2. Partnering with Consumers

Healthcare rights and informed consent

Action 2.3

The health service organisation has a charter of rights that is:

a. Consistent with the Australian Charter of Healthcare Rights

b. Easily accessible for patients, carers, families and consumers

Intent

Consumers are provided with information about their healthcare rights.

Reflective questions

Does the health service organisation have a charter of rights that is consistent with the Australian Charter of Healthcare Rights?

How do patients, carers, families and consumers use the charter at different points throughout their healthcare journey?

Key tasks

  • Adopt the Australian Charter of Healthcare Rights (with or without amendments)

  • Provide ready access to copies of the charter, in appropriate languages or formats, to all patients, and their carers and families.

Strategies for improvement

Hospitals

The Australian Charter of Healthcare Rights1 was developed by the Australian Commission on Safety and Quality in Health Care (the Commission) and adopted by all health ministers in 2008. It describes the rights of patients and other people using the Australian healthcare system. These rights are essential to ensure that safe and high-quality care is provided to all people, in all health settings in Australia (including public and private hospitals).

Review or develop a charter of rights

If the organisation does not have a charter of rights, use the Australian Charter of Healthcare Rights as a foundation for developing a charter.

Review the Australian Charter of Healthcare Rights and, if necessary, adapt it to meet the specific needs of the organisation; however, the seven original rights must remain in place.

If the organisation already has a charter of rights in place, review how it aligns with the Australian Charter of Healthcare Rights.

Health service organisations may need to:

  • Replace their existing charter with the Australian Charter of Healthcare Rights
  • Edit the existing charter so that it better aligns with the Australian Charter of Healthcare Rights
  • Keep the existing charter, noting that it is consistent with the Australian Charter of Healthcare Rights but may include modifications to suit the organisation’s services.

Adopt the charter of rights

Support the effective adoption of the charter in the organisation. Strategies may include:

  • Allocating responsibility for implementing and reviewing the charter to a manager with decision-making authority
  • Including information about the charter during orientation for new members of the workforce
  • Running regular education and training sessions for the workforce on their responsibilities for implementing the charter; this includes clinical and non clinical members of the workforce, and, if relevant, volunteers
  • Building the charter into organisational processes, policies and codes of conduct
  • Developing policies and procedures that outline how the rights in the charter will be achieved at the organisation.

Inform patients, carers and families about the charter, and make sure that they can find it easily. Strategies may include:

  • Discussing the charter with patients
  • Displaying brochures or posters advertising the charter at reception desks, and in waiting areas, wards, corridors, consulting rooms and other strategic locations
  • Incorporating information about the charter into communication with patients, such as on the organisation’s website or in information brochures
  • Incorporating the charter into information packs sent to elective patients before admission
  • Making information about the charter available to patients at their bedside
  • Ensuring that copies of the charter are available in community languages, and providing copies of the charter to any nominated interpreters
  • Providing information in a format that is suitable for patients who are visually impaired, such as audio, in braille or on fully accessible websites.

Review the effectiveness of the charter

Measure the impact of the charter to see whether promotion efforts are successful and whether this affects patient experience. Strategies may include:

  • Conducting surveys of patients to check whether they have received the charter, and whether the rights in the charter have been respected
  • Conducting surveys of the workforce about their awareness of, and attitudes towards, the charter
  • Monitoring patient requests for the charter
  • Monitoring printing of the charter.

The brochure Using the Australian Charter of Healthcare Rights in Your Health Service2 is a guide that outlines ways in which health service organisations can provide information about health rights and incorporate a charter in their systems. This brochure is available on the Commission’s website, along with other resources to assist with the adoption of the Australian Charter of Healthcare Rights.

Day Procedure Services

The Australian Charter of Healthcare Rights1 was developed by the Australian Commission on Safety and Quality in Health Care (the Commission) and adopted by all health ministers in 2008. It describes the rights of patients and other people using the Australian healthcare system. These rights are essential to ensure that safe and high-quality care is provided to all people, in all health settings in Australia (including day procedure services).

Review or develop a charter of rights

If the day procedure service is part of a larger or networked group that has developed a charter of healthcare rights, ensure that the requirements of the charter are being met by the service.

