as signs, posters, or stickers on how to call
for assistance
Orientation and ongoing education resources and attendance records
Record of operational and mechanical call device testing
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- add to
action plan
Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
C/D
This criterion will be
achieved by:
Actions required
Examples of evidence that can be used to demonstrate an action is being
met.
Self assessment
This is not a checklist. Use only those examples that show that you have met the
Standards
C
C
there are concerns
that a patient’s
condition is
deteriorating
9.4.2 Use of escalation processes,
including failure to act on triggers for
seeking emergency assistance are
regularly audited
9.4.3 Action is taken to maximise the
appropriate use of escalation processes








Provision of data to relevant committees and clinical workforce
Review of escalation processes
Reports on the workforce survey relating to escalation of care
Education resources and training attendance records related to escalation
processes


Risk register or log that includes actions to address identified risks
Agenda papers, meeting minutes and/or reports of relevant committee(s) that
detail improvement actions taken
Quality improvement plan includes actions to address issues identified
Examples of improvement activities that have been implemented and
evaluated
Communication material developed for the workforce and/or patients



Australian Commission on Safety and Quality in Health Care
Policies, procedures and/or protocols describe the frequency and processes
for auditing escalation processes
Feedback to clinical workforce on audit of escalation processes
Results of audits of medical records
Results of audits of observations charts
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action plan
Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
Criterion: Responding to clinical deterioration
Appropriate and timely care is provided to patients whose condition is deteriorating.
C/D
This criterion will be
achieved by:
Actions required
Examples of evidence that can be used to demonstrate an action is being
met.
Self assessment
This is not a checklist. Use only those examples that show that you have met
the Standards
C
9.5 Using the system in
place to ensure that
specialised and timely
care is available to
patients whose
condition is
deteriorating
C
C
C
9.6 Having a clinical
workforce that is able to
respond appropriately
when a patient’s
condition is
deteriorating
9.5.1 Criteria for triggering a call for
emergency assistance are included in
the escalation policies, procedures
and/or protocols
9.5.2 The circumstances and outcome
of calls for emergency assistance are
regularly reviewed
9.6.1 The clinical workforce is trained
and proficient in basic life support



Link with Standard 1

Records of audits, reviews and routine data collection about calls for
emergency assistance

Agenda papers, meeting minutes and/or reports of relevant committees
outlining the review and recommended changes

Feedback to the clinical workforce on calls for emergency assistance




9.6.2 A system is in place for ensuring
access at all times to at least one
clinician, either on-site or in close
proximity, who can practise advanced
life support
Australian Commission on Safety and Quality in Health Care
Escalation policies, procedures and/or protocols that include calling criteria
Data on the use of the rapid response system
Education resources and training attendance records related to care for
patients whose condition is deteriorating
Policy, procedures and/or protocols describe the requirements and
processes for basic life support
Education resources and attendance records related to competencies in
basic life support
Record of audits, reviews and routine data collection about calls for
emergency assistance
Agenda papers, meeting minutes and/or reports of relevant committees
relating to basic life support competency of the workforce
- add to
action plan
- add to
action plan
- add to
action plan
(i) More information about advanced life support and basic life support is available from the Australian
Resuscitation Council

Policies, procedures and/or protocols describe processes for rostering 24
hour access to a clinician or ambulance officer who can practice advanced
life support

Delegation of roles and responsibilities to clinicians who can practice
- add to
advanced life support
action plan

Position descriptions, staff duty statements and/or employment contracts
that describe an individual clinician’s delegated safety and quality roles and
responsibilities

Record of currency of advance life support skills
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C/D
This criterion will be
achieved by:
Actions required
Examples of evidence that can be used to demonstrate an action is being
met.
Self assessment
This is not a checklist. Use only those examples that show that you have met
the Standards


Access to at least one clinicians or ambulance officer who can practise
advanced life support
Audit of compliance with policies, procedures and/or protocols policy
(i) Information on calls to the recognition and response system that could be collected about each call
for emergency assistance includes:

patient demographics

date and time of call, response time and stand down time

reason for the call

treatment or intervention provided

outcomes of the call, including the disposition of the patient
Australian Commission on Safety and Quality in Health Care
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Criterion: Communicating with patients and carers
Patients, families and carers are informed of recognition and response systems and can contribute to the processes of escalating care.
C/D
D
This criterion will be
achieved by:
Actions required
9.7 Ensuring patients,
families and carers are
informed about, and are
supported so that they
can participate in,
recognition and
response systems and
processes
9.7.1 Information is provided to
patients, families and carers in a
format that is understood and
meaningful. The information
should include:
This is not a checklist. Use only those examples that show that you have met the
Standards


D
9.8 Ensuring that
information about
advance care plans and
treatment-limiting orders
is in the patient clinical
record, where
appropriate
Examples of evidence that can be used to demonstrate an action is being met.
the importance of
communicating concerns
and signs and symptoms of
deterioration, which are
relevant to the patient’s
condition, to the clinical
workforce
local systems for responding
to clinical deterioration,
including how they can raise
concerns about potential
deterioration
9.8.1 A system is in place for
preparing and/or receiving
advance care plans in
partnership with patients, families
and carers







Material available for patients about recognition and response systems such as
incorporated in an information pack
Documentation that delegates responsibility for informing and orienting patients,
families and/or carers
Observation of mechanisms such as signs, posters or stickers on how to
participate in recognition and response systems and processes
Audit of patient clinical records shows that information on recognising and
responding to clinical deterioration has been provided to patients, families and/or
carers
Policies, procedures and/or protocols describe the process for preparing advanced
care directives in partnership with patients, families and/or carers
Forms of instructions used to assists with the preparation of advanced care
directives in partnership with patients, families and/or carers
Reviews of advanced care directives
- add to
action plan
- add to
action plan
(i) A range of different names can be used to describe advanced care directives and limiting treatment
orders. These include advanced care plans, living wills, respecting patient choices, not for resuscitation,
or do not resuscitate orders.
Information that can be included in an advanced care directive includes:

treatment options discussed

people involved in the discussion

patient’s wishes (if known)

specific goals of therapy

agreed treatment plan

appropriate treatment to be provided
Australian Commission on Safety and Quality in Health Care
Self
assessment
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C/D
This criterion will be
achieved by:
D
D
D
Actions required
This is not a checklist. Use only those examples that show that you have met the
Standards
9.8.2 Advance care plans and
other treatment-limiting orders
are documented in the patient
clinical record
9.9 Enabling patients,
families and carers to
initiate an escalation of
care response
Examples of evidence that can be used to demonstrate an action is being met.
9.9.1 Mechanisms are in place
for a patient, family member or
carer to initiate an escalation of
care response
9.9.2 Information about the
system for family escalation of
care is provided to patients,
families and carers
Australian Commission on Safety and Quality in Health Care



review date of plans
specific triggers required to escalate care
health professionals to be contacted when triggers are breached

Audit of patient clinical record for variance between the advanced care directives
and treatment provided
Self
assessment
- add to
action plan


Policies, procedures and/or protocols describe the process for family escalation
Information provided to families on escalation processes
- add to
action plan
(i) When developing policies, procedures and/or protocols regarding family escalation, the following
issues will need to be considered:
 the criteria for patient, family, carer to trigger an escalation of care response
 what defines a ‘critical situation’, and if the family considers the patient is not receiving the medical
attention they believe is necessary, what is sufficient reason to escalate care
 the method for activating the escalation of care response. This may include an emergency phone
number from all hospital telephones or an emergency call bell
 the response that will be provided when patients, family or carers escalate care. This may include the
attendance of a medical emergency or rapid response team, an alternative group of clinicians, or one
clinician
Further information is available from Implementation Guide for the National Consensus Statement:
Essential Elements for Recognising and Responding to Clinical Deterioration

