Action 5.1

Clinicians use the safety and quality systems from the Clinical Governance Standard when:

a. Implementing policies and procedures for comprehensive care

b. Managing risks associated with comprehensive care

c. Identifying training requirements to deliver comprehensive care

Intent

Safety and quality systems support clinicians in the delivery of comprehensive care and minimising patient harm.

Reflective questions

How are the health service organisation’s safety and quality systems used to:

  • Support implementation of policies and procedures for the delivery of comprehensive care
  • Identify and manage risks associated with the delivery of comprehensive care
  • Identify training requirements for the delivery of comprehensive care?

Key tasks

  • Establish and implement governance structures for comprehensive care and minimising patient harm.

  • Develop and implement policies and procedures for comprehensive care and minimising patient harm.

  • Use organisation-wide risk management systems to identify, monitor, manage and review risks associated with comprehensive care and minimising patient harm.

  • Deliver or provide access to training on comprehensive care and minimising patient harm based on the patient population.

Strategies for improvement

Hospitals

The Clinical Governance Standard has specific actions relating to health service organisations’ safety and quality systems.

Action 1.7 – policies and procedures

Action 1.10 – risk management systems

Actions 1.19, 1.20 and 1.21 – education and training

Health service organisations should:

• Use these and other established safety and quality systems to support the policies and procedures, risk management and training for comprehensive care and minimising patient harm

• Ensure that current versions of all relevant policies and procedures are readily available and accessible to clinicians.

Policies may be developed or adapted at different levels within the organisation. However, all policy documents should be incorporated into a single, coherent set to maximise the effectiveness of the policy development process.

Implement policies and procedures

Provide guidance about aspects of comprehensive care in policies and procedures, such as:

  • Performing a risk assessment of the population served and the services provided to inform decisions about required screening and assessment processes
  • Using organisation-wide integrated screening and assessment processes
  • Ensuring shared decision making in the context of comprehensive care planning, and in making decisions about end-of-life care
  • Documenting screening and assessment findings, the outcome of shared decision making processes, agreed goals of care and comprehensive care plans
  • Outlining the roles, responsibilities and accountabilities of multidisciplinary team members in developing, documenting, evaluating and reviewing comprehensive care plans, and delivering comprehensive care
  • Using processes for identifying patients with end-of-life care needs; receiving, documenting and using advance care plans; accessing supervision and support; and reviewing the safety and quality of end-of-life care
  • Using processes relating to the specific harms identified in the ‘Minimising patient harm’ criterion of this standard.

Manage risks

Use established risk management systems (see Action 1.10) to identify, monitor, manage and review risks associated with comprehensive care. Develop processes to manage clinical risks for different populations served within the organisation, clinical and workplace risks for the workforce, and organisational risks.

Use information from measurement and quality improvement systems, adverse events, clinical outcomes and patient experiences to inform and update risk assessments and the risk management system.

Identify training requirements

Assess the competency and training needs of the workforce in line with the requirements of Actions 1.19, 1.20 and 1.21. Perform a risk assessment to inform the training schedule and to set priorities for the members of the workforce who require training. Develop or provide access to training and education resources to meet the needs of the workforce in relation to comprehensive care.

Consider the training the workforce may need to effectively use the clinical incident management and investigation system to inform risk management, and to plan and implement quality improvement processes to mitigate risks.

Day Procedure Services

The Clinical Governance Standard has specific actions relating to health service organisations’ safety and quality systems.

Action 1.7 – policies and procedures

Action 1.10 – risk management systems

Actions 1.19, 1.20 and 1.21 – education and training

Health service organisations should:

• Use these and other established safety and quality systems to support the policies and procedures, risk management and training for comprehensive care and minimising patient harm

• Ensure that current versions of all relevant policies and procedures are readily available and accessible to clinicians.

Policies may be developed or adapted at different levels within the organisation. However, all policy documents  should be incorporated into a single, coherent set to maximise the effectiveness of the policy development process.