If the day procedure service needs to implement its own charter of rights, use the Australian Charter of Healthcare Rights as a foundation for developing a charter for people seeking and receiving health care in the service.

Review the Australian Charter of Healthcare Rights and, if necessary, adapt it to meet the specific needs of the organisation; however, the seven original rights must remain in place.

If the organisation already has a charter of rights in place, review how it aligns with the Australian Charter of Healthcare Rights.

Health service organisations may need to:

  • Replace their existing charter with the Australian Charter of Healthcare Rights
  • Edit the existing charter so that it better aligns with the Australian Charter of Healthcare Rights
  • Keep the existing charter, noting that it is consistent with the Australian Charter of Healthcare Rights but may include modifications to suit the organisation’s services.

Adopt the charter of rights

Support the effective adoption of the charter in the organisation. Strategies may include:

  • Allocating responsibility for implementing and reviewing the charter to a manager with decision-making authority
  • Including information about the charter during orientation for new members of the workforce and consumer representatives
  • Running regular education and training sessions for the workforce on their responsibilities for implementing the charter; this includes clinical and non clinical members of the workforce, and, if relevant, volunteers.

Inform patients, families and carers about the charter, and make sure that they can easily gain access to it. Strategies may include:

  • Discussing the charter with patients
  • Displaying brochures or posters advertising the charter
  • Including information about the charter in communication with patients, such as on the organisation’s website or in information brochures
  • Including the charter in information packs sent to elective patients before their procedure
  • Making information about the charter available to patients at their bedside
  • Ensuring that copies of the charter are available in community languages, and providing copies of the charter to any nominated interpreters
  • Providing information in a format that is suitable for patients who are visually impaired
  • Seeking support from external agencies, such as telephone interpreting services.

Review the effectiveness of the charter

Measure the impact of the charter to see whether promotion efforts are successful and whether this affects patient experience. Strategies may include:

  • Conducting surveys of patients to see whether they have received the charter, and whether the rights in the charter have been respected
  • Conducting surveys of the workforce about their awareness of, and attitudes towards, the charter
  • Monitoring patient requests for the charter
  • Monitoring printing of the charter.

The brochure Using the Australian Charter of Healthcare Rights2 is a guide that outlines ways in which health service organisations can provide information about health rights and incorporate a charter in their systems. This brochure is available on the Commission’s website, along with other resources to assist with the adoption of the Australian Charter of Healthcare Rights.

Examples of evidence

Select only examples currently in use:

  • Policy documents that describe the use of a charter of rights
  • Charter of rights that is consistent with the Australian Charter of Healthcare Rights in different languages and formats, consistent with the patient profile
  • Observation that a charter of rights is displayed in areas that are accessible to the public
  • Consumer and carer information packages or resources that explain consumer healthcare rights
  • Evidence that patients and carers received information about their healthcare rights and responsibilities, such as audits of patients, interviews or surveys
  • Admission checklist that includes provision and explanation of a charter of rights
  • Feedback from patients and consumers about awareness of the charter of rights.
MPS & Small Hospitals

MPSs or small hospitals that are part of a local health network or private hospital group should use the established charter of healthcare rights and ensure that the requirements are met.

Small hospitals that are not part of a local health network or private hospital group should use the Australian Charter of Healthcare Rights1 as a foundation for developing a charter. Review the charter and, if necessary, adapt it to meet the specific needs of the organisation; however, the seven original rights must remain in place.

If the organisation already has a charter of rights in place, review how it aligns with the Australian Charter of Healthcare Rights. Support the effective adoption of the charter in the organisation. Strategies may include:

  • Allocating responsibility for implementing and reviewing the charter to a manager with decision-making authority
  • Including information about the charter during orientation for new members of the workforce
  • Running regular education and training sessions for the workforce on their responsibilities for implementing the charter; this includes clinical and non-clinical members of the workforce, and, if relevant, volunteers
  • Building the charter into organisational processes, policies and codes of conduct
  • Developing policies and procedures that outline how the rights will be achieved at the organisation.

Inform patients, carers and families about the charter, and make sure that they can find it easily.