Observation of mechanisms such as signs, posters or stickers on how to
participate in escalation processes, including information about how to call for
assistance

Information broadcast on patient television and audio service
- add to

Patient feedback on information provided
action plan
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C/D
D
D
This criterion will be
achieved by:
Actions required
Examples of evidence that can be used to demonstrate an action is being met.
This is not a checklist. Use only those examples that show that you have met the
Standards
9.9.3 The performance and
effectiveness of the system for
family escalation of care is
periodically reviewed
9.9.4 Action is taken to improve
the system performance of the
for family escalation of care
 Agenda papers, meeting minutes and/or reports from relevant committee(s) include
safety and quality of care indicators and data
 Documentation of outcomes of review of policies, procedures and/or protocols for
calls made by families
 Audit of calls made by families
 Qualitative data from communication with families
 Patient feedback survey on family escalation of care
Self
assessment
- add to
action plan
(i) Key points to consider when evaluating a family escalation system include:

level of awareness of the patient, family, carer, and the clinical workforce on the escalation system

the number of times the escalation system is triggered by a patient, family, or carer

reason for triggering escalation of care

outcome following an escalation of care
 Risk register or log that includes actions to address identified risks
 Agenda papers, meeting minutes and/or reports of relevant committee(s) that detail
improvement actions taken
 Quality improvement plan includes actions to address issues identified
- add to
 Examples of improvement activities that have been implemented and evaluated
action plan
 Communication material developed for the workforce and/or patients
Additional information and resources
Australian Commission on Safety and Quality in Health Care (2011). Implementation Guide for the National Consensus Statement: Essential Elements for Recognising and
Responding to Clinical Deterioration: www.safetyandquality.gov.au
Australian Commission on Safety and Quality in Health Care (2010). National Consensus Statement: Essential Elements for Recognising and Responding to Clinical
Deterioration, Sydney: www.safetyandquality.gov.au
Australian Commission on Safety and Quality in Health Care (2011). Recognising and Responding to Clinical Deterioration program, including work on observation chart,
www.safetyandquality.gov.au/internet/safety/publishing.nsf/Content/prog-patientsrisk-lp
Australian Resuscitation Council website contains information about advanced and basic life support: www.resus.org.au
Australian Commission on Safety and Quality in Health Care
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Standard 10: Preventing Falls and Harm from Falls
Clinical leaders and senior managers of a health service organisation implement systems to prevent patient falls and minimise harm from falls.
Clinicians and other members of the workforce use the falls prevention and harm minimisation systems.
The intention of this Standard is to:
Reduce the incidence of patient falls and minimise harm from falls.
Context
It is expected that this Standard will be applied in conjunction with Standard 1, ‘Governance for Safety and Quality in Health Service Organisations’
and Standard 2, ‘Partnering with Consumers’.
Criteria to achieve the Preventing Falls and Harm from Falls Standard:
Governance and systems for preventing falls
Screening and assessing risks of falls and harm from falling
Preventing falls and harm from falling
Communicating with patients and carers
Australian Commission on Safety and Quality in Health Care
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Criterion: Governance and systems for preventing falls
Health service organisations have governance structures and systems in place to reduce falls and minimise harm from falls.
C/D
This criterion will be
achieved by:
Actions required
Examples of evidence that can be used to demonstrate an action is being
met.
Self assessment
This is not a checklist. Use only those examples that show that you have met
the Standards
C
C
10.1 Developing,
implementing and
reviewing policies,
procedures and/or
protocols, including the
associated tools, that are
based on the current
national guidelines for
preventing falls and harm
from falls
10.1.1 Policies, procedures
and/or protocols are in use
that are consistent with best
practice guidelines (where
available) and incorporate
screening and assessment
tools




10.1.2 The use of policies,
procedures and/or protocols
is regularly monitored





C
10.2 Using a robust,
organisation-wide system
of reporting, investigation
and change management
to respond to falls
incidents
10.2.1 Regular reporting,
investigating and monitoring
of falls incidents is in place
Australian Commission on Safety and Quality in Health Care




Policies, procedures and/or protocols are evidence-based and consistent
with current national Preventing Falls and Harm from Falls Best Practice
Guidelines, where available, and incorporate screening and assessment
tools
Policies, procedures and/or protocols describe delegated roles and
responsibilities of the workforce for falls management
Agenda papers, meeting minutes and/or reports of relevant committee(s)
relating to falls and harm form falls
The Preventing Falls and Harm from Falls Best Practice Guidelines are
available and accessible to the workforce
Policies, procedures and/or protocols are accessible to the clinical workforce
Observational audit of compliance with policies, procedures and/or protocols
Patient clinical record is reviewed against policies, procedures and/or
protocols
Education and attendance at training
Reports are made to key committees, such as a Quality Activity Committee
Agenda papers, meeting minutes and/or reports of relevant committees or
key groups responsible for falls management
Reports on causes of falls incidents across the organisation, including
trends in falls incidents and causes, and near misses
Benchmarking of falls incidents
Minimum data set for reporting and recording falls
110
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action plan
- add to
action plan
Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
C/D
This criterion will be
achieved by:
Actions required
Examples of evidence that can be used to demonstrate an action is being
met.
Self assessment
This is not a checklist. Use only those examples that show that you have met
the Standards
C
10.2.2 Administrative and
clinical data are used to
monitor and investigate
regularly the frequency and
severity of falls in the health
service organisation
C
10.2.3 Information on falls is
reported to the highest level
of governance in the health
service organisation
C
10.2.4 Action is taken to
reduce the frequency and
severity of falls in the health
service organisation














C
10.3 Undertaking quality
improvement activities to
address safety risks and
ensure the effectiveness of
the falls prevention system
10.3.1 Quality improvement
activities are undertaken to
prevent falls and minimise
patient harm









Australian Commission on Safety and Quality in Health Care
Trend analysis reports on falls incident reports, adverse events and near
misses
Audit reports on patient clinical records of the frequency and severity of falls
Incidents and accidents register including data on types of injuries sustained
Falls dataset checklists
Agenda papers, meeting minutes and/or reports of relevant committees,
such as an occupational health and safety committee
Reports to coroners, departments or other authorities
Agenda papers, meeting minutes and/or reports of relevant senior executive
committees relating to falls and harm form falls
Annual reports containing falls incidents information
Clinical indicator reports to jurisdictional bodies, where applicable
Audit of patient clinical record for falls risk assessments of patients screened
and identified as being at high risk
Information provided to the workforce on falls risks
Medication reviews for patients at risk of falls
Referrals of at risk patients to services, such as physiotherapist and/or
occupational therapists, where available
Educational resources and mandatory education and training sessions for
the workforce related to falls prevention and management
Audit of environmental falls risks
Register of environmental and equipment falls hazards and actions taken
Risk register or log including actions taken
Audit patient clinical records for patients with a falls risk assessment
Risk register or log that includes actions to address identified risks
Agenda papers, meeting minutes and/or reports of relevant committee(s)
that detail improvement actions taken
Quality improvement plan includes actions to address issues identified
Examples of improvement activities that have been implemented and
evaluated
Communication material developed for the workforce and/or patients
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action plan
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action plan
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action plan
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Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
C/D
This criterion will be
achieved by:
Actions required
Examples of evidence that can be used to demonstrate an action is being
met.
Self assessment
This is not a checklist. Use only those examples that show that you have met
the Standards
C
10.4 Implementing falls
prevention plans and
effective management of
falls
10.4.1 Equipment and
devices are available to
implement prevention
strategies for patients at risk
of falling and management
plans to reduce the harm
from falls
Australian Commission on Safety and Quality in Health Care
 Agenda papers, meeting minutes and/or reports of relevant committee
responsible for evaluating the efficacy of products, equipment and devices
 Inventories of equipment and audits of clinical use
 Maintenance register or log of equipment and devices
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Criterion: Screening and assessing risks of falls and harm from falling
Patients on presentation, during admission, and when clinically indicated, are screened for risk of a fall and the potential to be harmed from falls.
C/D
This criterion will be
achieved by:
Actions required
Examples of evidence that can be used to demonstrate an action is being
met.
Self
assessment
This is not a checklist. Use only those examples that show that you have met the
Standards
C
10.5 Using a best practice
based tool to screen
patients on presentation,
during admission and when
clinically indicated for the
risk of falls
C
C
C
10.6 Conducting a
comprehensive risk
assessment for patients
identified at risk of falling in
initial screening processes
10.5.1 A best practice
screening tool is used by the
clinical workforce to identify
the risk of falls


