1. Clinical Governance

Safety and quality training

Action 1.19

The health service organisation provides orientation to the organisation that describes roles and responsibilities for safety and quality for:

a. Members of the governing body

b. Clinicians, and any other employed, contracted, locum, agency, student or volunteer members of the organisation

Intent

Members of the governing body and the workforce understand the approach to, and the roles and responsibilities for, safe and high-quality performance in the organisation.

Reflective question

What information is provided to new members of the governing body and workforce about their roles and responsibilities for safety and quality?

Key task

Review the organisation’s orientation policies and programs, and consider whether they provide appropriate and effective orientation in safety, quality and clinical governance.

Strategies for improvement

Hospitals

Orientation introduces a member of the governing body or workforce to the organisation. A well-designed orientation program will detail the key safety and quality systems.

Provide orientation that, among other things, covers the essential elements of clinical governance and quality improvement systems to set expectations for members of the governing body and managers, and help develop or maintain their competence and expertise in clinical governance.

Consider whether induction is reliably provided to all members of the workforce, including contracted, locum, agency, student and volunteer members.

Periodically evaluate the content of the orientation and induction training program for its effectiveness and currency of content.

Examples of evidence

Select only examples currently in use:

  • Orientation and induction documents that detail the safety and quality roles and responsibilities of the workforce and the governing body
  • Attendance records for orientation and induction training
  • Reports on evaluation of orientation and induction training content.
Day Procedure Services

Orientation introduces a member of the governing body or workforce to the organisation. A well-designed orientation program will detail the key safety and quality systems.

Provide orientation that, among other things, covers the main elements of clinical governance and quality improvement systems to set expectations for members of the governing body and managers, and help develop or maintain their competence and expertise in clinical governance.

Consider whether induction is reliably provided to all members of the workforce, including contracted, locum, agency, student and volunteer members.

Periodically evaluate the content of the orientation and induction training program for its effectiveness and currency of content.

Examples of evidence

Select only examples currently in use:

  • Orientation and induction documents that detail the safety and quality roles and responsibilities of the workforce and the governing body
  • Attendance records for orientation and induction training
  • Reports on evaluation of orientation and induction training content.
MPS & Small Hospitals

MPSs and small hospitals should routinely review the organisation’s orientation policies and programs, and consider whether the content is current and provides appropriate and effective orientation in safety, quality and clinical governance.

Orientation introduces a member of the governing body or workforce to the organisation’s safety and quality systems, policies, procedures and protocols; clinical safety; quality; leadership; and risk.

Consider whether induction is reliably provided to all members of the workforce, including contracted, locum, agency, student or volunteer members.

Examples of evidence

Select only examples currently in use:

  • Orientation and induction documents that detail the safety and quality roles and responsibilities of the workforce and the governing body
  • Attendance records for orientation and induction training
  • Reports on evaluation of orientation and induction training content.

Action 1.20

The health service organisation uses its training systems to:

a. Assess the competency and training needs of its workforce

b. Implement a mandatory training program to meet its requirements arising from these standards

c. Provide access to training to meet its safety and quality training needs

d. Monitor the workforce's participation in training

Intent

The workforce is appropriately trained to meet the need of the organisation to provide safe and high-quality care.

Reflective questions

How does the health service organisation test the skills level of the workforce?

What training does the health service organisation provide on safety and quality?

How does the health service organisation identify workforce training needs to ensure that workforce skills are current and meet the health service organisation’s service delivery requirements?

Key task

Review the organisation’s education and training policies and programs, and consider whether they provide appropriate and effective education and training in safety, quality and clinical governance.

Strategies for improvement

Hospitals

Maintaining a competent and capable workforce requires education and training. All health service organisations have a responsibility to provide access to ongoing education and training for their workforce.

The governing body and management should consider whether regular training in safety, quality, leadership and risk (including orientation to relevant organisational policies, procedures and protocols) is reliably provided to the whole workforce.

The governing body and management should ensure that the organisation’s education and training policies:

  • Define mandatory education and training requirements in relevant aspects of safety, quality, leadership and clinical risk for all members of the workforce
  • Support the provision of education and training to the workforce based on comprehensive and regularly updated assessment of need
  • Require evaluation of the outcomes of education and training in safety, quality, leadership and risk
  • Ensure that appropriate records are maintained of education and training undertaken by each member of the workforce
  • Provide each member of the workforce with the opportunity (through performance review and development programs) to define their education and training goals, and agree with their manager on opportunities to achieve these goals.