Measure the impact of the charter to see whether promotion efforts are successful and whether this affects patient experience. Strategies may include:

  • Conducting surveys of patients to determine whether they have received the charter, and whether the rights in the charter have been respected
  • Conducting surveys of the workforce about their awareness of, and attitudes towards, the charter
  • Monitoring patient requests for the charter
  • Monitoring printing of the charter.

The brochure Using the Australian Charter of Healthcare Rights in Your Health Service2 is a guide that outlines ways in which health service organisations can provide information about health rights and incorporate a charter in their systems. This brochure is available on the website of the Commission on Safety and Quality in Health Care (the Commission), along with other resources to assist with the adoption of the Australian Charter of Healthcare Rights.

Action 2.4

The health service organisation ensures that its informed consent processes comply with legislation and best practice

Intent

Patients are involved in appropriate informed consent processes.

Reflective questions

How does the health service organisation ensure that its informed consent policy complies with legislation and best practice?

How does the health service organisation monitor compliance with consent processes?

Key tasks

  • Adopt a comprehensive policy and associated procedures on informed consent by patients in clinical decision-making
  • Schedule periodic reviews of the effectiveness and outcomes of the policy.

Strategies for improvement

Hospitals

Informed consent is a person’s voluntary decision about their health care that is made with knowledge and understanding of the benefits and risks involved.1

Ensure that the organisation has effective processes in place to:

  • Inform patients (and, if applicable, their carers and substitute decision-makers) about the risks, benefits and alternatives of a treatment, including any fees and charges associated with treatment and referrals
  • Determine patient preferences for treatment
  • Document patient consent to treatment.

This includes processes for consent relating to transfusions of blood or blood products (Action 7.3), and specific situations that require informed consent for treatment with a medicine (Action 4.11).

Effective processes may include policies and procedures to guide and support the clinical workforce towards good standards of practice that meet legal and ethical requirements.

Review current informed consent processes

Informed consent processes should comply with legislation and best practice. The following are best practice principles for informed consent systems 1, 2 :

  • Provide information to patients in a way that they can understand before asking for their consent – for example, provide an accredited interpreter to help with communication, or adapt information into accessible formats (such as translation into community languages, or providing audio or visual information); other strategies for tailoring communications to the diverse needs of the patient population are provided in Action 2.8
  • Obtain informed consent or other valid authority before undertaking any examination or investigation, or providing treatment (except in an emergency)
  • Document consent appropriately, and provide guidance on what to do if there are concerns about a patient’s capacity to provide consent
  • Meet the common law and legal requirements of the relevant state or territory relating to
    • providing information about treatment
    • obtaining consent to treatment, including the requirement to disclose all risks
  • Nominate a manager who is responsible for maintaining the integrity of the consent system and its continuous improvement
  • Support informed consent through safety and quality systems across all areas of the organisation that ensure that
    • no treatment is provided without the patient’s informed consent (or, if applicable, that of their substitute decision-maker)
    • specific consent requirements established by state or territory legislation – such as mental health Acts, guardianship and administration Acts, and human tissue Acts – are complied with
  • Support informed consent through education and training for all members of the clinical workforce in
    • effective communication to underpin good clinical practice
    • the legal, ethical and practical foundations of requirements for patient consent and engagement in clinical decision-making
    • the organisation’s consent policy and procedures
    • understanding how individual health literacy levels and the health literacy environment can act as barriers to understanding during the consent process
  • Incorporate protocols for receiving, investigating and managing complaints about consent processes
  • Link informed consent to the organisation’s open disclosure policy and the state or territory consent policy (if applicable).

If an organisation’s informed consent processes do not meet the best-practice principles outlined above, adapt the policies and procedures accordingly.

Some states and territories have developed informed consent templates or identified appropriate consent strategies for use in that state or territory. Adopt or adapt these if available; otherwise, develop processes for the health service organisation.

The National Health and Medical Research Council’s General Guidelines for Medical Practitioners on Providing Information to Patients2 provides guidance on the information that clinicians need to give to patients.

The Queensland Health Guide to Informed Decision-Making in Health Care3 provides guidance on how to implement the principles of informed decision-making in clinical practice.