10.5.2 Use of the screening
tool is monitored to identify the
proportion of at-risk patients
that were screened for falls


10.5.3 Action is taken to
increase the proportion of atrisk patients who are screened
for falls upon presentation and
during admission


10.6.1 A best practice
assessment tool is used by the
clinical workforce to assess
patients at risk of falling
Australian Commission on Safety and Quality in Health Care


Pre admission assessment tool
Orientation and ongoing education resources on the use of pressure injury
screening for the relevant clinical workforce
Schedule of training and attendance records for relevant clinical workforce
Audit of patient clinical records for use of screening assessment on admission
and when clinically indicated
- add to
action plan
Audit of patient clinical records for compliance with screening requirements
Observational audit of the use of screening tool
- add to
action plan




Risk register or log that includes actions to address identified risks
Agenda papers, meeting minutes and/or reports of relevant committee(s) that
detail improvement actions taken
Quality improvement plan includes actions to address issues identified
Examples of improvement activities that have been implemented and
evaluated
Communication material developed for the workforce and/or patients
Policies, procedures and/or protocols describe the assessment to be used,
that is evidence-based, consistent with national guidelines
- add to
action plan
- add to
action plan
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C/D
This criterion will be
achieved by:
Actions required
Examples of evidence that can be used to demonstrate an action is being
met.
Self
assessment
This is not a checklist. Use only those examples that show that you have met the
Standards
C
C
10.6.2 The use of the
assessment tool is monitored
to identify the proportion of atrisk patients with a completed
falls assessment
10.6.3 Action is taken to
increase the proportion of atrisk patients undergoing a
comprehensive falls risk
assessment
Australian Commission on Safety and Quality in Health Care



Audits of patient clinical records that show at risk patients
Reports on the number of patients screened and the incidence of falls
Observational audit of the use of the assessment tool
- add to
action plan

Same evidence options as 10.5.3
- add to
action plan
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Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
Criterion: Preventing falls and harm from falling
Prevention strategies are in place for patients at risk of falling.
C/D
This criterion will be
achieved by:
Actions required
Examples of evidence that can be used to demonstrate an action is
being met.
Self
assessment
This is not a checklist. Use only those examples that show that you have met
the Standards
C
10.7 Developing and
implementing a
multifactorial falls
prevention plan to
address risks identified
in the assessment
C
10.7.1 Use of best practice multifactorial
falls prevention and harm minimisation
plans is documented in the patient
clinical record
10.7.2 The effectiveness and
appropriateness of the falls prevention
and harm minimisation plan are
regularly monitored









C
10.7.3 Action is taken to reduce falls
and minimise harm for at-risk patients

Policies, procedures an/or protocols describe best practice multifactorial
falls plans and provide tools and resources
Audits of patient clinical records for the use of multifactorial fall prevention
plans
Audits of patient clinical records with a multifactorial falls prevention plan
against care provided
Root cause analysis of falls resulting in serious harm
Evaluation of patient functional status and incidents of falls and near
misses pre and post implementation of the plan
Reports form administration and clinical data that analyse trends in falls
and near misses
Agenda papers, meeting minutes and/or reports of relevant committees
or groups responsible for falls management related to falls and harm from
falls
Falls indicator data
Audits of patient clinical records with a multifactorial falls prevention plan
against care provided
Same evidence options as 10.5.3
- add to
action plan
- add to
action plan
- add to
action plan
C
10.8 Patients at risk of
falling are referred to
appropriate services,
where available, as part
of the discharge
process
10.8.1 Discharge planning includes
referral to appropriate services, where
available
Australian Commission on Safety and Quality in Health Care

Audit of patient clinical records referrals to:
o community health services
o specialist medical practitioners (such as geriatrician,
ophthalmologist)
o continence consultant or nurse
o allied health professionals such as physiotherapist, occupational
therapist, podiatrist, dietician, optometrist
115
- add to
action plan
Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
Criterion: Communicating with patients and carers
Patients and carers are informed of the identified risks from falls and are engaged in the development of a falls prevention plan.
C/D
D
D
This criterion will be
achieved by:
Actions required
10.9 Informing patients and
carer about the risk of falls,
and falls prevention
strategies
10.9.1 Patient information
on falls risks and
prevention strategies is
provided to patients and
carers in a format that is
understood and
meaningful
10.10 Developing falls
prevention plans in
partnership with patients
and carers
Examples of evidence that can be used to demonstrate an action is being met.
Self assessment
This is not a checklist. Use only those examples that show that you have met the
Standards
10.10.1 Falls prevention
plans are developed in
partnership with patients
and carers









