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HospitalAccreditationWorkbookOctober 2012


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ISBN:

Print: 978-1-921983-23-8

Electronic : 978-1-921983-24-5

Suggested citation: Australian Commission on Saety and Quality in Health Care.

Hospital Accredi tation Workbook. Sydney. ACSQHC, 2012.

Commonwealth o Australia 2012

This work is copyright. It may be reproduced in whole or in part or study or training purposes subject to the

inclusion o an acknowledgement o the source. Requests and inquiries concerning reproduction and rights

or purposes other than those indicated above requires the written permission o the Australian Commission

on Saety and Quality in Health Care:

Australian Commission on Saety and Quality in Health Care

GPO Box 5480

Sydney NSW 2001Email: [email protected]

Acknowledgements

This document was prepared by the Australian Commission on Saety and Quality in Health Care in

collaboration with numerous expert working groups, members o the Commissions standing committees

and individuals who generously gave o their time and expertise.

The Commission wishes to acknowledge the work o its sta in the development o this document.


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Austra lian Co mmiss ion on Sa ety and Qualit y in Heal th Care | Hospi tal Acc redit ation Wor kboo k | 1

Table o Contents: Hospital Accreditation Workbook

Introduction 3

Accreditation 4

Time rame 6

Enrolling in an accreditation program 6

Approved accredi ting agencies 6

Core and developmental actions 6

Non-applicable criteria or actions 10

Assessment and ra ting scale 15

Actions which are not met 20

Appeals p rocess 20

Accred itati on award 20

Data and reporting 20

How to use this workbook 21

Examples o evidence 24

Workbook resources 24

Addi tiona l resources 43

Terms and defnitions 44

Standard 1: Governance or Saety and Quality in Health

Service Organisations51

Governance and quality improvement systems 52Clinical practice 60

Perormance and skills management 63

Incident and complaints management 68

Patient rights and engagement 73

Standard 2: Partnering with Consumers 78

Consumer partnership in service planning 79

Consumer partnership in designing care 82

Consumer pa rtne rship in service measurement and eva luation 84

Standard 3: Preventing and Controlling Healthcare

Associated Inections87

Governance and systems or inection prevention,

control and surveillance88

Inection prevention and control strategies 94

Managing patients with inections or colonisations 100

Antim icrob ial stewardship 105

Cleaning, disinection and sterilisation 108

Communicating with patients and carers 112


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Table o Contents: Hospital Accreditation Workbook (continued)

Standard 7: Blood and Blood Products 152

Governance and systems or blood and blood product

prescribing and clinical use153

Documenting patient inormation 158

Managing blood and blood product saety 161


Standard 6: Clinical Handover 144

Governance and leadership or eective clinical handover 145

Clinical handover processes 147

Patient and carer involvement in clinical handover 151

Standard 5: Patient Identifcation and Procedure Matching 137

Identication o individual patients 138

Processes to transer care 142

Processes to match patients and their care 143

Standard 10: Preventing Falls and Harm rom Falls 192

Governance and systems or preventing alls 194

Screening and assessing ri sks o all s and harm rom al li ng 197

Preventing alls and harm rom alling 200


Reerences 203

Standard 8 : Preventing and Managing Pressure Injuries 165

Governance and systems or the prevention and managemento pressure injuries 166

Preventing pressure injuries 170

Managing pressure injuries 174


Standard 9: Recognising and Responding to Clinical

Deterioration in Acute Health Care177

Establishing recognition and response systems 178

Recognising clinical deterioration and escalating care 182

Responding to clinical deterioration 186


Standard 4: Medication Saety 113

Governance and systems or medication saety 114Documentation o patient inormation 123

Medication management processes 126

Continuity o medication management 132



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The Austral ian Commiss ion on Saety and Quali ty in Heal th Care (the Commiss ion) has

developed this Accreditation Workbook to assist hospitals to determine i they meet the

requirements o the National Saety and Quality Health Service (NSQHS) Standards.1

The NSQHS Standards were endorsed by Australian Health Ministers in 2011 and

provide a clear statement about the level o care consumers can expect rom

health service organisations. They also play an essential part in new accreditation

arrangements under the Australian Health Service Saety and Quality Accreditation

(AHSSQA) Scheme.

This Workbook ocuses on the process o accred itati on, and :

outlines the key steps in an accreditation process

provides examples o evidence that could be used to demonstrate

the NSQHS Standards have been met.

The Workbook has been deve loped or individuals wi thin health serv ice organisations

who are responsible or coordinating accreditation processes. This may includequality managers or health managers who are responsible or supporting improvement

activities in a hospital and collating the outcomes o improvement processes to provide

evidence or hospital accreditation.

Introduction


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Under the new accreditation model, state and territory health departments have

agreed that hospitals, day procedure services and public dental clinics are required

to be accredited to the NSQHS Standards. Further, some states and territories have

determined that additional health service organisations will be required to be accreditedto the NSQHS Standards. Contact the relevant state or territory health departments or

more inormation.

Accred itation is one tool , in a range o strategies, which can be used to improve saet y

and quality in a hospital. It is a way o veriying:

actions are being taken

system data is being used to inorm activity

improvements are made in saety and quality.

To be eligible or an accreditation award, a health serv ice organisation may undergo:

periods o sel-assessment

comprehensive assessment against the NSQHS Standards

interim or mid cycle assessment against some NSQHS Standards.

You can nd urther details in Figure 1.

Accreditation


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Figure 1: The accreditation process

Enrol with Accrediting Agency: Enrolled health service organisations can access inormation on processes, timing and resources available rom their accrediting

agency and ACSQHC. An accreditation process involves sel assessment and external assessments (organisation-wide assessment and mid-cycle assessment).

Sel Assessment:An assessment conducted by the health service o rganisation to review thei r processes and practices and determ ine the extent to wh ich they meet

the NSQHS Standards. Timing: Specied by accrediti ng agency.

Assessment : Assessment can be organisation-wide or mid cycle. Organisation-wide assessment is undertaken as an external visit. Mid cycle is generally an

external visit but may be a desk top assessment. The collated evidence is reviewed to determine i the actions required in the NSQHS Standards have been met.

Timing: Length o onsite assessment agreed between accrediting agency and health service.

Notiy Regulators: Health service organisations and regulators are advised by the accrediting agency

i a signicant risk has been identied. Timing: Once identied.

Response: Health service organisation implement improvements. Regulators take action appropriateto the issue. Timing: Specied by jurisdiction.

Report on Assessment: Following assessment, the accrediting agency will provide a written report o their assessment. The report will speciy all not met actions and

provide detail o why the acti on is not met.Timing: Within 7 days rom external assessment visit.

Core actions met: Routine reporting by accrediting

agencies to regulators and ACSQHC. Mid cycle,

accreditation maintained. Full assessment to all

Standards, accreditation awarded. Timing: Subject to

assessment type and accrediting agency processes.