Monitor design and performance of informed consent processes

Periodically review the design and performance of informed consent processes to evaluate whether they comply with best-practice principles. This will support effective clinical governance, including risk management.

For private sector organisations where informed consent may be obtained in a process separate from the health service organisation, it is not intended that visiting medical officer practices are monitored. Rather, the health service organisation takes a risk management approach and confirms with patients on admission, or at the commencement of an episode of care, that they understand why they are there and what treatment they will receive.

Day Procedure Services

Informed consent is a person’s voluntary decision about their health care that is made with knowledge and understanding of the benefits and risks involved.1

If the day procedure service is part of a larger or networked group that has informed consent policies and procedures, ensure that the service has adopted these.

If no such policies or procedures exist, the day procedure service should develop and implement effective processes to:

  • Inform patients (and, if applicable, their carers and substitute decision-makers) about the risks, benefits and alternatives of a treatment, including any fees and charges
  • Determine patient preferences for treatment
  • Document patient consent to treatment.

This includes processes for consent relating to transfusions of blood or blood products (Action 7.3), and specific situations that require informed consent for treatment with a medicine (Action 4.11).

Have a process in place to ensure that informed consent has been obtained, including by maintaining a copy of the signed consent form. In some instances, the patient may have given informed consent to the referring clinician before being admitted to the day procedure service. However, the day procedure service should not assume that consent has been obtained before admission.

Effective processes may include policies and procedures to guide and support the clinical workforce towards good standards of practice that meet legal and ethical requirements.

Review current informed consent processes

Informed consent processes should comply with legislation and best practice. The following are best practice principles for informed consent systems 2, 3 :

  • Provide information to patients in a way that they can understand before asking for their consent – for example, provide an accredited interpreter to help with communication, or adapt information into accessible formats (such as translation into community languages, or providing audio or visual information); other strategies for tailoring communications to the diverse needs of the patient population are provided in Action 2.8
  • Obtain informed consent or other valid authority before undertaking any examination or investigation, or providing treatment (except in an emergency)
  • Document consent appropriately, and provide guidance on what to do if there are concerns about a patient’s capacity to provide consent
  • Meet the common law and legal requirements of the relevant state or territory relating to
    • providing information about treatment
    • obtaining consent to treatment, including the requirement to disclose all risks
  • Nominate a manager who is responsible for maintaining the integrity of the consent system and its continuous improvement
  • Support informed consent through safety and quality systems across all areas of the organisation that ensure that
    • no treatment is provided without the patient’s informed consent (or, if applicable, that of their substitute decision-maker)
    • specific consent requirements established by state or territory legislation – such as mental health Acts, guardianship and administration Acts, and human tissue Acts – are complied with
  • Support informed consent through education and training for all members of the clinical workforce
  • Incorporate protocols for receiving, investigating and managing complaints about consent processes
  • Link informed consent to the organisation’s open disclosure policy and the state or territory consent policy (if applicable).

If an organisation’s informed consent processes do not meet the best-practice principles outlined above, adapt the policies and procedures accordingly.

Some states and territories have developed informed consent templates or identified appropriate consent strategies for use in that state or territory. Adopt or adapt these if available; otherwise, develop a local system.

The National Health and Medical Research Council’s General Guidelines for Medical Practitioners on Providing Information to Patients3 provides guidance on the information that clinicians need to give to patients.

The Queensland Health Guide to Informed Decision-Making in Health Care4 provides guidance on how to implement the principles of informed decision-making in clinical practice.

Monitor design and performance of informed consent processes

Periodically review the design and performance of informed consent processes to evaluate whether they comply with best-practice principles and whether enough resources have been allocated. This will support effective clinical governance, including risk management.

For private sector organisations where informed consent may be obtained in a process separate from the health service organisation, it is not intended that visiting medical officer practices are monitored. Rather, the health service organisation takes a risk management approach and confirms with patients on admission, or the commencement of an episode of care, that they understand why they are there and what treatment they will receive.