Materials used in patient education such as brochures, fact sheets, posters
Patient information that is available for distribution by the clinical workforce in a
range of formats and language
Audit of patients’ clinical records for patients provided with information on falls
risks and prevention strategies
Report on available patient feedback on information provided
Information for patients and/or carers on falls risks and prevention strategies
Patient comments on and signs falls prevention plans and receives a copy
Observational audits of consumers participating in making decisions about their
care
Audits of patient clinical records demonstrate the clinical workforce and patients
have collaborated in the development of falls prevention plans and discharge
summaries if the individual remains at risk following discharge
Results of patient and/or carer satisfaction surveys regarding in relation to fall
prevention plan
- add to
action plan
- add to
action plan
Link to Standard 1.18.1 and Standard 2
Additional information and resources
Australian Commission on Safety and Quality in Healthcare (2009). Preventing Falls and Harm from Falls in Older People. Best Practice Guidelines for Australian Hospitals:.
www.safetyandquality.gov.au
World Health Organization. Falls links. Available from: http://www.who.int/violence_injury_prevention/other_injury/falls/links/en/index.html
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Action Plan Template
Health service organisations may choose to use this template to compile a record of areas requiring improvement strategies to address actions rated as not me
during the self assessment.
Action Plan
What needs to be done?
What risks and barriers
exist?
Australian Commission on Safety and Quality in Health Care
What strategies can be used to
implement changes?
117
Who is responsible?
What are the timeframes?
Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
Glossary
Accreditation: A status that is conferred on an organisation or an individual when they have been
assessed as having met particular standards. The two conditions for accreditation are an explicit
definition of quality (i.e. standards) and an independent review process aimed at identifying the level of
congruence between practices and quality standards. 2
Acute health care facility: A hospital or other health care facility providing healthcare services to
patients for short periods of acute illness, injury or recovery. 3
ACSQHC: Australian Commission on Safety and Quality in Health Care (the Commission).
Advance care directive: Instructions that consent to, or refuse the future use of specified medical
treatments (also known as a healthcare directive, advance plan or another similar term). 3
Advanced life support: The preservation or restoration of life by the establishment and/or maintenance
of airway, breathing and circulation using invasive techniques such as defibrillation, advanced airway
management, intravenous access and drug therapy. 3
Adverse drug reaction: A drug response that is noxious and unintended, and which occurs at doses
normally used or tested in humans for the prophylaxis, diagnosis or therapy of disease, or for the
modification of physiological function.4
Adverse event: An incident in which harm resulted to a person receiving health care.
Adverse medicines event: An adverse event due to a medicine. This includes the harm that results
from the medicine itself (an adverse drug reaction) and the potential or actual patient harm that comes
from errors or system failures associated with the preparation, prescribing, dispensing, distribution or
administration of medicines (medication incident). 5
Antibiotic: A substance that kills or inhibits the growth of bacteria.6
Antimicrobial: A chemical substance that inhibits or destroys bacteria, viruses and fungi, including
yeasts or moulds. 6
Antimicrobial stewardship: A program implemented in a health service organisation to reduce the risks
associated with increasing microbial resistance and to extend the effectiveness of antimicrobial
treatments. Antimicrobial stewardship may incorporate a broad range of strategies including the
monitoring and reviews of antimicrobial use.6
Approved patient identifiers: Items of information accepted for use in patient identification, including
patient name (family and given names), date of birth, gender, address, medical record number and/or
Individual Healthcare Identifier. Health service organisations and clinicians are responsible for specifying
the approved items for patient identification. Identifiers such as room or bed number are not to be used.
Basic life support: The preservation of life by the initial establishment of, and/or maintenance of, airway,
breathing, circulation and related emergency care, including use of an automated external defibrillator. 7
Blood: Includes homologous and autologous whole blood. Blood includes red blood cells, platelets, fresh
frozen plasma, cryoprecipitate and cryodepleted plasma. 8
Blood products: Plasma derivatives and recombinant products excluding medication products. 8
Carers: People who provide unpaid care and support to family members and friends who have a disability,
mental illness, chronic condition, terminal illness or general frailty. 9 Carers include parents and guardians
caring for children.
Clinical communication: An exchange of information that occurs between treating clinicians.
Communication can be formal (when a message conforms to a predetermined structure for example in a
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health record or stored electronic data) or informal (when the structure of the message is determined
solely by the relevant parties; for example, a face-to-face or telephone conversation.10
Clinical governance: A system through which organisations are accountable for continuously improving
the quality of their services and safeguarding high standards of care. This is achieved by creating an
environment in which there is transparent responsibility and accountability for maintaining standards and
by allowing excellence in clinical care to flourish.11
Clinical handover: The transfer of professional responsibility and accountability for some or all aspects
of care for a patient, or group of patients, to another person or professional group on a temporary or
permanent basis. 12
Clinical workforce: The nursing, medical and allied health workforce who provide patient care and
students who provide patient care under supervision. This may also include laboratory scientists. 13
Clinician: A healthcare provider, trained as a health professional. Clinicians include registered and nonregistered practitioners, or a team of health professionals providing health care who spend the majority of
their time providing direct clinical care.
Competency-based training: An approach to training that places emphasis on what a person can do in
the workplace as a result of training completion.
Complementary healthcare products: Vitamin, mineral, herbal, aromatherapy and homeopathic
products, also known as 'traditional' or 'alternative' medicines. 14
Consumer (health): Patients and potential patients, carers and organisations representing consumers’
interests. 15
Consumer medicines information: Brand-specific leaflets produced by a pharmaceutical company, in
accordance with the Therapeutic Goods Regulations (Therapeutic Goods Act 1989), to inform patients
about prescription and pharmacist-only medicines. These are available from a variety of sources: for
example, a leaflet enclosed within the medication package or supplied by a pharmacist; or a computer
printout, provided by a doctor, nurse or hospital, and obtained from the pharmaceutical manufacturer or
from the internet.4
Continuous improvement: A systematic, ongoing effort to raise an organisation’s performance as
measured against a set of standards or indicators. 16
Disease surveillance: An epidemiological practice that involves monitoring the spread of disease to
establish progression patterns. The main role of surveillance is to predict, observe and provide a
measure for strategies that may minimise the harm caused by outbreak, epidemic and pandemic
situations, as well as to increase knowledge of the factors that might contribute to such circumstances.6
Emergency assistance: Clinical advice or assistance provided when a patient’s condition has
deteriorated severely. This assistance is provided as part of the rapid response system, and is additional
to the care provided by the attending medical officer or team. 3
Environment: The overall surroundings where health care is being delivered, including the building,
fixtures, fittings and services such as air and water supply. Environment can also include other patients,
visitors and the workforce.
Escalation protocol: The protocol that sets out the organisational response required for different levels
of abnormal physiological measurements or other observed deterioration. The protocol applies to the
care of all patients at all times. 3
Fall: An event that results in a person coming to rest inadvertently on the ground or floor or another
lower level. 17
Guidelines: Clinical practice guidelines are ‘systematically developed statements to assist practitioner
and patient decisions about appropriate health care for specific circumstances’.18
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Governance: The set of relationships and responsibilities established by a health service organisation
between its executive, workforce and stakeholders (including consumers). Governance incorporates the
set of processes, customs, policy directives, laws and conventions affecting the way an organisation is
directed, administered or controlled. Governance arrangements provide the structure through which the
corporate objectives (social, fiscal, legal, human resources) of the organisation are set and the means by
which the objectives are to be achieved. They also specify the mechanisms for monitoring performance.
Effective governance provides a clear statement of individual accountabilities within the organisation to
help in aligning the roles, interests and actions of different participants in the organisation to achieve the
organisation’s objectives. In these Standards, governance includes both corporate and clinical
governance.
Hand hygiene: A general term referring to any action of hand cleansing.
Healthcare associated infections: Infections that are acquired in healthcare facilities (nosocomial
infections) or that occur as a result of healthcare interventions (iatrogenic infections). Healthcare
associated infections may manifest after people leave the healthcare facility. 19
Health outcome: The health status of an individual, a group of people or a population that is wholly or
partially attributable to an action, agent or circumstance.
Health service organisation: A separately constituted health service that is responsible for the clinical
governance, administration and financial management of a service unit(s) providing health care. A
service unit involves a grouping of clinicians and others working in a systematic way to deliver health
care to patients and can be in any location or setting, including pharmacies, clinics, outpatient facilities,
hospitals, patients’ homes, community settings, practices and clinicians’ rooms.
Health service record: Information about a patient held in hard or soft copy. The health service record
may comprise of clinical records (such as medical history, treatment notes, observations,
correspondence, investigations, test results, photographs, prescription records, medication charts),
administrative records (such as contact and demographic information, legal and occupational health and
safety reports) and financial records (such as invoices, payments and insurance information).
High-risk medicines: Medicines that have a high risk of causing serious injury or death to a patient if
they are misused. Errors with these products are not necessarily more common, but the effects can be
more devastating. Examples of high-risk medicines include anticoagulants, opioids and chemotherapy. 20
Hospital: A healthcare facility licensed by the respective regulator as a hospital or declared as a hospital.
Human factors: Study of the interactions between humans and other elements of a system, and the
profession that applies theory, principles, data and methods to design in order to optimise human
wellbeing and overall system performance.21
Incident: An event or circumstance that resulted, or could have resulted, in unintended and/or
unnecessary harm to a person and/or a complaint, loss or damage.
Infection: The invasion and reproduction of pathogenic or disease causing organisms inside the body.
This may cause tissue injury and disease. 6
Infection control or infection control measures: Actions to prevent the spread of pathogens between
people in a healthcare setting. Examples of infection control measures include targeted healthcare
associated infection surveillance, infectious disease monitoring, hand hygiene and personal protective
equipment.6
Informed consent: A process of communication between a patient and their medical officer that results
in the patient’s authorisation or agreement to undergo a specific medical intervention. 22 This
communication should ensure the patient has an understanding of all the available options and the
expected outcomes such as the success rates and/or side effects for each option. 23
Interventional procedures: Any procedure used for diagnosis or treatment that penetrates the body.
These procedures involve incision, puncture, or entry into a body cavity.
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Invasive devices: Devices inserted through skin, mucosal barrier or internal cavity, including central
lines, peripheral lines, urinary catheters, chest drains, peripherally inserted central catheters and
endotracheal tubes.
Medication: The use of medicine for therapy or for diagnosis, its interaction with the patient and its
effect.
Medication authorities: An organisation’s formal authorisation of an individual, or group of individuals,
to prescribe, dispense or administer medicines or categories of medicine consistent with their scope of
practice.
Medication error: Any preventable event that may cause or lead to inappropriate medication use or
patient harm while the medication is in the control of the healthcare professional, patient or consumer. 24
Medication history: An accurate recording of a patient’s medicines. It comprises a list of all current
medicines including all current prescription and non-prescription medicines, complementary healthcare
products and medicines used intermittently; recent changes to medicines; past history of adverse drug
reactions including allergies; and recreational drug use.25
Medication incident: See Adverse medicines event.
Medication management system: The system used to manage the provision of medicines to patients.
This system includes dispensing, prescribing, storing, administering, manufacturing, compounding and
monitoring the effects of medicines as well as the rules, guidelines, decision-making and support tools,
policies and procedures in place to direct the use of medicines. These are specific to a healthcare
setting.
Medications reconciliation: The process of obtaining, verifying and documenting an accurate list of a
patient’s current medications on admission and comparing this list to the admission, transfer, and/or
discharge medication orders to identify and resolve discrepancies. At the end of the episode of care the
verified information is transferred to the next care provider.
Medicine: A chemical substance given with the intention of preventing, diagnosing, curing, controlling or
alleviating disease, or otherwise improving the physical or mental welfare of people. Prescription, nonprescription and complementary medicines, irrespective of their administration route, are included. 26
Monitoring plan: A written plan that documents the type and frequency of observations to be recorded
as referred to in Standard 9, ‘Recognising and Responding to Clinical Deterioration in Acute Health
Care’.3
Near miss: An incident that did not cause harm, but had the potential to do so.27
Non-clinical workforce: The workforce engaged in a health service organisation who do not provide
direct clinical care but support the business of health service delivery through administration, hotel
service and corporate record management, management support or volunteering.
Non-prescription medicines: Medicines available without a prescription. Some non-prescription
medicines can be sold only by pharmacists or in a pharmacy; others can be sold through non-pharmacy
outlets. Examples of non-prescription medicines include simple analgesics, cough medicines and
antacids.26
Open disclosure: An open discussion with a patient about an incident(s) that resulted in harm to that
patient while receiving health care. The criteria of open disclosure are an expression of regret and a
factual explanation of what happened, the potential consequences and the steps taken to manage the
event and prevent recurrence.28
Orientation: A formal process of informing and training workforce upon entry into a position or
organisation, which covers the policies, processes and procedures applicable to the organisation.
Patient: A person receiving health care. Synonyms for ‘patient’ include consumer and client.
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Patient-care mismatching events: Events where a patient receives the incorrect procedure, therapy,
medication, implant, device or diagnostic test. This may be as a result of the wrong patient receiving the
correct treatment (such as the wrong patient receiving an X-ray) or as a result of the correct patient
receiving the wrong care (such as a surgical procedure performed on the wrong side of the body or the
provision of an incorrect meal, resulting in an adverse event).
Patient-centred care: The delivery of health care that is responsive to the needs and preferences of
patients. Patient-centred care is a dimension of safety and quality.
Patient clinical record: Consists of, but is not limited to, a record of the patient’s medical history,
treatment notes, observations, correspondence, investigations, test results, photographs, prescription
records and medication charts for an episode of care.
Patient information: Formal information that is provided by health services to a patient. Patient
information to ensures the patient is informed before making decisions about their health care.
Patient blood management: Involves a precautionary approach and aims to improve clinical outcomes
by avoiding unnecessary exposure to blood components. It includes the three pillars of blood
management:

optimisation of blood volume and red cell mass

minimisation of blood loss

optimisation of the patient’s tolerance of anaemia.29
Patient master index: An organisation’s permanent listing or register of health information on patients
who have received or are scheduled to receive services.30
Periodic review: Infrequent review, the frequency of which is determined by the subject, risk, scale and
nature of the review.
Point of care: The time and location where an interaction between a patient and clinician occurs for the
purpose of delivering care.
Policy: A set of principles that reflect the organisation’s mission and direction. All procedures and
protocols are linked to a policy statement.
Prescription medicine: A prescription medicine is any medicine that requires a prescription before it can
be supplied. A prescription must be authorised by an appropriately registered practitioner. 31
Pressure injuries: These are localised to the skin and/or underlying tissue, usually over a bony
prominence and caused by unrelieved pressure, friction or shearing. Pressure injuries occur most
commonly on the sacrum and heel but can develop anywhere on the body. Pressure injury is a
synonymous term for pressure ulcer.
Procedure: The set of instructions to make policies and protocols operational and are specific to an
organisation.
Protocol: An established set of rules used for the completion of tasks or a set of tasks.
Rapid response system: The system for providing emergency assistance to patients whose condition is
deteriorating. The system includes the clinical team or individual providing emergency assistance, and
may include on-site and off-site personnel. 3
Recognition and response systems: Formal systems that help workforce promptly and reliably
recognise patients who are clinically deteriorating, and appropriately respond to stabilise the patient.
3
Regular: Performed at recurring intervals. The specific interval for regular review, evaluation, audit or
monitoring and so on needs to be determined for each case. In these Standards, the time period should
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be consistent with best practice, be risk based, and be determined by the subject and nature of the
review.
Risk: The chance of something happening that will have a negative impact. It is measured by
consequences and likelihood.
Risk management: The design and implementation of a program to identify and avoid or minimise risks
to patients, employees, volunteers, visitors and the institution.
Senior level of governance: The most senior committee or individual with the delegated authority to act
or influence change to bring about improvement is care or processes.
System: The resources, policies, processes and procedures that are organised, integrated, regulated
and administered to accomplish the objective of the Standard. The system:

interfaces risk management, governance, operational processes and procedures, including
education, training and orientation

deploys an active implementation plan and feedback mechanisms

includes agreed protocols and guidelines, decision support tools and other resource material