Training for the governing body and the workforce can be provided internally or externally using a variety of formats, including:

  • Face-to-face programs
  • Short sessions
  • Peer review, mentoring and supervised practice
  • Self-directed programs
  • Online learning modules
  • Audio or video content
  • Competency-based assessments
  • Conferences and seminars
  • Secondments and placements.

Regularly assess the training needs of workforce members, and implement a training program that both meets the needs of the workforce to effectively perform their roles and incorporates elements to meet the requirements of the NSQHS Standards. Training needs may be identified through several pathways, including professional development activities, analysis of incident management and investigation systems, or a workforce survey.

Use a risk management approach to schedule training for the workforce based on a needs assessment.

Use external training providers if training cannot be efficiently provided internally. Record and monitor attendance at training sessions to ensure that the workforce maintains skills and competencies.

The organisation is responsible for ensuring that members of the workforce who are employed indirectly (for example, using contract or locum arrangements) have the required qualifications, training and skills to effectively perform their roles.

Organisations may:

  • Have a contractual arrangement with agencies that provide temporary or locum members of the workforce
  • Implement a formal process to verify that visiting medical practitioners or locum members of the workforce have the required qualifications, training and skills
  • Provide training to locum or agency members of the workforce at orientation and induction.

Examples of evidence

Select only examples currently in use:

  • Policy documents about orientation and training of the clinical workforce
  • Employment records that detail the skills and competencies required of the position, as well as the safety and quality roles and responsibilities
  • Evidence of the assessment of clinicians’ needs for education and competency-based training
  • Schedule of clinical workforce education and competency-based training that includes the requirements of the NSQHS Standards
  • Orientation manuals, education resources or records of attendance at workforce training
  • Audit results of the proportion of the workforce with completed performance reviews
  • Skills appraisals and records of competencies for the workforce, including the locum and agency workforce
  • Feedback from the workforce about their training needs
  • Reviews and evaluation reports of education and training programs
  • Communication to the workforce about annual mandatory training requirements.
Day Procedure Services

Maintaining a competent and capable workforce requires education and training. All health service organisations have a responsibility to provide access to ongoing education and training. Day procedure services that do not have the capability to provide in-house training should consider using external training providers.

The governing body and management should consider whether regular training in safety, quality, leadership and risk (including orientation to relevant organisational policies, procedures and protocols) is reliably provided to the whole workforce.

The governing body and management should ensure that the organisation’s education and training policies:

  • Define mandatory education and training requirements in relevant aspects of safety, quality, leadership and clinical risk for all members of the workforce
  • Support the provision of education and training to the workforce based on comprehensive and regularly updated assessment of need
  • Require evaluation of the outcomes of education and training in safety, quality, leadership and risk
  • Ensure that appropriate records are maintained of education and training undertaken by each member of the workforce
  • Provide each member of the workforce with the opportunity (through performance review and development programs) to define their education and training goals, and agree with their manager on opportunities to achieve these goals.

Training for the governing body and the workforce can be provided internally or externally using a variety of formats, including:

  • Face-to-face programs
  • Short sessions
  • Peer review, mentoring and supervised practice
  • Self-directed programs
  • Online learning modules
  • Audio or video content
  • Competency-based assessments
  • Conferences and seminars
  • Secondments and placements.

Regularly assess the training needs of workforce members, and implement a training program that both meets the needs of the workforce to effectively perform their roles and incorporates elements to meet the requirements of the NSQHS Standards. Training needs may be identified through several pathways, including professional development activities, analysis of incident management and investigation systems, or a workforce survey.

Use a risk management approach to schedule training for the workforce based on a needs assessment. Use external training providers if training cannot be efficiently provided internally. Record and monitor attendance at training sessions to ensure that the workforce maintains skills and competencies.

The organisation is responsible for ensuring that members of the workforce who are employed indirectly (for example, using contract or locum arrangements) have the required qualifications, training and skills to effectively perform their roles. Organisations may:

  • Have a contractual arrangement with agencies that provide temporary or locum members of the workforce
  • Implement a formal process to verify that credentialed medical practitioners or locum members of the workforce have the required qualifications, training and skills
  • Provide training to locum or agency members of the workforce at orientation and induction.