Examples of evidence

Select only examples currently in use:

  • Policy documents for informed consent that reference relevant legislation or best practice and consider issues such as
    • when consent should be obtained
    • when consent is not required
    • when written consent is required
    • requirements for valid consent
    • refusal of treatment or consent
    • obtaining consent from patients from culturally and linguistically diverse backgrounds
    • consent ages and consent for minors
    • guardianship or advocacy
  • Training documents on informed consent processes
  • Standardised consent form that is in use
  • Audit results of healthcare records for compliance with informed consent policies, procedures or protocols
  • Audit results of healthcare records to see whether patients are informed of the risks and benefits of treatment, and whether there is a record of consent
  • Results of consumer and carer experience surveys, and actions taken to deal with issues identified about informed consent
  • Patient information packages or resources about treatment and consent processes that are available for consumers in different formats and languages, consistent with the patient profile
  • Feedback about the consent process from patients and carers after treatment.
MPS & Small Hospitals

MPSs or small hospitals that are part of a local health network or private hospital group should use the established informed consent policies and procedures.

Small hospitals that are not part of a local health network or private hospital group should develop or adapt effective processes to:

  • Inform patients (and, if applicable, their carers and substitute decision-makers) about the risks, benefits and alternatives of a treatment, including any fees and charges associated with treatment and referrals
  • Determine patient preferences for treatment
  • Document patient consent to treatment
  • Support the clinical workforce to meet legal and ethical requirements.

The following are best-practice principles for informed consent systems 1, 2 :

  • Provide information to patients in a way that they can understand before asking for their consent – for example, provide an accredited interpreter to help with communication, or adapt information into accessible formats (such as translation into community languages, or providing audio or visual information)
  • Obtain informed consent or other valid authority before undertaking any examination or investigation, or providing treatment (except in an emergency)
  • Document consent appropriately, and provide guidance on what to do if there are concerns about a patient’s capacity to provide consent
  • Meet the common law and legal requirements of the relevant state or territory relating to
    • providing information about treatment
    • obtaining consent to treatment, including the requirement to disclose all risks
  • Nominate a manager who is responsible for maintaining the integrity of the consent system and its continuous improvement
  • Support informed consent through education and training for all members of the clinical workforce in
    • effective communication to underpin good clinical practice
    • the legal, ethical and practical foundations of requirements for patient consent and engagement in clinical decision-making
    • the organisation’s consent policy and procedures
    • understanding how individual health literacy levels and the health literacy environment can act as barriers to understanding during the consent process

The Queensland Health Guide to Informed Decision-Making in Health Care 3 provides guidance on how to implement the principles of informed decision-making in clinical practice.

Periodically review the design and performance of informed consent processes to evaluate whether they comply with best-practice principles. This will support effective clinical governance, including risk management.

Action 2.5

The health service organisation has processes to identify:

a. The capacity of a patient to make decisions about their own care

b. A substitute decision maker if a patient does not have the capacity to make decisions for themselves

Intent

Patients who do not have the capacity to make decisions about their care are identified, and systems are put in place so that they, or agreed substitute decision makers, are involved in decision making, including informed consent.

Reflective questions

What processes are in place to support clinicians to identify a patient’s capacity to make decisions about their own care?

How are clinicians supported to identify a substitute decision-maker?

Key tasks

  • Adopt a comprehensive policy and associated procedures to identify patients who do not have the capacity to make decisions about their own care.

  • Schedule periodic reviews of the effectiveness and outcomes of the policy.

Strategies for improvement

Hospitals

Under Australian legislation, all adults are presumed to have the capacity to decide whether they wish to receive health care, except when it can be shown that they lack the capacity to do so.

A person has the capacity to make a decision about their care if they can:1

  • Understand and retain the information needed to make a decision

  • Use the information to make a judgement about the decision

  • Communicate the decision in some way, including by speech, gestures or other means.

Decision-making capacity can be decision- and situation-specific. This means that a person’s capacity can vary at different times, in different circumstances and between different types of decisions.

Review processes for determining patients’ capacity to make decisions

Ensure that effective processes are in place to identify:

  • Patients who do not have the capacity to make decisions about their own health care

  • Appropriate substitute decision makers who can make decisions on behalf of the patient.