Core actions NOT met: Health service organisations have 90 days to implement quality improvement strategies

to address not met actions. Timing: approximately 90 days rom written notication (120 days during 2013).

Re-assessment: Evidence o improvement provided by health service organisation to accrediting agency

and determination made on not met items.

Actions NOT met: Accreditation not awarded or accreditation not retained or mid cycle assessment. Quality

improvement and sel assessment process recommenced. Regulators contact ocer are inormed in writing by

accrediting agency. Timing: Health service and regulator notied.

Remediation: Health service organisation to implement improvements, address any action not met

rom accreditation process. Action will be consistent with timing and processes specied by jurisdiction.

Timing: Specied by the Re gulator.

Repeat all processes or mid-cycle

assessment and ull assessment to all

Standards across the organisation.


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Timerame

Accred itati on to the NSQHS Standards commences on 1 Januar y 2013. This means

that ater 1 January 2013, the next scheduled recertication audit or organisation-wideaccreditation visit will involve assessment against all 10 NSQHS Standards.

For a mid-cycle assessment, periodic review or surveillance audit scheduled

any time ater 1 January 2013, hospitals will not need to be assessed against

all 10 NSQHS Standards. Any mid-cycle assessment will, at a minimum, involve:

1 Standards 1, 2 and 3

2 the organisational quality improvement plan

3 recommendations rom previous accreditation assessments.

Health services or accrediting agencies may agree to additional assessment

requirements or the mid-cycle assessment.

Enrolling in an accreditation program

By selecting an approved accrediting agency, a hospital will be selecting the style and

timing o assessment against the NSQHS Standards. Not all accrediting agencies will

take the same approach. The accreditation cycle ranges rom three to our years, and

the requency and style o the mid-cycle assessment, periodic review or surveillance

audit may vary between agencies.

Approved accrediting agencies

The Commiss ion approves accred iting agencies to assess health service organisationsagainst the NSQHS Standards. In order to be able to accredit to the NSQHS Standards,

the Commission requires accrediting agencies to:

be accredited by an internationally recognised body

work with the Commission to ensure the consistent app lication o the

NSQHS Standards

provide data on accreditation outcomes to state and territory health

departments and the Commission.

A li st o all approved accred iting agencies is available on the Commiss ions webs ite

at www.saetyandquality.gov.au 2

Core and developmental actionsThe NSQHS Standards apply to a wide variety o health service organisations.

Because o the variation in size, structure and complexity o health service delivery

models a degree o fexibility is required in the application o the NSQHS Standards.

To achieve this fex ibil ity, each acti on within a Standard is des ignated as ei ther:

Core, which are critical or saety and quality. All core actions must be met

beore a hospital can achieve an accredi tation award to the NSQHS Standards; or

Developmental, which are areas where hospitals should ocus their uture

eorts and resources to improve patient saety and quality. Activity in these

areas is still required, but the actions do not need to be ully met in order to

achieve accreditation.

Commonwealth, state and territory health departments (reerred to as Regulators)

requi re hosp itals to meetallcore actions listed in Table 1 in order to achieve

accred itation to the NSQHS Standards .

Please note that in July 2012, a number o actions were re-cl assied. For hospitals,

47 actions have been classied as developmental and these are listed at Table 1.

In addition, Action 3.12.1 in Standard 3 has been re-classied as core. The Commission

will carr y out the next ormal review o all core and developmental items in 2015.

Accreditation (continued)
http://www.safetyandquality.gov.au/http://www.safetyandquality.gov.au/


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Table 1: Core and developmental actions or hospitals

Standard Core Actions Developmental Actions

Standard 1

Governance or Saety and Quality

in Health Service Organisations

1.1.1

1.1.2

1.2.1

1.2.2

1.3.1

1.3.2

1.3.3

1.5.1

1.5.2

1.6.1

1.6.2

1.7.1

1.7.2

1.8.1

1.8.2

1.8.3

1.9.1

1.9.2

1.10.1

1.10.2

1.10.3

1.10.4

1.10.5

1.11.1

1.11.2

1.12.1

1.13.1

1.13.2

1.14.1

1.14.2

1.14.3

1.14.4

1.14.5

1.15.1

1.15.2

1.15.3

1.15.4

1.17.1

1.17.2

1.18.1

1.18.2

1.19.1

1.19.2

1.20.1

1.4.1

1.4.2

1.4.3

1.4.4

1.16.1

1.16.2

1.17.3

1.18.3

1.18.4

Subtotal 44 9

Standard 2

Partnering with Consumers

2.4.1 2.4.2 2.6.1 2.7.1 2.1.1

2.1.2

2.2.1

2.2.2

2.3.1

2.5.1

2.6.2

2.8.1

2.8.2

2.9.1

2.9.2

Subtotal 4 11

Standard 3

Preventing and Controlling

Healthcare Associated Inections

3.1.1

3.1.2

3.1.3

3.1.4

3.2.1

3.2.2

3.3.1

3.3.2

3.4.1

3.4.2

3.5.1

3.5.2

3.5.3

3.6.1

3.7.1

3.8.1

3.9.1

3.10.1

3.10.2

3.10.3

3.11.1

3.11.2

3.11.3

3.11.4

3.11.5

3.12.1

3.13.1

3.13.2

3.14.1

3.14.2

3.14.3

3.14.4

3.15.1

3.15.2

3.15.3

3.16.1

3.17.1

3.18.1

3.19.1

3.4.3

3.19.2

Subtotal 39 2


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Standard 4

Medication Saety

4.1.1

4.1.2

4.2.1

4.2.2

4.3.1

4.3.2

4.3.3

4.4.1

4.4.2

4.5.1

4.5.2

4.6.1

4.6.2

4.7.1

4.7.2

4.7.3

4.9.1

4.9.2

4.9.3

4.10.1

4.10.2

4.10.3

4.10.4

4.10.5

4.10.6

4.11.1

4.11.2

4.12.1

4.12.2

4.12.3

4.12.4

4.8.1

4.13.1

4.13.2

4.14.1

4.15.1

4.15.2

Subtotal 31 6

Standard 5

Patient Identifcation and

Procedure Matching

5.1.1

5.1.2

5.2.1

5.2.2

5.3.1

5.4.1

5.5.1

5.5.2

5.5.3

Nil

Subtotal 9 0

Standard 6

Clinical Handover

6.1.1

6.1.2

6.1.3

6.2.1

6.3.1

6.3.3

6.3.4

6.4.1

6.4.2

6.3.2

6.5.1

Subtotal 9 2

Standard 7Blood and Blood Products

7.1.17.1.2

7.1.3

7.2.1

7.2.2

7.3.17.3.2

7.3.3

7.4.1

7.5.1

7.5.27.5.3

7.6.1

7.6.2

7.6.3

7.7.17.7.2

7.8.1

7.8.2

7.9.1

7.9.27.10.1

7.11.1

Subtotal 20 3


(continued)