Examples of evidence

Select only examples currently in use:

  • Policy documents about orientation and training of the clinical workforce
  • Employment records that detail the skills and competencies required of the position, as well as the safety and quality roles and responsibilities
  • Evidence of the assessment of clinicians’ needs for education and competency-based training
  • Schedule of clinical workforce education and competency-based training that includes the requirements of the NSQHS Standards
  • Orientation manuals, education resources or records of attendance at workforce training
  • Audit results of the proportion of the workforce with completed performance reviews
  • Skills appraisals and records of competencies for the workforce, including the locum and agency workforce
  • Feedback from the workforce about their training needs
  • Reviews and evaluation reports of education and training programs
  • Communication to the workforce about annual mandatory training requirements.
MPS & Small Hospitals

MPSs or small hospitals that are part of a local health network or private hospital group should adopt or adapt the established training policies and programs.

Small hospitals that are not part of a local health network or private hospital group should develop or adapt a training policy and program to provide appropriate and effective education and training in safety, quality and clinical governance.

The organisation’s education and training policies should:

  • Define mandatory education and training requirements in relevant aspects of safety, quality, leadership and clinical risk for all members of the workforce
  • Support the provision of education and training to the workforce based on comprehensive and regularly updated assessment of need
  • Require evaluation of the outcomes of education and training in safety, quality, leadership and risk
  • Ensure that appropriate records are maintained of education and training undertaken by each member of the workforce
  • Provide each member of the workforce with the opportunity (through performance review and development programs) to define their education and training goals, and agree with their manager on opportunities to achieve these goals.

Regularly assess the training needs of workforce members, and implement a training program that both meets the needs of the workforce to effectively perform their roles and incorporates elements to meet the requirements of the NSQHS Standards. Training needs may be identified through several pathways, including professional development activities, analysis of incident management and investigation systems, or a workforce survey.

Use a risk management approach to schedule training for the workforce based on a needs assessment. Use external training providers if training cannot be efficiently provided internally. Record and monitor attendance at training sessions to ensure that the workforce maintains skills and competencies.

The organisation is responsible for ensuring that members of the workforce who are employed indirectly (for example, using contract or locum arrangements) have the required qualifications, training and skills to effectively perform their roles. Organisations may:

  • Have a contractual arrangement with agencies that provide temporary or locum members of the workforce
  • Implement a formal process to verify that credentialed medical practitioners or locum members of the workforce have the required qualifications, training and skills
  • Provide training to locum or agency members of the workforce at orientation and induction.

Examples of evidence

Select only examples currently in use:

  • Policy documents about orientation and training of the clinical workforce
  • Employment records that detail the skills and competencies required of the position, as well as the safety and quality roles and responsibilities
  • Evidence of the assessment of clinicians’ needs for education and competency-based training
  • Schedule of clinical workforce education and competency-based training that includes the requirements of the NSQHS Standards
  • Orientation manuals, education resources or records of attendance at workforce training
  • Audit results of the proportion of the workforce with completed performance reviews
  • Skills appraisals and records of competencies for the workforce, including the locum and agency workforce
  • Feedback from the workforce about their training needs
  • Reviews and evaluation reports of education and training programs
  • Communication to the workforce about annual mandatory training requirements.

Action 1.21

The health service organisation has strategies to improve the cultural awareness and cultural competency of the workforce to meet the needs of its Aboriginal and Torres Strait Islander patients

Intent

Health service organisations provide a supportive environment and clear processes for the workforce to explore the cultural needs of Aboriginal and Torres Strait Islander patients.

Reflective question

How does the health service organisation work to meet the needs of Aboriginal and Torres Strait Islander patients?

Key tasks

  • Ensure that actions to improve cultural competency are implemented and monitored for effectiveness.

  • Review the organisation’s education and training policies and programs to ensure that they adequately cover cultural competency and monitor workforce participation in training.

  • Review and maintain the organisation’s targets regarding the participation of Aboriginal and Torres Strait Islander people in the health workforce across clinical, managerial, support and advocacy roles.

Strategies for improvement

Hospitals

Having an effective culture in place means that an organisation has a defined set of values and principles, and demonstrates behaviours, attitudes, policies and structures that enable it to work effectively.1

Health service organisations should acknowledge and be respectful of the cultural factors and complex kinship relationships that exist in the local Aboriginal and Torres Strait Islander community.2

Aboriginal and Torres Strait Islander people do not always see mainstream health services as offering them a safe and secure place to get well. In many instances, they experience3:

  • Isolation from community and kin
  • Language barriers in understanding health messages and difficulty in informing clinicians of their needs
  • Financial difficulties in gaining access to treatments (for example, travel costs) and funding the costs of the treatment
  • Perceived inferior treatment.