If these systems are not in place, use the strategies below to develop them:

  • Review the local legislation regarding the criteria for a patient to be considered capable of making decisions about their own care, and incorporate these criteria into any policies and procedures that the organisation develops; state and territory legislation may differ in its definition of patients who have the capacity to make healthcare decisions.1, 2 

  • Develop an organisational policy that outlines the requirements of clinicians to assess patients for their capacity to make health decisions.

  • Work with clinicians and consumers to develop procedures to support the organisational policy, including guidance on:

    • assessing fluctuations in decision-making capacity

    • considerations for special populations, such as children

    • requirements for recording and documenting decisions.

  • Educate the workforce about assessing a person’s capacity to make decisions about their care; consider training from a third party with expertise in this area, such as Capacity Australia.

  • Develop or provide resources and tools to reinforce training and assist the workforce to assess a person’s capacity to make decisions. SA Health’s Impaired Decision-Making Factsheet3 is an example.

Review processes for identifying substitute decision-makers

If a patient does not have the capacity to make decisions about their own care, a substitute decision-maker may be appointed.1 Consult local legislation and best-practice guidelines to identify who is authorised to provide substitute decision-making in the state or territory. Examples of substitute decision-makers are a nominated carer, a health attorney, or a person nominated under an enduring power of attorney or guardianship arrangement.

Incorporate a list of appropriate substitute decision-makers into the organisation’s informed consent policy. Educate the workforce about these appropriate substitute decision-makers during orientation and ongoing training sessions.

Include information about substitute decision-makers in any consumer communications about informed consent.

Develop an associated procedure for identifying and appointing a substitute decision-maker, such as a determination flowchart.

Periodically review the design and performance of these processes

Periodically review processes to evaluate whether they meet the needs of patients and reflect best practice. Strategies may include:

  • Collecting informal feedback from patients during discussions in waiting rooms and during ward rounds to see whether they felt involved in their healthcare decision-making

  • Collecting formal feedback from consumers through submissions and events (such as focus groups or community meetings) to see whether they felt involved in their healthcare decision-making

  • Surveying patients to self-report on their experience and satisfaction with the level of engagement they had in their healthcare decision-making.

For guidance on undertaking consultations and surveys, see the Scottish Health Council’s Participation toolkit.4

Day Procedure Services

Under Australian legislation, all adults are presumed to have the capacity to decide whether they wish to receive health care, except when it can be shown that they lack the capacity to do so.

A person has the capacity to make a decision about their care if they can1:

  • Understand and retain the information needed to make a decision
  • Use the information to make a judgement about the decision
  • Communicate the decision in some way, including by speech, gestures or other means.

Decision-making capacity can be decision- and situation-specific. This means that a person’s capacity can vary at different times, in different circumstances and between different types of decisions.

Review processes for determining patients’ capacity to make decisions

If the day procedure service is part of a larger or networked group of day procedure service providers, see whether the wider group has any policies or procedures for identifying patients who do not have the capacity to make decisions about their own care. Ensure that the organisation has adopted any such existing policies or procedures.

If no such policies or procedures exist, the day procedure service should implement a system to identify:

  • Patients who do not have the capacity to make decisions about their own health care
  • Appropriate substitute decision-makers who can make decisions on behalf of the patient.

If these systems are not in place, use the strategies below to develop them:

  • Review the local legislation regarding the criteria for a patient to be considered capable of making decisions about their own care, and incorporate these criteria into any policies and procedures that the organisation develops; state and territory legislation may differ in its definition of patients who have the capacity to make healthcare decisions1, 2
  • Develop an organisational policy that outlines the requirements of clinicians to assess patients for their capacity to make healthcare decisions
  • Work with clinicians and consumers to develop procedures to support the organisational policy, including guidance on
    • assessing decision-making capacity during pre-admission screening
    • assessing fluctuations in decision-making capacity
    • considerations for special populations, such as children
    • requirements for recording and documenting decisions
  • Educate the workforce about assessing a person’s capacity to make decisions about their care; consider training from a third party with expertise in this area, such as Capacity Australia
  • Develop or provide resources and tools to reinforce training and assist the workforce to assess a person’s capacity to make decisions; SA Health’s Impaired Decision Making Factsheet3 is an example.