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Standard 8

Preventing and Managing

Pressure Injuries

8.1.1

8.1.2

8.2.1

8.2.2

8.2.3

8.2.4

8.3.1

8.4.1

8.5.1

8.5.2

8.5.3

8.6.1

8.6.2

8.6.3

8.7.1

8.7.2

8.8.1

8.8.2

8.8.3

8.8.4

8.7.3

8.7.4

8.9.1

8.10.1

Subtotal 20 4

Standard 9

Recognising and Responding

to Clinical Deterioration in Acute

Health Care

9.1.1

9.1.2

9.2.1

9.2.2

9.2.3

9.2.4

9.3.2

9.3.3

9.4.1

9.4.2

9.4.3

9.5.1

9.5.2

9.6.1

9.6.2

9.3.1

9.7.1

9.8.1

9.8.2

9.9.1

9.9.2

9.9.3

9.9.4

Subtotal 15 8

Standard 10

Preventing Falls

and Harm rom Falls

10.1.1

10.1.2

10.2.1

10.2.2

10.2.3

10.2.4

10.3.1

10.4.1

10.5.1

10.5.2

10.5.3

10.6.1

10.6.2

10.6.3

10.7.1

10.7.2

10.7.3

10.8.1

10.9.1

10.10.1

Subtotal 18 2

TOTAL 209 47

(continued)


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Austr alian Co mmiss ion on Sa ety and Q ualit y in Heal th Care | Hospi tal Acc redita tion Wor kboo k | 10


Non-applicable criteria or actions

In some circumstances a Standard, criterion or action may be considered

non-applicable. Non-applicable actions are those which are inappropriate ina specic service context or or which assessment would be meaningless.

There are two ways i n which a cr iteri on or ac tion c an be c lassi ed as non-applicable :

1 The Commission has designated non-applicable actions or a health service

by category. Table 2 summarises non-applicable actions by service type.

2 During the accreditation process, there may be instances where an individual

hospital decides that a criterion or action is non-applicable. A hospital can

apply to their accredi ting agency to have either core or developmental actions

considered non-applicable. The process or applying or non-applicable actions

is outlined in Table 3.


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Table 2: Non-applicable actions or hospitals

Type oHealth serviceorganisation

Denition NSQHS Standards

1 2 3 4 5 6 7 8 9 10

Acute hospital services public or privately unded

Principal reerral Health service organisations

providing a comprehensive

range o specialist services

and complex care, including

emergency department,

outpatient and admitted

patient services. May include

satellite services.

All actions

applicable

All actions

applicable

All actions

applicable

All actions

applicable

All actions

applicable

All actions

applicable

All actions

applicable

All acti ons

applicable

All actions

applicable

All actions

applicable

Large Health service organisations

providing a wide range

o general and specialist

services, including

emergency department,

outpatient and admitted

patient services.

All acti ons

applicable

All actions

applicable

All actions

applicable

All actions

applicable

All actions

applicable

All actions

applicable

All actions

applicable

All actions

applicable

All actions

applicable

All actions

applicable

Small acute Health service organisations

providing primarily general

care, reerring and receiving

rom large and reerralhospitals. Care includes

admitted patients, at a

lower level o acuity and

complexity. This includes

small rural hospitals.

All acti ons

applicable

All actions

applicable

All acti ons

applicable

All actions

applicable

All acti ons

applicable

All actions

applicable

All acti ons

applicable

All actions

applicable

All actions

applicable

All actions

applicable



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1 2 3 4 5 6 7 8 9 10

Specialist

womens and

childrens

Health service organisations

specialising in maternity and/

or paediatric services.

All action

applicable

All actions

applicable

All actions

applicable

All actions

applicable

All actions

applicable

All actions

applicable

All actions

applicable

All acti ons

applicable

All actions

applicable

All actions

applicable

Multi-purpose Health service organisations

providing low level acute and

non-acute admitted care,

community, and residential

aged care.

All acti ons

applicable

All actions

applicable

All action

applicable

All action

applicable

All actions

applicable

All actions

applicable

May not be

applicable

i blood

and blood

products are

not held or

administered.

All actions

applicable

All actions

applicable

All actions

applicable

Sub acute hospital services public or privately unded

Rehabilitation

hospitals

Health service organisations

providing care to minimise

impairment, disability or

handicap.

All actions

applicable

All actions

applicable

All actions

applicable

All actions

applicable

All actions

applicable

All action

applicable

May not be

applicable

i blood

and blood

products are

not held or

administered.

All acti on

applicable

All action

applicable

All actions

applicable

Palliative care Health service organisations

providing end o lie care

or patients with little or no

prospect o cure.

All acti ons

applicable

All actions

applicable

All actions

applicable

All actions

applicable

All actions

applicable

All actions

applicable

Not

applicable

All actions

applicable

All actions

applicable

All actions

applicable

(continued)


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1 2 3 4 5 6 7 8 9 10

Specialist

mothercrat

hospitals

or services

(non-maternity)

Specialist health service

organisations providing

non-acute care in

mothercrat.

All Items

applicable

All Items

applicable

All Items

applicable

All Items

applicable

All Items

applicable

All Items

applicable

Not

applicable

Items

8.58.8

may not be

applicable

Not

applicable

(Meets this

requirement

under

Action 1.8.3)

All Items

applicable

Psychiatric

hospitals

Specialist health service

organisations providing care

and treatment o people with

mental health illnesses.

All Items

applicable

All Items

applicable

All Items

applicable

All Items

applicable

All Items

applicable

All Items

applicable

Not

applicable

Items

8.58.8

may not be

applicable

All Items

applicable

All Items

applicable

(continued)


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Table 3: Steps in applying or non-applicable actions

Application

A heal th ser vice o rganisation assesses an action as non-a pplicable and appl ies to the acc redi ting agency by provid ing ev idence or a rguments or the action to be rated

as non-applicable.

Assessment

Assessment o submissions or non-appl icab le act ions by the accredi ting agency w ill be aga inst c riter ia such as:

The hea lth se rvice organisati on demonstrates an ac tion, crite ria or standard is non-app licable because a par ticular ser vice o r product is not provided by the hea lth se rvi ce

organisation, or example, blood and blood products or wristbands.

The hea lth se rvice organisati on demonstrates an ac tion, crite ria or standard has limi ted applicabil ity to the servi ces i t prov ides. For example, Standard 9 : Recognisi ng and

responding to clinical deterioration is non-applicable in a non-acute health care setting.

I a health service organisation changes the types o services oered and an action, criteria or standard that was previously assessed is no longer applicable.

Conrmation

The acc redit ing agency conrms w ith the heal th ser vice organisation, surveyor and regula tor that an acti on is non-app licable or the purpose o accred itation o that ac ili ty

based on the evidence, context and precedence. A health service can appeal any decision with their accrediting agency, which will have their own appeals process.