Implement policies and procedures

Provide guidance about aspects of comprehensive care in policies and procedures, such as:

  • Performing a risk assessment of the population served and the services provided to inform decisions about required screening and assessment processes
  • Following requirements for pre-admission screening and assessment
  • Using processes relating to the management of the specific harms identified in the ‘Minimising patient harm’ criterion of this standard.

Manage risks

Use established risk management systems (see Action 1.10) to identify, monitor, manage and review risks associated with comprehensive care. Use information from measurement and quality improvement systems, adverse events, clinical outcomes and patient experiences to inform and update risk assessments and the risk management system.

Identify training requirements

Assess the competency and training needs of the workforce in line with the requirements of Actions 1.19, 1.20 and 1.21. Perform a risk assessment to inform the training schedule and to set priorities for the members of the workforce who require training. Develop or provide access to training and education resources to meet the needs of the workforce in relation to comprehensive care.

Consider the training the workforce may need to effectively use the clinical incident management and investigation system to inform risk management, and to plan and implement quality improvement processes to mitigate risks.

Examples of evidence

Select only examples currently in use:

  • Policy documents or by-laws that provide guidance on aspects of comprehensive care, including
    • organisation-wide screening and assessment processes
    • documentation of screening and assessment findings, the outcome of shared decision-making processes, agreed goals of care and comprehensive care plans
    • roles, responsibilities and accountabilities of the multidisciplinary team in delivering comprehensive care
    • processes for identifying patients at the end of life and managing their care appropriately
    • processes relating to the specific harms identified in the ‘Minimising patient harm’ criterion of this standard
  • Risk management system to identify, monitor, manage, review and manage risks associated with comprehensive care
  • Audit results of clinical practice in the delivery of comprehensive care
  • Results from audits, prevalence surveys and incident reporting relating to comprehensive care
  • Documentation of governance structures, including committees or other bodies, to discuss planning and delivery of comprehensive care
  • Committee and meeting records in which planning and delivery of comprehensive care were discussed
  • Risk assessment of workforce competency and training needs, and actions taken to manage risks
  • Training documents relating to planning and delivering comprehensive care, including care at the end of life, and care relating to falls, pressure injuries, mental health, nutrition and hydration, and cognitive impairment.
MPS & Small Hospitals

The Clinical Governance Standard has specific actions relating to health service organisations’ safety and quality improvement systems.

Action 1.7 – policies and procedures

Action 1.10 – risk management systems

Actions 1.19, 1.20 and 1.21 – education and training

Health service organisations should:

  • Use these and other established safety and quality systems to support the policies and procedures, risk management and training for comprehensive care and minimising patient harm
  • Ensure that current versions of all relevant policies and procedures are readily available and accessible to clinicians.

Policies may be developed or adapted at different levels within the organisation. However, all policy documents should be incorporated into a single, coherent set to maximise the effectiveness of the policy development process.

Implement policies and procedures

Provide guidance about aspects of comprehensive care in policies and procedures.

Manage risks

Use established risk management systems (Action 1.10) to identify, monitor, manage and review risks associated with comprehensive care. Develop processes to manage clinical risks for different populations served within the organisation, clinical and workplace risks for the workforce, and organisational risks.

Use information from measurement and quality improvement systems, adverse events, clinical outcomes and patient experiences to inform and update risk assessments and the risk management system.

Identify training requirements

Assess the competency and training needs of the workforce in line with the requirements of Action 1.19, 1.20 and 1.21. Perform a risk assessment to inform the education plan and to set priorities for the members of the workforce who require training. Develop or provide access to training and education resources to meet the needs of the workforce in relation to comprehensive care.

Consider the training the workforce may need to effectively use the clinical incident management and investigation system to inform risk management, and to plan and implement quality improvement processes to mitigate risks.

Last updated 4th July, 2018 at 10:34pm
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