employs a range of incentives and sanctions to influence behaviours and encourage compliance with
policy, protocol, regulation and procedures.
Training: The development of knowledge and skills.
Treatment-limiting orders: Orders, instructions or decisions that involve the reduction, withdrawal or
withholding of life-sustaining treatment. These may include ‘no cardiopulmonary resuscitation’ or ‘not for
resuscitation’.3
Workforce: All those people employed by a health service organisation.
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57. Wong MC, Yee KC, Turner P. Clinical Handover Literature Review, eHealth Services Research Group,
University of Tasmania Australia: Australian Commission on Safety and Quality in Health Care, 2008.
58. Clark E, Squire S, Heyme A, Mickle MA, Petrie E. The PACT Project: improving communication at handover.
Medical Journal of Australia 2009;190(11):S125-S127.
59. Hatten-Masterton S, Griffiths M. SHARED maternity care: enhancing clinical communication in a private
maternity setting. Medical Journal of Australia 2009;190(11):S150-S151.
60. Aldrich R, Duggan A, Lane K, Nair K, Hill K. ISBAR revisited: identifying and solving barriers to effective clinical
handover in inter-hospital transfer – public report on pilot study. Newcastle: Hunter New England Health 2009.
61. Wong MC, Yee KC, Turner P. Nursing and medical handover in general surgery, emergency medicine and
general medicine at the Royal Hobart Hospital - public report on pilot study. Hobart: University of Tasmania, 2008.
62. Graves N, Birrell FA, Whitby M. Modeling the economic losses from pressure ulcers among hospitalized patients
in Australia. Wound Repair and Regeneration 2005;13(5):462-467.
63. Van Den Bos J, Rustagi K, Gray T, Halford M, Ziemkiewicz E, Shreve J. The $17.1 Billion Problem: The Annual
Cost Of Measurable Medical Errors. Health Affairs 2011;30(4):596-603.
64. Buist M, Bernard S, Nguyen TV, Moore G, Anderson J. Association between clinical abnormal observations and
subsequent in-hospital mortality: a prospective study. Resuscitation 2004;62:137-141.
65. Calzavacca P, Licari E, Tee A, Egi M, Downey A, Quach J, et al. The impact of rapid response system on
delayed emergency team activation patient characteristics and outcomes - A follow-up study. Resuscitation
2010;81:31-35.
66. MERIT Study Investigators. Introduction of the medical emergency team (MET) system: a cluster-randomised
controlled trial. Lancet 2005;365:2091-2097.
67. Cioffi J, Salter C, Wilkes L, Vonu-Boriceanu O, Scott J. Clinicians' responses to abnormal vital signs in an
emergency department. Australian critical care 2006;19(2):66-72.
68. Endacott R, Kidd T, Chaboyer W, Edington J. Recognition and communication of patient deterioration in a
regional hospital: A multi-methods study. Australian critical care 2007;20:100-105.
69. McQuillan P, Pilkington S, Allan A, Taylor B, Short A, Morgan G, et al. Confidential inquiry into quality of care
before admission to intensive care. British Medical Journal 1998;316:1853-1858.
70. Australian Commission on Safety and Quality in Health Care. Preventing Falls and Harm From Falls in Older
People: Best Practice Guidelines for Australian Residential Aged Care Facilities 2009. Sydney: ACSQHC, 2009.
71. Australian Commission on Safety and Quality in Health Care. Preventing Falls and Harm From Falls in Older
People: Best Practice Guidelines for Australian Community Care 2009. Sydney: ACSQHC, 2009.
72. Australian Commission on Safety and Quality in Health Care. Preventing Falls and Harm From Falls in Older
People: Best Practice Guidelines for Australian Hospitals 2009. Sydney: ACSQHC, 2009.
Australian Commission on Safety and Quality in Health Care
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Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
Appendix 1 - Decision Support Tool for determining the level of performance to meet the NSQHS Standards
Issue
Policies, procedures and/or
protocols are in use
Satisfactory Performance

Documents details the date they become effective and the date
of the next revision

Source documents are referenced, particularly where they are
represented as best practice

Documents may reference the consultation processes
undertaken or collaborative group involved in their development

The documents are adapted to the specific context and setting in
which they are used by the health service

The workforce know the documents exist, can access them, and
know and use the contents

Include the tolls, forms and processes refaced in the Standards
Unsatisfactory Performance
Documentation is:

Outdated

Incomplete

Either overly complex and detailed or lacking in specificity

Not related to the organisation, for example policy developed by
another organisation or body and not adapted for use by the
health services, and/or

Not accessible or unknown to users
Monitor and report




Data sampling or collection occurs across the health service
Quality of data is known
Processes exist to test and improve the quality of the data
Feedback is provided to targeted areas and/or available across
the health service
Data presented in reports is meaningful and relevant
Data collection and reporting informs a problem area or an area
of specific risk
Timeliness of the collection and review of the data is consistent
with the issue being examined

The action being taken:
o is applicable broadly across the health service, and/or
o is readily transferable across the organisation, and/or
o focuses on key risks or priority areas identified by the
health service
Action outcomes will inform future improvement plans across the
health service or target specific risks
Action outcomes are, or will be, communicated to the workforce,
patients, and governance committees
Action is timely and responsive to issues as they arise, and/or
Action is coordinated




Action is taken to improve





Australian Commission on Safety and Quality in Health Care






Data is not sufficiently proximal to the issue being examined to
provide meaningful information
No feedback is provided or the feedback provided is not
sufficiently specific to be of use
Feedback is not available to, individuals, the workforce, units,
governance committees or areas that can make improvements,
and/or
Data is not sufficiently recent to be relevant to the current
provisioning of service
Action claims to be organisation wide, but relates to a localised
issue, process or situation and there is no clear outcome with the
transfer of lessons learned across the health service
Action is limited to an area of interest rather than an
organisational priority or risk
Significant delays exist between the identification of an issue and
action being taken, and/or
Action is disparate and not coordinated, duplicated across the
organisation
127
Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
Issue
Training
Satisfactory Performance

Training provided or accessed is matched to workforce training
needs;

A system, such as a register, is in place to track workforce
participation in training and qualifications, and/or

Training programs are evaluated
Risk Assessment




Regular review



Clear and agreed processes exist to identify risks for the
organisation and for individual service areas
A scale to rate risk is consistently applied
The risks are reviewed on a regular basis, and/or
Risks are assessed at all levels of an organisation
Review occurs across the relevant organisation or a
representative sample that is appropriate for the issue under
review;
Risk assessment is used as the basis to determine the location
and size of the sample, and/or
Frequency and timing of the review is both organisationally
appropriate and consistent with the level of risk of the issue.
Unsatisfactory Performance

Training does not address safety and quality of care needs, or
workforce training needs

The workforce are not aware of training

The workforce are not able to access training, and/or

The workforce are not given the opportunity to provide feedback
on training

There is no formal process for identifying and rating of risk, or
where risk exists, the formal process is not applied, and/or

Risks are identified and rated at an organisational level, not at an
individual service level

Reference is current and source is accepted as reputable and
authoritative, and may include professional body, published
articles, published research
May be peer reviewed, and/or
Where possible or appropriate, are consistent with national
specifications or standards.
Processes/systems:
o are responsive in their ability to address issues
o clearly delineate roles and responsibilities
o interface with risk management, governance, operational
processes and procedures for each Standard



Frequency of review is insufficient in providing information that
can be used to introduce change
Size of the review is too small or limited to provide meaningful
information
Data collected is not current, incomplete and/or poor quality
Reviewed data is not representative of all areas where the issue
occurs
The review inappropriately excludes consumers
Material or resources are not referenced, or source is not clear,
Reference material is out of date, and/or
Inconsistencies are apparent in the material or resources.