Notication

All actions that are conrmed as non-appli cable and the basi s or the decision is provided to the Commission, as the nati onal coordinator, to determine national t rends

with a view to:

clariying the requirements o the action

providing additional tools and resources or health services to meet a Standard

making amendments to the Workbooks

considering amendments to the NSQHS Standards.


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Assessment and rating scale

Accred iting agencies may use the ir own rating scales when assess ing hospita ls, but

will be required to use the ollowing three point rating scale to report accreditation

outcomes to state and territory health departments and the Commission:

Not Met the actions required have not been achieved

Satisactorily Met the actions required have been achieved

Met with Merit in addition to achieving the actions required, measures o good

quality and a higher level o achievement are evident. This would mean a culture

o saety, evaluation and improvement is evident throughout the hospital in relation

to the action or standard under review.

This rating scale can be used to rate individual actions within a Standard and to rate

the Standard overall.

A decision support tool is prov ided in Table 4. This can be used as a guide or making

an assessment o evidence against each action.


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Table 4: Decision support tool or determining the level o perormance to meet the NSQHS Standards

This decis ion suppor t tool has been developed as general guidance or health services under taking sel-assessment. It is designed to be read in conjunction with

the 10 Saety and Quality Improvement Guides developed by the Commission.3-12

Issue Satisactory perormance Unsatisactory perormance

Policies, procedures and/or

protocols are in use

Documents detail the date they become eective and the

date o the next revision

Source documents are reerenced, particularly where they are

represented as best practice

Documents may reerence the consultation processes

undertaken or collaborative group involved in their development

The documents are ada pted to the specic context and setting

in which they are used by the health service organisation

The workorce knows the documents exist, can access them,and know and use the contents

Documentation is:

Outdated

Incomplete

Either overly complex and detailed or lacking in specicity

Not related to the organisation, or example poli cy developed

by another organisation or body and not adapted or use by

the health service organisation

Not accessible or unknown to users

Monitor and report Data sampling or collection occurs across the health

service organisation

Quality o data is known

Processes exist to test and improve the quali ty o the data

Feedback is provided to targeted areas and/or available

across the health service organisation

Data presented in reports is meaningul and relevant

Data collection and reporting inorms a problem area or an

area o specic risk Timel iness o the collection and review o the data is consistent

with the issue being examined

Data is not suciently proximal to the issue being examined

to provide meaningul inormation

No eedback is provided or the eedback provided is not

suciently specic to be o use

Feedback is not available to individuals, the workorce, units,

governance committees or areas that can make improvements

Data is not suciently recent to be relevant to the current

provisioning o service


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Action is t aken to improve The act ion being taken:

is applicable broadly across the health service organisation

is readily transerable across the organisation

ocuses on key risks or priority areas identied by

the health service organisation

Action outcomes will inorm utu re improvement plans across

the health service organisation or target specic risks

Action outcomes are, or will be, communicated to the workorce,

patients and carers, and governance committees Action is timely and responsi ve to is sues as they ar ise

Action is coo rdinated

Action claims to be organisation-wide, but re lates to a loca lised

issue, process or situation and there is no clear outcome with the

transer o lessons learned across the health service organisation

Action is limited to an a rea o interest rather than an

organisational priority or risk

Signicant delays exist between the identication o an issue

and action being taken

Action is di sparate and not coordinated, duplicated across

the organisation

Training Training p rovide d or accessed is matched to work orce

training needs

A system, such as a register, is in p lace to track workorce

participation in training and qualications

Training p rograms are eva luated

Training does not addre ss saet y and quali ty o care needs,

or workorce training needs

The workorce are not aware o tra ining

The workorce are not able to access training

The workorce are not given the oppor tunit y to provide

eedback on training

Risk assessment Clear and agreed processes exist to identiy risks or

the organisation and or individual service areas

A scale to rate risk is consistent ly applied

The ri sks are reviewed on a regular basis

Risks are assessed at all levels o a health service organisation

There is no ormal process or iden ti ying and rat ing o risk,

or where risk exists, the ormal process is not applied

Risks are identied and rated at an organisational level,

not at an individual service level

Table 4: Decision support tool or determining the level o perormance to meet the NSQHS Standards (continued)




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Regular review Review occurs across the relevant organisation or a

representative sample that is appropriate or the issue

under review

Risk assessment is used as the basis to determine the location

and size o the sample

Frequency and timing o the review is organisationally

appropriate, and consistent with the level o risk o the issue

Frequency o review is insucient in providing inormation

that can be used to introduce change

Size o the review is too small or limited to provide

meaningul inormation

Data collected is not current

Reviewed data is not representative o all areas where

the issue occurs

The rev iew inappropriately excludes consumers

Evidence-base or best practice Reerence is current and source is accepted as reputable

and authoritative, and may include p roessional body,

published articles, published research

May be peer reviewed

Where possible or appropriate, are consistent with national

specications or standards

Material or resources are not reerenced, or source i s not clear

Reerence material is out o date

Inconsistencies are apparent in the material or resources

Processes and/or systems

are in place

Processes and/or systems:

are responsive in their ability to address issues

clearly delineate roles and responsibilities

interace with risk management, governance, operationalprocesses and procedures or each Standard

The workorce are not aware o the processes and/or systems

Processes and/or systems are cumbersome and/or not

adhered to





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Communication Format o communication (or example email, posters

or website updates) is appropriate to the purpose

Language is clear and concise

Workorce is aware o the communication

Processes in place or routinely distributing relevant

communication materials are in place

The e ectiveness o the communication strategy is evaluated

The nee ds o culturally and l inguistica lly d iverse popu lations

are taken into consideration Communication strategies are evaluated and

modied accordingly

Format is inappropriate or purpose

Communication is not adapted or the target aud ience

Key pieces o communication do not reach the target aud ience

Communication strategies are rarely or not evaluated

Equipment Workorce is trained in use o equipment

Records are kept o equipment maintenance

Workorce do not know how to use the available

equipment appropriately

Equipment is not available

Equipment is not maintained

Met with merit:

For an action to be assessed as met with merit it is expected that the health service would be able to demonstrate all o the ollowing:

all o the requirements o satisactory perormance are met

the improvement is apparent in all relevant areas o the organisation

the improvement is sustainable

the improvement is built i nto day to day operations

the perormance refects the saety and quality culture o the organisation

the improvement is evaluated.





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Actions which are not met

When an accrediting agency nds a hospi tal does not meet the requirements o the

NSQHS Standards, the accrediting agency will inorm the health service organisation

in order to provide the opportunity or remedial action.

Following an assessment, hospitals will have 90 days rom the receipt o a written

report to address any not met actions beore a nal determination on accreditati on

is made. Where improvements are not implemented or patient risks not addressed,

accrediting agencies will notiy the relevant health department and an accreditation

award will not be issued.

When a signicant risk to patient saety is identied, accrediting agencies will notiy

the relevant health department immediately. The health department will then veriy

the scope, scale and implications o the reported non-compliance and will take

urther action i the hospital does not rectiy the patient saety risk. State and territory

health departments can be contacted or urther inormation about their regulatory

response process.