Review processes for identifying substitute decision-makers

If a patient does not have the capacity to make decisions about their own care, a substitute decision-maker may be appointed.1 Consult local legislation and best-practice guidelines to identify who is authorised to provide substitute decision-making in the state or territory. Examples of substitute decision-makers are a nominated carer, a health attorney, or a person nominated under an enduring power of attorney or guardianship arrangement.

Incorporate a list of appropriate substitute decision-makers into the organisation’s informed consent policy. Educate the workforce about these appropriate substitute decision-makers during orientation and ongoing training sessions.

Include information about substitute decision-makers in any consumer communications about informed consent.

Develop an associated procedure for identifying and appointing a substitute decision-maker, such as a determination flowchart.

Periodically review the design and performance of these processes

Periodically review processes to evaluate whether they meet the needs of patients and reflect best practice. Strategies may include:

  • Collecting informal feedback from patients during discussions in waiting rooms and on discharge to see whether they felt involved in their healthcare decision-making
  • Collecting formal feedback from consumers through submissions and events (such as focus groups or community meetings) to see whether they felt involved in their healthcare decision-making
  • Surveying patients to self-report on their experience and satisfaction with the level of engagement they had in their healthcare decision-making.

For guidance on undertaking consultations and surveys, see the Victorian Government’s Engagement Toolkit5 or the Scottish Health Council’s Participation Toolkit.4

Examples of evidence

Select only examples currently in use:

  • Policy documents or processes for
    • identifying a patient’s capacity for making decisions about their care
    • identifying a substitute decision-maker, if a patient does not have the capacity to make decisions about their care
    • documenting substitute decision-makers such as next of kin, advocates, people with power of attorney and legal guardians
  • Admission screening and assessment tools that identify the patient’s capacity for choice and decision-making
  • Audit results of healthcare records that identify patients’ capacity to make decisions, and confirm the identity of the substitute decision-maker, if required
  • Audit results of healthcare records for compliance with policies, procedures or protocols, and completeness of documentation relating to advocacy or guardianship
  • Patient information packages or resources about advocacy, power of attorney and legal guardianship that are available for consumers in different formats and languages, consistent with the patient profile
  • Examples of applications regarding guardianship or use of the Office of the Public Advocate.
MPS & Small Hospitals

A person has capacity to make a decision about their care if they can1:

  • Understand and retain the information needed to make a decision
  • Use the information to make a judgement about the decision
  • Communicate the decision in some way, including by speech, gestures or other means.

Decision-making capacity can be decision- and situation-specific. This means that a person’s capacity can vary at different times, in different circumstances and between different types of decisions.

MPSs or small hospitals that are part of a local health network or private hospital group should adopt or adapt and use the established processes for identifying patients who do not have capacity to make decisions about their own care.

Small hospitals that are not part of a local health network or private hospital group should develop or adapt policies or procedures to identify:

  • Patients who do not have the capacity to make decisions about their own health care
  • Appropriate substitute decision-makers who can make decisions on behalf of the patient.

Educate the workforce about assessing a person’s capacity to make decisions about their care and identifying an appropriate substitute decision-maker. Consider training from a third party with expertise in this area, such as Capacity Australia.6

Develop or provide resources and tools to reinforce training and assist the workforce to assess a person’s capacity to make decisions. SA Health’s Impaired Decision-Making Factsheet3 is an example.

Develop an associated procedure for identifying and appointing a substitute decision-maker, such as a determination flowchart.

Periodically review processes to evaluate whether they meet the needs of patients and reflect best practice.

Last updated 7th June, 2018 at 10:14pm
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References

Queensland Health. Guide to informed decision-making in health care. 2nd ed. Brisbane: Queensland Health; 2017.

ACT Health. Standard operating procedure: consent and treatment – capacity and substitute decision making. Canberra: ACT Health; 2012.

SA Health. Impaired decision-making factsheet. Adelaide: SA Health; 2014 (accessed Sep 2017).

Scottish Health Council. The participation toolkit. Edinburgh: SHC; 2010.

Victoria Department of Environment and Primary Industries. The engagement toolkit – version 4. Melbourne: DEPI; 2014.