Workforce are not aware of the processes/systems, and/or
Processes/systems are cumbersome and/or not adhered to
Format of communication (for example email, posters or website
updates) is appropriate to the purpose
Language is clear and concise
Workforce are aware of the communication
Processes in place for routinely distributing relevant
communication materials are in place;
The effectiveness of the communication strategy is evaluated




Format is inappropriate for purpose
Communication is not adapted for the target audience, and/or
Key pieces of communication do not reach the target audience
Communication strategies are rarely or not evaluated




Evidence base or best
practice



Processes and/or systems
are in place

Communication





Australian Commission on Safety and Quality in Health Care
128
Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
Issue
Equipment
Satisfactory Performance
and/or

The needs of culturally and linguistically diverse populations are
taken into consideration

Communication strategies are evaluated and modified
accordingly

Workforce are trained in use of equipment and/or

Records are kept of equipment maintenance
Unsatisfactory Performance



Australian Commission on Safety and Quality in Health Care
Workforce do not know how to use the available equipment
appropriately
Equipment is not available and/or
Equipment is not maintained
129
Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
Appendix 2 - Summary of items and actions that require auditing or review by health services
Number
Audit of
clinical
information
Item or action
Review of
process
Standard 1: Governance for safety and quality in health service organisations
Completed
Yes No
1.1.1
An organisation-wide management system is in place for the development, implementation and regular review of
policies, procedures and/or protocols



1.6.1
An organisation wide quality management system is in use and regularly monitored.



1.10.1
A system is in place to defined and regularly review the scope of practice for the clinical workforce



1.11.2
The clinical workforce participates in regular performance reviews that support individual development and
improvement



1.13.1
Feedback from the workforce on their understanding and use of safety and quality systems is analysed.



1.15.3
Feedback is provided to the workforce on the analysis of reported complaints.



1.15.4
Patient feedback and complaints are reviewed by the highest level of governance in the organisation.



1.18.2
Mechanisms are in place to monitor and improve documentation of informed consent



Standard 2: Partnering with consumers
Yes No
2.4.1
Consumers and/or carers provide feedback on patient information publications prepared by the health service
organisation



2.9.2
Consumers and/or carers participate in the implementation of quality activities relating to patient feedback data



Standard 3: Preventing and controlling healthcare associated infections
Yes No

3.1.2
The use of policies, protocols and procedures is regularly monitored
3.1.3
The effectiveness of the infection prevention and control systems is regularly reviewed at the highest level of
governance in the organisation
Australian Commission on Safety and Quality in Health Care
130





Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
Number
Audit of
clinical
information
Item or action
Review of
process
Completed
Developing, implementing and auditing a hand hygiene program consistent with the current national hand hygiene
initiative



3.8.1
Compliance with the system for the use and management of invasive devices is monitored



3.10.2
Compliance with aseptic non-touch technique is regularly audited



3.11.2
Compliance with standard precautions is monitored



3.11.4
Compliance with transmission-based precautions is monitored



3.5
Developing, implementing and regularly reviewing the effectiveness of the antimicrobial stewardship system



3.15.2
Policies, procedures and/or protocols for environmental cleaning are regularly reviewed



3.15.3
An established environmental cleaning schedule is in place and environmental cleaning audits are undertaken
regularly



3.16.1
Compliance with relevant national or international standards and manufacturer’s instructions for cleaning,
disinfection and sterilisation of reusable instruments and devices is regularly monitored



3.14
Standard 4: Medication safety
4.2
Yes No
Undertaking a regular, comprehensive assessment of medication use systems to identify risks to patient safety
and implementing system changes to address the identified risks



4.3.2
The use of the medication authorisation system is regularly monitored



4.4.1
Adverse medicines incidents are regularly monitored, reported and investigated



4.5.1
The performance of the medication safety system is regularly assessed



4.9.2
The use of the information and decision support tools is regularly reviewed



4.10.1
Risks associated with secure storage and safe distribution of medicines are regularly reviewed



4.10.3
The storage of temperature-sensitive medicines is monitored



Australian Commission on Safety and Quality in Health Care
131
Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
Number
Audit of
clinical
information
Item or action
Review of
process
Completed
4.10.5
The system for disposal of unused, unwanted or expired medications is regularly monitored



4.11.1
The risks for storing, prescribing, dispensing and administration of high-risk medicines are regularly reviewed



Standard 5: Patient identification and procedure matching
Yes No





Developing, implementing and regularly reviewing the effectiveness of the patient identification and matching
system at patient handover, transfer and discharge



The process to match patients to any intended procedure, treatment or investigation is regularly monitored




5.1.1
Use of an organisation-wide patient identification system is regularly monitored
5.2.1
The system for reporting, investigation and analysis of patient care mismatching events is regularly monitored
5.4.
5.5.2
Standard 6 Clinical handover
Yes No
6.1.1
Clinical handover policies, procedures and/or protocols are used by the workforce and regularly monitored
6.1.3
Tools and guides are periodically reviewed
6.3












Monitoring and evaluating the agreed structured clinical handover processes, including
-regularly reviewing local processes based on current best practice in collaboration with clinicians, patients and
carers
-undertaking quality improvement activities and acting on issues identified from clinical handover reviews
-reviewing the results of clinical handover reviews at executive level of governance
6.4.1
Regular reporting, investigating and monitoring of clinical handover incidents is in place
Standard 7: Blood and Blood Products
Yes No
7.1.2
The use of policies, procedures and/or protocols is regularly monitored



7.2.1
The risks associated with transfusion practices and clinical use of blood and blood products are regularly
assessed



Australian Commission on Safety and Quality in Health Care
132
Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
Number
Audit of
clinical
information
Item or action
7.5.2
The patient clinical records of transfused patients are periodically reviewed to assess the proportion of records
completed
7.7.1
Regular review of the risks associated with receipt, storage and transport of blood and blood products is
undertaken
7.8.1
Blood and blood product wastage is regularly monitored
Review of
process
Completed









Standard 8: Preventing and managing pressure injuries
Yes No
8.1.2
The use of policies, procedures and/or protocols are regularly monitored.



8.2.2
Administrative and clinical data are used to regularly monitor and investigate the frequency and severity of
pressure injuries





8.3
Undertaking quality improvement activities to address safety risks and monitor the systems that prevent and
manage pressure injuries

8.5.2
The use of the screening tool is monitored to identify the proportion of at risk patients that are screened for
pressure injuries on presentation



8.6.2
Patient clinical records, transfer and discharge documentation are periodically audited to identify the proportion of
at risk patients with documented skin assessments



Implementing and monitoring pressure injury prevention plans and reviewing when clinically indicated



Patient clinical records are monitored to determine compliance with evidence-based pressure injury management
plans



8.7
8.8.3
Standard 9: Recognising and responding to clinical deterioration in acute health care
9.2.2
9.3.2
Yes No
Deaths or cardiac arrests for a patient without an agreed treatment-limiting order (such as not for resuscitation or
do not resuscitate) are reviewed to identify the use of the recognition and response systems, and any failures in
these systems

Mechanisms for recording physiological observations are regularly audited to determine the proportion of patients
with complete sets of observations recorded in accordance with the monitoring plan for that patient

Australian Commission on Safety and Quality in Health Care
133




Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
Number
Audit of
clinical
information
Item or action
Review of
process

9.5.2
The circumstances and outcome of calls for emergency assistance are regularly reviewed
9.9.3
The performance and effectiveness of the system for family escalation of care is periodically reviewed

Standard 10: Preventing falls and harm from falls
10.1
Completed




Yes No
Developing, implementing and reviewing policies, procedures and/or protocols, including the associated tools, are
based on the current national guidelines for preventing falls and harm from falls



10.2.1
Regular reporting, investigation and monitoring of falls incidents is in place



10.5.2
Use of the screening tool is monitored to identify the proportion of at risk patients that were screened for falls



10.6.2
The use of the assessment tool is monitored to identify the proportion of at risk patients with a completed falls
assessment



10.7.2
The effectiveness and appropriateness of the falls prevention and harm minimisation plan are regularly monitored


Australian Commission on Safety and Quality in Health Care
134
Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
Appendix 3 - Summary of actions that require workforce training
Item or Action
Completed
Standard
Standard 1: Governance
Yes No
1.4.2
Annual mandatory training programs to meet the requirements of these Standards 2 - 10


1.4.4
Competency-based training is provided to the clinical workforce to improve safety and quality


1.12
Ensuring that systems are in place for ongoing safety and quality education and training


The clinical workforce are trained in open disclosure processes


1.16.2
Standard 2: Partnering with Consumers
2.3
2.6.2
Yes No
Facilitating access to relevant orientation and training for consumers and/or carers partnering with the organisation