Appeals process

All accred iting agencies have a well -established appeals process by which hospit als

can appeal assessment decisions. Inormation on these processes should be accessed

via your approved accrediting agency.

Accreditation award

Hospitals that meet the requirements o the NSQHS Standards will be issued

an award by their accrediting agency speciying they are:

Accredited to the National Saety and Quality Health Service Standards.

In addition, awards will include:

the period o accreditation (date awarded and expiry date)

the name o the acility

a description o the services covered by the award.

Where an application or non-applicable actions has been supported by the

accrediting agency, the award will indicate that there are exclusions. These exclusions

will also be detailed on the accrediting agencys website, along with details o the

accreditation status o the hospital.

Data and reporting

The accredi tation model allows state and ter ritor y heal th departments and the

Commission to receive inormation rom accrediting agencies on the accreditation

outcomes o hospitals.

The Commiss ion wi ll use this inormation to review and maintain the NSQHS

Standards and to report to Health Ministers on the saety and quality o health service

organisations across Australia.

The o llowing data wil l be submitted to state and ter ritor y heal th departments

and the Commission: name and description o the hospital

any non-applicable Standards, criteria or actions excluded rom the

assessment process

ratings or core and developmental acti ons not met, satisactorily met and

met with merit

any high priority recommendations.

Flexible arrangements or health service organisations are in place or the

introductory year 2013, and are detailed on the Commissions website at

www.saetyandquality.gov.au 2
http://www.safetyandquality.gov.au/http://www.safetyandquality.gov.au/http://www.safetyandquality.gov.au/


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Hospitals can use this Workbook to prepare or accreditation to the NSQHS Standards

and to determine i there is sucient evidence available to demonstrate that systems

and processes meet these requirements.

Figure 2 illustrates how a Standard is presented in this Workbook. For each o theNSQHS Standards the Workbook includes:

a description o the Standard

a statement o intent or the desired outcome or the Standard

the context in which the Standard must be applied

key criteria o the Standard

a series oactions relevant to each criterion

reective questions to clariy the intent o each criterion

examples o evidence or meeting the Standards

a column to assist health services to identiy i urther action is required.

How to use this Workbook


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Figure 2: How the Standards are presented

Governance for Safety and Qualityin Health Service Organisations

Standard 1

Austral ian Commis sion on Sa fety an d Qualit y in Healt h Care | Hospital Accredit ation Work book | 51

Standard 1: Governance for Safety and Quality in HealthService Organisations

Health service organisation leaders implement governance systems to set, monitor andimprove the performance of the organisation and communicate the importance of the

patient experience and quality management to all members of the workforce. Cliniciansand 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 reliabilityand quality of patient care, as well as improve patient outcomes.

Context:

This S tandard provides the safety and qu ality g overnance f ramework for health serviceorganisations. It is expected that this Standard will apply to the implementation of allother Standards in conjunction with Standard 2: Partnering with Consumers.

Criteria to achieve the Governance for Safety and Qualityin Health Service Organisations Standard:

Governance and quality improvement systems

Clinical practice

Performance and skills management

Incident and complaints management

Patient rights and engagement

Each Standard is represented by an

icon and colour scheme or easyrecognition. Tools and resources

developed by the Commission that

relate to a specic Standard will also

display the logo and colour scheme.

The Standard describes the minimum

perormance expectations, processes

or structures that should be in place to

ensure sae and high quality services.

The context highlights the link between

Standard 1, Standard 2 and the other

eight Standards.

Each criterion groups similar items

together and sets out the areas the

Standard addresses.

The intention describes the

desired outcome o each Standard.


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Figure 2: How the Standards are presented (continued)

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

Australia n Commissio n on Saet y and Qua lity in Hea lth Care | Hospita l Accredit ation Workb ook | 56

Governance and quality improvement systems

There are in tegrated systems o gover nance to actively manag e patient saety an d quality ris ks.

Actions required Reectivequestions

Examples of evidence select only examples currently in use Evidenceavailable?

1.3 Assigning workforce roles, responsibilities and accountabilities to individuals for:

patient safety and quality in their delivery of health care

the management of safety and quality specied in each of these Standards (continued)

1.3.3 Agency orlocum workorce

are aware o theirdesignated rolesand responsibilities

How do we inormlocum or agencyworkorce otheir roles andresponsibilities or

saety and qualityo care?

Policies, procedures and protocols that address the roles and responsibilities o locum and agency workorce

Contracts or locum and agency workorce that speciy designated roles and responsibilities, including orsaety and quality

Position descriptions, duty statements and employment contracts or locum and agency workorce speciydesignated roles and responsibilities

Induction checklists

Other

No urtheraction isrequired

Yes listsource o

evidence

1.4 Implementing training in the assigned safety and quality roles and responsibilities

1.4.1 Orientationand ongoing trainingprograms providethe workorce

with the skill andinormation neededto ulfl their saety

and quality roles andresponsibilities

What training must

new memberso the workorcehave to meettheir roles andresponsibilities orsaety and quality?

How do weprovide theworkorce withthe skills andinormationnecessary ortheir roles and

responsibilities orsaety and quality?

Evidence o the assessment o training needs through review o incidents, perormance data,workorce eedback, workorce reviews, system audits and policy

Education resources and records o attendance at training by the workorce on saety and quality rolesand responsibilities

Review and evaluation reports o education and training

Feedback rom the workorce regarding their training needs

Relevant guidelines, legislation and standards that are accessible to the workorce

OtherLinks with Table 5: Summary of actions for policies, procedures and protocols

No urtheraction isrequired

Yes listsource oevidence

A heal th ser vice o rganis ation

assesses the quality o the evidence indemonstrating the action is met. I there

is insucient evidence, the No box is

there to prompt urther action.

Evidence or an action can be linked

with similar actions elsewhere in this

or other Standards.

Reective questions help

health service organisations

consider the intent o the action.

Actions

describe what

must be done.

The

criterion.

Items describe

how a criterion

is to be met.

Services do not need to meet all the evidence listed. This is only a guide.

Other examples o evidence may be applicable. When used, it is recommended

that other evidence be documented here.

Actions that are:

unshaded are core and thereore

must be met

shaded are developmental and

health service organisations need

to demonstrate they are working

towards implementation.


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Austra lian Co mmissi on on Sae ty and Qu ality in Heal th Care | Hospi tal Ac credit ation Wo rkboo k | 24

How to use this Workbook (continued)

Examples o evidence

This Workbook includes examples o the kind o ev idence a hospita l may use to

demonstrate that it meets each o the actions required or the NSQHS Standards.

The evidence list is designed to assist a hospi tal to show that :

saety and quality processes and systems are in place

they are reviewed and evaluated

practices are changed when necessary.

