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TitleStandard 1: Governance for Safety and Quality in Health Service
LanguageEnglish
File Size1.1 MB
Total Pages63
Table of Contents
                            Table of Contents
The National Safety and Quality Health Service Standards
	Safety and Quality Improvement Guides
	Additional resources
	Overarching NSQHS Standards
	Core and developmental actions
	Quality improvement approaches in health care
	Roles for safety and quality in health care
Terms and definitions
Standard 1: Governance for Safety and Quality in Health Service Organisations
Criterion: Governance and quality improvement system
Criterion: Clinical practice
Criterion: Performance and skills management
Criterion: Incident and complaints management
Criterion: Patient rights and engagement
References
Appendix: Links to resources
                        
Document Text Contents
Page 1

1
1

1
111
1

October 2012

Standard 1
Governance for Safety

and Quality in Health
Service Organisations

Safety and Quality Improvement Guide

Page 2

ISBN:
Print: 978-1-921983-27-6
Electronic: 978-1-921983-28-3

Suggested citation: Australian Commission on Safety and Quality in Health Care. Safety and Quality
Improvement Guide Standard 1: Governance for Safety and Quality in Health Service Organisations
(October 2012). Sydney. ACSQHC, 2012.

© Commonwealth of Australia 2012

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:

Australian Commission on Safety and Quality in Health Care
GPO Box 5480
Sydney NSW 2001
Email: [email protected]

Acknowledgements
This document was prepared by the Australian Commission on Safety and Quality in Health Care in
collaboration with numerous expert working groups, members of the Commission’s standing committees
and individuals who generously gave of their time and expertise.

The Commission wishes to acknowledge the work of DLA Piper and Commission staff in the development
of this document.

Page 31

Standard 1: Governance for Safety and Quality in Health Service Organisations | 29

Actions required Implementation strategies

1.8 Adopting processes to support the early identification, early intervention
and appropriate management of patients at increased risk of harm (continued)

1.8.3 Systems exist
to escalate the level
of care when there
is an unexpected
deterioration in
health status

Key task:

• Incorporate into the quality management system a systematic review of
the organisation’s policies and associated procedures and protocols for
recognising and responding to clinical deterioration, with the objective of
ascertaining whether the system is well designed and performing well

Suggested strategies:

Organisations that comply with NSQHS Standard 9: Recognising and Responding to
Clinical Deterioration in Acute Health Care will meet this action. You can undertake
monitoring of compliance with Standard 9, and associated clinical outcomes, via the
quality management system and report to the governing body, enabling it to ascertain
that the Standard has been achieved and a cycle of continuous improvement has
been implemented.

Organisations that are not required to comply with Standard 9 will still need to
implement reliable systems including policies, procedures and protocols to:

• measure and document appropriate physiological observations in accordance
with evidence-based practice

• establish a documented protocol for responding to abnormal physiological
observations including access to emergency assistance

• ensure appropriate communication with patients and carers about the risks
of possible deterioration.

Outputs of improvement processes may include:

• policies, procedures, protocols and tools to recognise and respond
to clinical deterioration

• evidence of evaluation of the effectiveness of procedures and protocols
for recognising and responding to clinical deterioration.

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30 | Australian Commission on Safety and Quality in Health Care

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

Actions required Implementation strategies

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

1.9.2 The design of
the patient clinical
record allows for
systematic audit of
the contents against
the requirements of
these Standards

Key tasks:

• Incorporate a systematic review of the organisation’s policies, procedures
and protocols for management of patient clinical records into the organisation’s
audit program, with the objective of ascertaining whether the system is
well-designed and performing well

• Review the design of the clinical record to ensure it facilitates documentation
of the relevant clinical elements of these Standards

Suggested strategies:

A clinical record is a documented account of a person’s health, illness or treatment in
hard copy or electronic format.20 It is a tool for planning provision of health care and for
contemporaneous tracking of the patient’s condition, care, services and interventions
performed by the care team. The clinical record allows for the transfer of important
clinical information between healthcare professionals. Further, it creates an historical
record of the care provided to the patient for later use for a variety of clinical, quality,
audit and research purposes. It is also a potentially rich source of information about
safety and quality of care that can be used to improve clinical and organisational
systems, and for research.

The role of the governing body and senior managers is to ensure an effective system
is in place for recording, communicating, using and securely storing patient clinical
information, for the purpose of providing safe, high quality care to individual patients
and enabling later extraction of relevant information for quality assurance, teaching
and research purposes.

A number of standards, guidelines and policies apply to clinical record documentation.
For example, the Medical Board of Australia defines medical record keeping requirements
for good medical practice.21 State health departments have published clinical record
documentation and data capture standards.20,22

You should ensure patient clinical record systems are effective and incorporate:

• a workforce which is appropriately qualified and experienced in the management
of clinical records systems, with appropriate leadership skills and authority

• policies, procedures and protocols addressing:

– standards and processes for management of clinical records (including retention,
access at the point of care, emergency access to electronic records when a
patient is unable to consent, and disposal requirements)

– standards of documentation, with a focus on the information that should
be recorded to enable monitoring of quality of care

– how changes to the clinical record are authorised

– standards and processes for establishing stand-alone clinical registries
for quality or research purposes

– the conduct of compliance audits

– legislative requirements and relevant standards.

• structures (for example, medical record committees) and processes to enable
clinical record risks and opportunities to be evaluated and changes made to improve
standards of documentation

• orientation and training of the clinical workforce in the organisation’s requirements
for clinical record documentation, including the safety and quality rationale for
those requirements

Page 62

60 | Australian Commission on Safety and Quality in Health Care

Notes

Page 63

Australian Commission on Safety and Quality in Health Care

Level 7, 1 Oxford Street, Darlinghurst NSW 2010
GPO Box 5480, Sydney NSW 2001

Phone: (02) 9126 3600 (international +61 2 9126 3600)
Fax: (02) 9126 3613 (international + 61 2 9126 3613)
Email: [email protected]
www.safetyandquality.gov.au

http://www.safetyandquality.gov.au

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