Consumers and/or carers are involved in training the clinical workforce


Standard 3: Health Associated Infection
Yes No
3.9.1
Education and competency-based training in invasive devices protocols and use is provided for the workforce who perform procedures
with invasive devices
3.10.1
The clinical workforce is trained in aseptic non-touch technique
3.18.1
Action is taken to maximise coverage of the relevant workforce trained in a competency-based program to decontaminate reusable
medical devices
Standard 9: Recognising and Responding to Clinical Deterioration in Acute Health Care
9.6.1





Yes No

The clinical workforce is trained and proficient in basic life support
Australian Commission on Safety and Quality in Health Care

135

Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
Appendix 4 - Summary of not applicable actions by day procedure type
Health Service Type
Definition
Standards
1
2
Day Procedure Services/ Independent stand-alone unit funded by a private enterprise
3
4
5
6
Day surgery hospitals
Facilities providing general and specialist
surgical procedures performed under general,
spinal, or sedation.
All Items
applicable
All Items
applicable
Item 3.14.3 may All Items
not be applicable applicable
All Items
applicable
All Items
applicable
Gynaecology
Specialist gynaecological facilities providing
surgical procedures performed under general,
spinal, or sedation.
All Items
applicable
All Items
applicable
Item 3.14.3 may All Items
not be applicable applicable
All Items
applicable
All Items
applicable
Endoscopy
Specialist facilities providing procedures
performed primarily under sedation.
All Items
applicable
All Items
applicable
Item 3.14.3 may All Items
not be applicable applicable
Item 5.3 may not All Items
be applicable
applicable
Haemotology /
Oncology
Facilities providing care and treatment for
cancer and blood disorders including:
chemotherapy, radiotherapy, pain
management, bone marrow biopsies,
blood/blood products transfusion.
Specialist facilities for treatment of infertility
including collection of eggs under sedation
All Items
applicable
All Items
applicable
Item 3.14.3 may All Items
not be applicable applicable
Item 5.3 may not All Items
be applicable
applicable
All Items
applicable
All Items
applicable
Item 3.14.3 may All Items
not be applicable applicable
Plastics / Cosmetic
surgery
Facilities providing elective care including
procedures performed under a general
anaesthetic or sedation.
All Items
applicable
All Items
applicable
Haemodialysis
Unit
Specialist facility providing treatment for kidney All Items
failure. Sedation is not generally required.
applicable
Opthamology
Unit
Specialist facility providing treatment of eye
conditions, including minor surgery under IV
sedation or local anaesthetic
Dental Practice
Dermotology Practice
In Vitro Fertilisation
7
8
9
10
May not be
Items 8.5 applicable if
8.8 may
blood not in use not be
applicable
May not be
Items 8.5 applicable if
8.8 may
blood not in use not be
applicable
Not
Items 8.5 applicable
8.8 may
not be
applicable
All items
Items 8.5 applicable
8.8 may
not be
applicable
Items
9.7 - 9.9
may not be
applicable
Items
9.7 - 9.9
may not be
applicable
Items
9.7 - 9.9
may not be
applicable
Items
9.7 - 9.9
may not be
applicable
Items
10.5-10.8
may not be
applicable
Items
10.5-10.8
may not be
applicable
Items
10.5-10.8
may not be
applicable
Items
10.5-10.8
may not be
applicable
Item 5.3 may not All Items
be applicable
applicable
Not
applicable
Items 8.5 -8.8
may not be
applicable
Item 3.14.3 may All Items
not be applicable applicable
Item 5.3 may not All Items
be applicable
applicable
Not
applicable
Items 8.5 -8.8
may not be
applicable
All Items
applicable
Item 3.14.3 may All Items
not be applicable applicable
Item 5.3 may not All Items
be applicable
applicable
All items
applicable
All Items
applicable
All Items
applicable
Item 3.14.3 may All Items
not be applicable applicable
Item 5.3 may not All Items
be applicable
applicable
Not
applicable
Practice providing dental care including minor
surgery under local anaesthetic or sedation
All Items
applicable
All Items
applicable
Item 3.14.3 may All Items
not be applicable applicable
Item 5.3 may not All Items
be applicable
applicable
Not
applicable
Specialist practice providing care of skin
conditions including minor surgery under local
anaesthetic
All Items
applicable
All Items
applicable
Item 3.14.3 may All Items
not be applicable applicable
Item 5.3 may not All Items
be applicable
applicable
Not
applicable
Items 8.5 8.8 may
not be
applicable
Items 8.5 8.8 may
not be
applicable
Items 8.5 8.8 may
not be
applicable
Items 8.5 8.8 may
not be
applicable
Items
9.7 - 9.9
may not be
applicable
Items
9.7 - 9.9
may not be
applicable
Items
9.7 - 9.9
may not be
applicable
Items
9.7 - 9.9
may not be
applicable
Items
9.7 - 9.9
may not be
applicable
Items
9.7 - 9.9
may not be
applicable
Items
10.5- 10.8
may not be
applicable
Items
10.5-10.8
may not be
applicable
Items
10.5-10.8
may not be
applicable
Items
10.5-10.8
may not be
applicable
Items
10.5-10.8
may not be
applicable
Items
10.5-10.8
may not be
applicable
Australian Commission on Safety and Quality in Health Care
136
Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
Primary Health Care
Centre
Diverse range of services eg Aboriginal and
All Items
Torres Strait Islander services, community
applicable
health. May undertake high risk procedures in
areas that are remote or have limited access to
higher level services
Australian Commission on Safety and Quality in Health Care
All Items
applicable
Item 3.14.3 may All Items
not be applicable applicable
Item 5.3 may not All Items
be applicable
applicable
137
Not
applicable
Items 8.5 8.8 may
not be
applicable
Items
9.7 - 9.9
may not be
applicable
Items
10.5-10.8
may not be
applicable
Draft National Safety and Quality Health Service Standards Guide: Day Procedure Services
Appendix 5 - Steps in determining additional not applicable actions
During the accreditation process, there may be instances where individual organisations consider that
a Standard or action is ‘not applicable’ to the operation of their health service. The proposed process
for identifying additional ‘not applicable’ actions is as follows:
1. A health service assesses an action as ‘not applicable’ and applies to the accrediting agency
providing evidence / arguments for the action to be rated as not applicable.
2. The accrediting agency confirms that an action is ‘not applicable’ for the purpose of accreditation
of that facility based on the evidence, context and precedence.
Assessment of submissions for ‘not applicable’ actions will be against agreed criteria. The
decisions of an Accrediting Agency can be appealed by health services.
All actions that are confirmed as ‘not applicable’ and the basis for the decision is provided to the
surveyor, regulator and national coordinator.
3. The surveyor assesses the evidence and makes a recommendation to the accrediting agency
making the decision on compliance.
4. The national coordinator assesses ‘not applicable’ actions to determine national trends with a view
to:




Clarifying the requirements of the action
Providing additional tools and resources for health services to met the Standard
Makes amendment to the Guides
Considers amendments to the Standards.
Draft criteria for determining not applicable items

The health service organisation demonstrates an action, criteria or Standard is not applicable
because a particular service or product is not provided by the health service organisation for
example, Blood and blood products, wrist bands.

The health service demonstrates an action, criteria or Standards has limited applicability to the
health service organisation eg Standard 9 Recognising and responding to clinical deterioration is
not be applicable in non-acute health care setting.

If a health service organisation changes the types of services offered and an action, criteria or
Standard that was previously assessed is no longer applicable.
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