The l ist can be used as a checklist, but remember that this Workbook does not cover

all possible sources o evidence that could be used by a hospital. You may want to use

additional or alternative examples o evidence that are not included in the list and you

can indicate this by ticking the Other box. It is not expected that a hospital will have

all the listed examples in place. This is because hospitals vary in size and structure,

and will have dierent ways o developing and presenting the evidence. For example,

a large organisation is more likely to have ormal committees and processes in place,

and thereore have ormal meeting agendas, minutes and repor ts. In contrast, a smaller

organisation may have structured meetings rather than committees and thereore

use dierent types o records such as meeting notes, workorce message books

and issues logs.

Quality improvement is an ongoing process. This means that activities aimed at

minimising risks to patients, employees, visitors and the organisation will be in

various stages o review and implementation. Not all strategies and actions will be

applicable or a priority in all parts o the health service organisation. You do not need

to demonstrate implementation o strategies in all parts o an organisation or an action

to be met, particular ly i they are areas o l ow risk or where the strategies may have

limited application.

Each hospital should interpret the evidence listed with regard to its own model o

service delivery. I a hospital nds there is insucient evidence available to demonstrate

an action has been met, select the No box in the last column o the Workbook tables

(see Figure 2) to prompt urther act ion to address identied gaps.

It is not expected that hospitals will have every orm o evidence provided in the

list o examp les. You are st rongly encouraged to provide only enough evidence to

show act ions a re be ing addressed. The evidence used would typ ical ly come rom

the usual business process improvement strategies you have in place, rather t han

strateg ies developed specifcally or accredi tation.

Workbook resources

A major ocus o the Commissions work is to suppor t heal th ser vice o rganisations to

implement the NSQHS Standards. This Workbook contains a number o tools to assist

hospitals to prepare or accreditation. These include:

Summary o actions or policies, procedures and protocols many o the

NSQHS Standards include a requirement to establish a process or developing,

reviewing and updating policies, procedures and protocols. These are summarised

in Table 5.

Summary o actions or training Table 6 will assist health service organisations

to identiy which NSQHS Standards require the workorce to participate in education

and training activities.

Summary o actions related to the patient clinical record This is in Table 7.

Summary o actions that require data collection or audit or review auditing

and review are key elements in many o the NSQHS Standards. These actions are

listed in Table 8. Terms and defnitions an explanation o key terms used throughout

this Workbook.


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Table 5: Summary o actions or policies, procedures and protocols

An overarch ing requirement o the NSQHS Standards is to establish a process or developing, reviewing and updating policies, procedures and protocols.

The table below will assis t hea lth service organisations to identiy criteria and act ions relating to po licies, procedures and protocols.

Key: C = Core action; D = Developmental action

This criterion will be achieved by: Actions required: C/D

1.1 Implementing a governance system that sets out the polici es, procedures

and/or protocols or:

establishing and maintaining a clinical governance ramework

identiying saety and quality risks

collecting and reviewing perormance data

implementing prevention strategies based on data analysis

analysing reported incidents

implementing perormance management procedures

ensuring compliance with legislative requirements and relevant

industry standards

communicating with and inorming the clinical and non-clinical workorce

undertaking regular clinical audits

1.1.1 An organisa tion-wide management system i s in p lace or the

development, implementation and regular review o policies,

procedures and/or protocols

C

1.17 Implementing through organisational policies and practices a patient

charter o rights that is consistent with the current national charter o

healthcare rights

1.17.1 The organisation has a charter o patient rights that is consistent with the

current national charter o healthcare rights

C

2.2 Implementing policies, procedures and/or protocols or partnering withpatients, carers and consumers in:

strategic and operational/services planning

decision making about saety and quality initiatives

quality improvement activities

2.2.1 The health service organisation establishes mechanisms or engagingconsumers and/or carers in the strategic and/or operational planning or

the organisation

D


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3.1 Developing and implementing governance systems or eective inection

prevention and control to minimise the ri sk to patients o healthcare

associated inections

3.1.1 A risk management approach is taken when implementing policies,

procedures and/or protocols or:

standard inection control precautions

transmission-based precautions

aseptic technique

sae handling and disposal o sharps

prevention and management o occupational exposure to bloodand body substances

environmental cleaning and disinection

antimicrobial prescribing

outbreaks or unusual clusters o communicable inection

processing o reusable medical devices

single-use devices

surveillance and reporting o data where relevant

reporting o communicable and notiable diseases

provision o risk assessment guidelines to workorce

exposure-prone procedures

C

3.1.2 The use o policies, procedures and/or protocols is regularly monitored C

3.1.4 Action is taken to improve the eectiveness o inection prevention and

control policies, procedures and/or protocols

C

(continued)


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3.7 Promoting collaboration with occupational health and saety programs

to decrease the risk o inection or injury to healthcare workers

3.7.1 Inection prevention and control consultation related to occupational

health and saety policies, procedures and/or protocols are implemented

to address:

communicable disease status

occupational management and prophylaxis

work restrictions

personal protective equipment assessment o risk to healthcare workers or occupational allergies

evaluation o new products and procedures

C

3.13 Developing and implementing protocols relating to the admission,

receipt and transer o patients with an inection

3.13.1 Mechanisms are in use to check or pre-existing healthcare associated

inection or communicable disease on presentation or care

C

(continued)


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Austra lian Co mmiss ion on S aety an d Qualit y in Heal th Care | Hospi tal Ac credit ation Wo rkboo k | 28







3.15 Using risk management principles to implement systems that maintain a

clean and hygienic environment or patie nts and healthcare workers

3.15.1 Policies, procedures and/or protocols or environmental cleaning

that address the principles o inection prevention and control are

implemented, including:

maintenance o building acilities

cleaning resources and services

risk assessment or cleaning and disinection based on transmission-based

precautions and the inectious agent involved

waste management within the clinical e nvironment

laundry and linen transportation, cleaning and storage

appropriate use o personal protective equipment

C

3.15.2 Policies, procedures and/or protocols or environmental cleaning

are regularly reviewed

C

4.1 Developing and implementing governance arrangements and organisational

policies, procedures and/or protocols or medication saety, which are

consistent with national and jurisdictional legislative requirements, policies

and guidelines

4.1.2 Policies, procedures and/or protocols are in place that are

consistent with legislative requirements, national, jurisdictional and

proessional guidelines

C

(continued)