To improve the cultural competency of both the workforce and the organisation, consider4:

  • Incorporating culturally specific requirements into recruitment processes, or including Aboriginal and Torres Strait Islander people on the interview panel
  • Addressing cultural competency as part of performance review processes
  • Ensuring that the workforce participates in cultural competency activities and training in a variety of learning formats, such as training exercises, reflective practice and face-to-face training whenever possible
  • Providing access to ongoing learning for individuals through training, professional development, critical reflection and practice improvement
  • Providing cultural competency training that is developed in collaboration with the local Aboriginal and Torres Strait Islander communities and includes content relevant to those communities
  • Monitoring and reporting on the implementation and effectiveness of the cultural competency program to the governing body or management
  • Implementing follow-up strategies (including counselling, performance improvement or more stringent approaches when necessary) if a culturally appropriate approach is not adopted
  • Expanding the Aboriginal and Torres Strait Islander workforce and supporting them to fulfil their role as cultural mentors
  • Incorporating cultural competency into policies and program development
  • Collaborating with partner communities about service and facility design, delivery and evaluation, and to seek feedback on, and improve, cultural competency.

Further strategies are available in the User Guide for Aboriginal and Torres Strait Islander Health.

Examples of evidence

Select only examples currently in use:

  • Evidence of assessment of the workforce’s needs for cultural competency and cultural awareness training
  • Training documents on Aboriginal and Torres Strait Islander cultural awareness and cultural competency
  • Policy documents in which the needs of Aboriginal and Torres Strait Islander patients are recognised
  • Review and evaluation reports of cultural awareness education and training programs
  • Committee and meeting records in which the cultural needs of Aboriginal and Torres Strait Islander patients are discussed, and strategies to meet their needs are monitored or evaluated
  • Employment documents that detail the roles and responsibilities of Aboriginal support officers
  • Strategies for increasing employment opportunities for Aboriginal and Torres Strait Islander people in the organisation
  • Data analysis and evaluation of feedback from the workforce and consumers about the workforce’s cultural competency and cultural awareness.
Day Procedure Services

Having an effective culture in place means that an organisation has a defined set of values and principles, and demonstrates behaviours, attitudes, policies and structures that enable it to work effectively.5

Health service organisations should acknowledge and be respectful of the cultural factors and complex kinship relationships that exist in the local Aboriginal and Torres Strait Islander community.6

Day procedure services may have a small Aboriginal and Torres Strait Islander patient population. For many Aboriginal and Torres Strait Islander people receiving care in a day procedure service, their risk of harm will be similar to that of the general patient population using the service. However, Aboriginal and Torres Strait Islander people do not always see mainstream health services as offering them a safe and secure place to get well. In many instances, they experience7:

  • Isolation from community and kin
  • Language barriers in understanding health messages and difficulty in informing clinicians of their needs
  • Financial difficulties in gaining access to treatments (for example, travel costs) and funding the costs of the treatment
  • Perceived inferior treatment.

To improve the cultural competency of both the workforce and the organisation, consider8:

  • Incorporating culturally specific requirements into recruitment processes, or including Aboriginal and Torres Strait Islander people on the interview panel
  • Addressing cultural competency as part of performance review processes
  • Ensuring that the workforce participates in cultural competency activities and training in a variety of learning formats, such as training exercises, reflective practice and face-to-face training whenever possible
  • Providing access to ongoing learning for individuals through training, professional development, critical reflection and practice improvement
  • Providing cultural competency training that is developed in collaboration with the local Aboriginal and Torres Strait Islander communities and includes content relevant to those communities
  • Monitoring and reporting on the implementation and effectiveness of the cultural competency program to the governing body or management
  • Implementing follow-up strategies (including counselling, performance improvement or more stringent approaches when necessary) if a culturally appropriate approach is not adopted
  • Expanding the Aboriginal and Torres Strait Islander workforce and supporting them to fulfil their role as cultural mentors
  • Incorporating cultural competency into policies and program development
  • Collaborating with partner communities about service and facility design, delivery and evaluation, and to seek feedback on, and improve, cultural competency.

Further strategies are available in the User Guide for Aboriginal and Torres Strait Islander Health.