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5.1 Developing, implementing and regularly reviewing the eectiveness

o a patient identication system including the associated policies,

procedures and/or protocols that:

dene approved patient identiers

require at least three approved patient identiers on registration or admission

require at least three approved patient identiers when care, therapy or other

services are provided

require at least three approved patient identiers whenever clinical handover,

patient transer or discharge documentation i s generated

5.1.1 Use o an organisation-wide patient identication system is

regularly monitored

C

6.1 Developing and implementing an organisational system or

structured clinical handover that is relevant to the healthcare

setting and specialities, including:

documented policy, procedures and/or protocols

agreed tools and guides

6.1.1 Clinical handover policies, procedures and/or protocols are used by

the workorce and regularly monitored

C

6.1.2 Action is taken to maximise the eectiveness o clinical handover policies,

procedures and/or protocols

C

6.2 Establishing and maintaining structured and documented processes or

clinical handover

6.2.1 The workorce has access to documented structured processes

or clinical handover that include:

preparing or handover, including setting the location and time whilst

maintaining continuity o patient care

organising relevant workorce members to participate

being aware o the clinical context and patient needs

participating in eective handover resulting in transer o responsibility and

accountability or care

C

(continued)


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Austra lian Co mmiss ion on S aety an d Qualit y in Heal th Care | Hospi tal Acc redit ation Wo rkboo k | 30







7.1 Developing governance systems or sae and appropriate prescr iption,

administration and management o blood and blood products

7.1.1 Blood and blood product policies, procedures and/or protocols are

consistent with national evidence-based guidelines or pre-transusion

practices, prescribing and clinical use o blood and blood products

C

7.1.2 The use o policies, procedures and/or protocols is regularly monitored C

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

C

8.1.2 The use o policies, procedures and/or protocols are regularly monitored C


o governance arrangements and the policies, procedures and/or

protocols that are consistent with the requirements o the National

Consensus Statement

9.1.2 Policies, procedures and/or protocols or the organisation are

implemented in areas such as:

measurement and documentation o observations

escalation o care

establishment o a rapid response system

communication about clinical deterioration

C

10.1 Developing, implementing and reviewing policies, procedures and/or

protocols, including the associated tools, that are based on the current

national guidelines or preventing alls and harm rom alls

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

C

(continued)


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Table 6: Summary o training actions

The table below w ill assis t heal th ser vice o rganisations ident iy which NSQHS Standards require the workorce to participate in education and training.

Health service organisations will need to identiy their saety and quality risks as well as the workorce knowledge and skills required to address these risks.Completing an assessment o traini ng needs, and strategies to address these needs, means that training can be targeted to the rel evant members o the workorce.



1.4 Implementing training in the assigned saety and quality roles

and responsibilities

1.4.1 Orientation and ongoing training programs provide the workorce with

the skill and inormation needed to ull their saety and quality roles


D

1.4.2 Annual mandatory training programs to meet the requirements

o these Standards

D

1.4.3 Locum and agency workorce have the necessary inormation, traini ng

and orientation to the workplace to ull their saety and quality roles


D

1.4.4 Competency-based training is provided to the clinical workorce to

improve saety and quality

D

1.12 Ensuring that systems are in place or ongoing saety and quality

education and training

1.12.1 The clinical and relevant non-clinical workorce have access to ongoing

saety and quality education and training or identied proessional and

personal development

C

1.16 Implementing an open disclosure process based on the national open

disclosure standard

1.16.2 The clinical workorce are trained in open disclosure processes D

2.3 Facilitating access to relevant orientation and training or consumers

and/or carers partnering with the organisation

2.3.1 Health service organisations provide orientation and ongoing training or

consumers and/or carers to enable them to ull their partnership role

D


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Table 6: Summary o training actions

The table below w ill assis t heal th ser vice o rganisations ident iy which NSQHS Standards require the workorce to participate in education and training.

Health service organisations will need to identiy their saety and quality risks as well as the workorce knowledge and skills required to address these risks.Completing an assessment o traini ng needs, and strategies to address these needs, means that training can be targeted to the rel evant members o the workorce.



2.6 Implementing training or clinical leaders, senior management and the

workorce on the value o and ways to acili tate consumer engagement

and how to create and sustain partnerships

2.6.1 Clinical leaders, senior managers and the workorce access training on

patient-centred care and the engagement o individuals in their care

C

2.6.2 Consumers and/or carers are involved in training the clinical workorce D

3.9 Implementing protocols or invasive device procedures regularly perormedwithin the organisation

3.9.1 Education and competency-based training in invasive device s protocolsand use is provided or the workorce who perorm procedures with

invasive devices

C

3.10 Developing and implementing protocols or aseptic technique 3.10.1 The clinical workorce is trained in aseptic technique C

3.18 Ensuring workorce who decontaminate reusable medical devices

undertake competency-based training in these practices

3.18.1 Action is taken to maximise coverage o the rel evant workorce

trained in a competency-based program to decontaminate reusable

medical devices

C

9.6 Having a clinical workorce that is able to respond appropriately when

a patients condition is deteriorating

9.6.1 The clinical workorce is trained and procient in basic lie support C

(continued)


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Austr alian Co mmissi on on Sae ty and Qu ality in Heal th Care | Hospi tal Acc redita tion Wor kbook | 33


Table 7: Summary o actions related to the patient clinical record

The table below w ill assis t heal th ser vice o rganisations to identi y cri teria and ac tions relati ng to pa tient clin ical records.



1.9 Using an integrated patient clinical record that identies all aspects

o the patients care

1.9.1 Accurate, integrated and readily accessible patient clinical records

are available to the clinical workorce at the point o care

C

1.9.2 The design o the patient clinical record allows or systematic audit

o the contents against the requirements o these Standards

C

1.18 Implementing processes to enable partnership with patients in decision

about their care, including inormed consent to treatment

1.18.2 Mechanisms are in place to monitor and improve documentation

o inormed consent

C

4.6 The clinical workorce taking an accurate medication history when a patient

presents to a health service organisation, or as early as possible in the

episode o care, which is then available at the point o care

4.6.1 A best possible medication history is documented or each patient C

4.7 The clinical workorce documenting the patients previously known adverse

drug reactions on initial presentation and updating this i an adverse

reaction to a medicine occurs during the episode o care

4.7.1 Known medication allergies and adverse drug reactions are documented

in the patient clinical record

C

4.8 The clinical workorce reviewing the patients current medication orders

against their medication history and prescribers plan, and reconciling

any discrepancies

4.8.1 Current medicines are documented and reconciled at admission

and transer o care between healthcare settings

D

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 patients clinical record

D


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7.5 As part o the patient treatment plan, the clinical workorce

accurately documenting:

relevant medical conditions

indications or transusion

any special product or transusion requirements

known patient transusion history

type and volume o product transusion

patient response to transusion

7.5.1 A best possible history o blood product usage and relevant clinical and

product inormation is documented in the patient clinical record

C

7.5.2 The patient clinical records o transused patients are periodically

reviewed to assess the proportion o records completed

C

7.5.3 Action is taken to increase the proportion o patient clinical records

o transused patients with a complete patient clinical record

C

7.6 The clinical workorce documenting any adverse reactions to blood

or blood products

7.6.1 Adverse reactions to blood or blood products are documented in the

patient clinical record

C

7.11 Implementing an inormed consent process or all blood and

blood product use

7.11.1 Inormed consent is undertaken and documented or all transusions o

blood or blood products in accordance with the inormed consent policy

o the health service organisation

D

8.5 Identiying risk actors or pressure injuries using an agreed screening tool

or all presenting patients within timerames set by best practice guidelines

8.5.2 The use o the screening tool is monitored to identiy the proportion o

at-risk patients that are screened or pressure injuries on presentation

C

8.6 Conducting a comprehensive skin inspection in timerames set by best

practice guidelines on patients with a high risk o developing pressure

injuries at presentation, regularly as clinically indicated during a patients

admission, and beore discharge

8.6.1 Comprehensive skin inspections are undertaken using an agreed

assessment tool and documented in the patient clinical record or

patients at risk o pressure injuries

C

(continued)


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8.7 Implementing and monitoring pressure injury prevention plans and

reviewing when clinically indicated

8.7.1 Prevention plans or all patients at risk o a pressure injury are

consistent with best practice guidelines and are documented in

the patient clinical record

C

8.7.3 Patient clinical records are monitored to determine the proportion o

at-risk patients that have an implemented pressure injury prevention plan

D

8.8 Implementing best practice management and ongoing monitoring

as clinically indicated

8.8.2 Management plans or patients with pressure injuries are consistent

with best practice and documented in the patient clinical record

C

8.8.3 Patient clinical records are monitored to determine compliance with

evidence-based pressure injury management plans

C

9.8 Ensuring that inormation about advance care plans and treatment-limiting

orders is in the patient clinical record, where appropriate

9.8.2 Advance care plans and other treatment-limiting order s are documented

in the patient clinical record

D

10.7 Developing and implementing a multiactorial alls prevention plan to

address risks identied in the assessment

10.7.1 Use o best practice multiactorial alls prevention and harm minimisation

plans is documented in the patient clinical record

C


(continued)


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Table 8: Summary o actions that require data collection or audit or review

The table below identies wh ich o the NSQHS Standards require health service organisations to undertake sample or comprehensive audits or reviews.



1.6 Establishing an organisation-wide quality management system that

monitors and reports on the saety and quality o patient care and inorms

changes in practice

1.6.1 An organisation-wide quality management system is used and

regularly monitored

C

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 workorce

C

1.7.2 The use o agreed clinical guidelines by the clinical workorce is monitored C

1.10 Implementing a system that determines and regularly reviews the

roles, responsibilities, accountabilities and scope o practice or

the clinical workorce

1.10.2 Mechanisms are in place to monitor that the clinical workorce are

working within their agreed scope o practice

C

1.18 Implementing processes to enable partnership with patients in decision

about their care, including inormed consent to treatment

1.18.2 Mechanisms are in place to monitor and improve documentation

o inormed consent

C

3.5 Developing, implementing and auditi ng a hand hygiene program consistent

with the current national hand hygiene initiative

3.5.1 Workorce compliance with current national hand hygiene guidelines

is regularly audited

C

3.8 Developing and implementing a system or use and management oinvasive devices based on the current national guidelines or preventing

and controlling inections in health care

3.8.1 Compliance with the system or the use and management o invasivedevices is monitored

C

3.10 Developing and implementing protocols or aseptic technique 3.10.2 Compliance with aseptic technique is regularly audited C



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3.11 Implementing systems or using standard precautions and transmission-

based precautions

3.11.2 Compliance with standard precautions is monitored C

3.11.4 Compliance with transmission-based precautions is monitored C


o the antimicrobial stewardship system

3.14.3 Monitoring o antimicrobial usage and resistance is undertaken C

3.15 Using risk management principles to implement systems that maintain

a clean and hygienic environment or pati ents and healthcare workers

3.15.3 An established environmental cleaning schedule is in place and

environmental cleaning audits are undertaken regularly

C

3.16 Reprocessing reusable medical equipment, instruments and devices

in accordance with relevant national or international standards and

manuacturers instructions

3.16.1 Compliance with relevant national or international standards and

manuacturers instructions or cleaning, disinection and sterilisation

o reusable instruments and devices is regularly monitored

C

4.2 Undertaking a regular, comprehensive assessment o medication use

systems to identiy risks to patient saety and implementing system

changes to address the identied risks

4.2.1 The medication management system is regularly assessed C

4.3 Authorising the relevant clinical workorce to prescribe, dispense

and administer medications

4.3.2 The use o the medication authorisation system is regularly monitored C

4.4 Using a robust organisation-wide system o repor ting, investigating

and managing change to respond to medication incidents

4.4.1 Medication incidents are regularly monitored, reported and investigated C

4.5 Undertaking quality improvement activities to enhance the saety

o medicines use

4.5.1 The perormance o the medication management system is

regularly assessed

C


(continued)


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Austr alian Co mmissi on on Sae ty and Qu ality in Heal th Care | Hospi tal Acc redita tion Wor kbook | 38





4.7 The clinical workorce documenting the patients previously known adverse

drug reactions on initial presentation and updating this i an adverse

reaction to a medicine occurs during the episode o care

4.7.3 Adverse drug reactions are reported within the organisation and

to the Therapeutic Goods Administration

C

4.9 Ensuring that current and accurate medicines inormation and decision

support tools are readily available to the clinical workorce when making

clinical decisions related to medicines use

4.9.2 The use o the inormation and decision support tools are

regularly reviewed

C

4.10 Ensuring that medicines are distributed and stored securely, saely and inaccordance with the manuacturers directions, legislation, jurisdictional

orders and operational directives

4.10.1 Risks associated with secure storage and sae distribution o medicinesare regularly reviewed

C

4.10.3 The storage o temperature-sensitive medicines is monitored C

4.10.5 The system or disposal o unused, unwanted or expired medications

is regularly monitored

C

4.11 Identiying high-risk medicines in the organisation and ensuring they

are stored, prescribed, dispensed and administered saely

4.11.1 The risks or storing, prescribing, dispensing and administration o

high-risk medicines are regularly reviewed

C

5.2 Implementing a robust organisation-wide system o reporting, investigationand change management to respond to any patient care mismatching

events

5.2.1 The system or reporting, investigating and analysis o patient caremismatching events is regularly monitored

C


o the patient identication and matching system at patient handover,

transer and discharge

5.4.1 A patient identication and matching system is implemented and

regularly reviewed as part o structured clinical handover, transer and

discharge processes

C


(continued)


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Key: C = Core action;D = Developmental action


5.5 Developing and implementing a documented process to match patients

to their intended procedure, treatment or investigation and implementing

the consistent national guidelines or patient procedure matching protocol

or other relevant protocols

5.5.2 The process to match patients to any intended procedure, treatment

or investigation is regularly monitored

C

6.1 Developing and implementing an organisational system or structured

clinical handover that is relevant to the healthcare setting and specialities,

including:

documented policy, procedures and/or protocols

agreed tools and guides

6.1.3 Tools and guides are periodically reviewed C

6.3 Monitoring and evaluating the agreed structured clinical handover

processes, including:

regularly reviewing loca