Examples of evidence

Select only examples currently in use:

  • Evidence of assessment of the workforce’s needs for cultural competency and cultural awareness training
  • Training documents on Aboriginal and Torres Strait Islander cultural awareness and cultural competency
  • Policy documents in which the needs of Aboriginal and Torres Strait Islander patients are recognised
  • Review and evaluation reports of cultural awareness education and training programs
  • Committee and meeting records in which the cultural needs of Aboriginal and Torres Strait Islander patients are discussed, and strategies to meet their needs are monitored or evaluated
  • Employment documents that detail the roles and responsibilities of Aboriginal support officers
  • Strategies for increasing employment opportunities for Aboriginal and Torres Strait Islander people in the organisation
  • Data analysis and evaluation of feedback from the workforce and consumers about the workforce’s cultural competency and cultural awareness.
MPS & Small Hospitals

Having an effective culture in place means that an organisation has a defined set of values and principles, and demonstrates behaviours, attitudes, policies and structures that enable it to work effectively.1

MPSs and small hospitals should:

  • Ensure that actions to improve cultural competency are implemented and monitored for effectiveness
  • Review the organisation’s education and training policies and programs to ensure that they adequately cover cultural competency, and monitor workforce participation in training
  • Review and maintain the organisation’s targets for the participation of Aboriginal and Torres Strait Islander people in the health workforce across clinical, managerial, support and advocacy roles.

Health service organisations should acknowledge and be respectful of the cultural factors and complex kinship relationships that exist in the local Aboriginal and Torres Strait Islander community.2

Aboriginal and Torres Strait Islander people do not always see mainstream health services as offering them a safe and secure place to get well. In many instances, they experience3:

  • Isolation from community and kin
  • Language barriers in understanding health messages and difficulty in informing clinicians of their needs
  • Financial difficulties in gaining access to treatments (for example, travel costs) and funding the costs of the treatment
  • Perceived inferior treatment.

To improve the cultural competency of both the workforce and the organisation, consider4:

  • Incorporating culturally specific requirements into recruitment processes, or including Aboriginal and Torres Strait Islander people on the interview panel
  • Addressing cultural competency as part of performance review processes
  • Ensuring that the workforce participates in cultural competency activities and training in a variety of learning formats, such as training exercises, reflective practice and face-to-face training whenever possible
  • Providing access to ongoing learning for individuals through training, professional development, critical reflection and practice improvement
  • Providing cultural competency training that is developed in collaboration with the local Aboriginal and Torres Strait Islander communities and includes content relevant to those communities
  • Monitoring and reporting on the implementation and effectiveness of the cultural competency program to the governing body or management
  • Implementing follow-up strategies (including counselling, performance improvement or more stringent approaches when necessary) if a culturally appropriate approach is not adopted
  • Expanding the Aboriginal and Torres Strait Islander workforce and supporting them to fulfil their role as cultural mentors
  • Incorporating cultural competency into policies and program development
  • Collaborating with partner communities about service and facility design, delivery and evaluation, and to seek feedback on, and improve, cultural competency.

Further strategies are available in the User Guide for Aboriginal and Torres Strait Islander Health.

Examples of evidence

Select only examples currently in use:

  • Evidence of assessment of the workforce’s needs for cultural competency and cultural awareness training
  • Training documents on Aboriginal and Torres Strait Islander cultural awareness and cultural competency
  • Policy documents in which the needs of Aboriginal and Torres Strait Islander patients are recognised
  • Review and evaluation reports of cultural awareness education and training programs
  • Committee and meeting records in which the cultural needs of Aboriginal and Torres Strait Islander patients are discussed, and strategies to meet their needs are monitored or evaluated
  • Employment documents that detail the roles and responsibilities of Aboriginal support officers
  • Strategies for increasing employment opportunities for Aboriginal and Torres Strait Islander people in the organisation
  • Data analysis and evaluation of feedback from the workforce and consumers about the workforce’s cultural competency and cultural awareness.
Last updated 31st May, 2018 at 09:45pm
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References

Dudgeon P, Wright M, Coffin J. Talking it and walking it: cultural competence. J Aus Indig Iss 2010;13(3):29–44.

Ware VA. Improving the accessibility of health services in urban and regional settings for Indigenous people. Canberra: Australian Institute of Health and Welfare; 2013 (accessed Oct 2017).

Dwyer J, Kelly J, Willis E, Glover J, Glover J, Mackean T, et al. Managing two worlds together: city hospital care for country Aboriginal people. Melbourne: Lowitja Institute; 2011.

Australian Commission on Safety and Quality in Health Care. Cultural competence in caring for Aboriginal and Torres Strait Islander consumers. Sydney: ACSQHC; 2016 (accessed Sep 2017).