Standard 5: Comprehensive Care

Planning for comprehensive care

Action 5.7

The health service organisation has processes relevant to the patients using the service and the services provided:

a. For integrated and timely screening and assessment

b. That identify the risks of harm in the ‘Minimising patient harm’ criterion

Intent

Processes are in place for integrated and timely screening, assessment and risk identification.

Reflective question

How does the health service organisation ensure that screening and assessment processes used to identify the risks of harm are integrated and timely?

Key tasks

  • Assess the risks and clinical requirements of the patients who use the health service organisation and agree on relevant screening and assessment processes.

  • Ensure that the risks of harm identified in the ‘Minimising patient harm’ criterion of this standard are addressed in these processes.

Strategies for improvement

Hospitals

Develop screening processes

Screening is used to identify existing conditions or issues that may predispose a patient to further harm, and to identify the level of risk for potential new harms to occur. The conditions, issues and risks identified through screening need to be properly assessed to determine what actions should be taken to manage them. Screening should shape the care delivered to a patient.

Many different conditions, issues and risks can potentially be identified through screening.

To develop appropriate screening processes for the health service organisation, consider:

  • The cognitive, behavioural, mental and physical conditions and risks encountered by the patient population(s) served by the organisation
  • The risks of harm identified in the ‘Minimising patient harm’ criterion of this standard
  • Feedback from quality improvement processes
  • The capacity and type of services that the organisation provides.

Use this information to work with clinicians and consumers to develop screening and assessment processes that are appropriate to the needs of patients and the clinical service being provided, and are integrated into clinical workflow.

If one or more of the risks of harm identified in the ‘Minimising patient harm’ criterion of this standard are not applicable to the organisation’s patient population, document the rationale for not including these risks in the organisation’s risk assessment processes.

Identify expectations about the timing of initial screening and assessment processes, and indications for repeated screening and assessment, in relevant policies, procedures and protocols.

Processes may vary for different groups of patients who attend the health service organisation and in different services. In some cases, different emphasis will be placed on screening versus comprehensive assessment. For example, in the anaesthetic assessment service, a detailed preoperative screening process may be needed to identify anaesthetic and surgical risks. In the geriatric section, screening processes may be minimal because patients routinely receive a thorough clinical assessment of the common conditions, issues and risks associated with older hospitalised patients.

Integrate screening and assessment

Integrate processes for screening and assessment, wherever possible. This means developing strategies to integrate:

  • The multiple tools used to screen for common conditions and risks
  • Screening activities with clinical assessment activities
  • The input of multiple clinicians.

A recent audit of Victorian health services found more than 150 different screening and assessment forms in use across 11 health services.1 Validated, integrated screening tools are not always available; however, significant Australian research is being undertaken in this area. Some health service organisations have developed their own integrated screening tools to reduce duplication of effort when patients are admitted.

Link screening activities to clinical decision-making and action when clinical risks are identified. This might mean ensuring that screening tools direct clinicians to the relevant assessments and interventions for managing an identified risk. For example, if a patient is identified as having cognitive impairment, specific assessments and clinical management strategies are recommended.1

Integrate the screening and clinical assessment findings of multiple clinicians. This will reduce the need for patients, carers and families to repeat the same information multiple times to different clinicians. It will also help to ensure that the information gained through different professional assessments is addressed in clinical decision-making and incorporated into the comprehensive care plan. Strategies to foster integrated multidisciplinary screening and assessment activities include the use of:

  • Shared electronic or paper-based screening and assessment tools and systems
  • Shared ward rounds and clinics, multidisciplinary rapid rounding and multidisciplinary case conferencing
  • Formalised communication strategies such as checklists, timeouts, multidisciplinary handover meetings and electronic patient journey boards.
Day Procedure Services

Develop screening processes

Screening is used to identify existing conditions or issues that may predispose a patient to further harm, and to identify the level of risk for potential new harms to occur. The conditions, issues and risks identified through screening need to be properly assessed to determine what actions should be taken to manage them. Screening should shape the care delivered to a patient.

In day procedure services, different emphases will be placed on pre-admission screening and comprehensive assessment. Services may use a detailed preoperative screening process to identify anaesthetic and surgical risks. The day procedure service may not need comprehensive assessment processes if clinical conditions and risks identified through the screening process are largely managed by referring the patient to other services. Services will need to develop clear guidance about processes for refusing service when a patient’s clinical risks cannot be safely managed.

Many different conditions, issues and risks can potentially be identified through screening. To develop appropriate screening processes for the health service organisation, consider:

  • The cognitive, behavioural, mental and physical conditions and risks encountered by the patient population served by the organisation
  • The relevant risks of harm identified in the ‘Minimising patient harm’ criterion of this standard
  • Feedback from quality improvement processes
  • The capacity and type of services that the organisation provides.
  • Other aspects requiring screening (for example, medication safety, Aboriginal and Torres Strait Islander consumers, diversity under the Partnering with Consumers Standard).

Use this information to work with clinicians and consumers to develop screening and assessment processes that are appropriate to the needs of patients and the clinical service being provided, and are integrated into clinical workflow.

Patients who have specific conditions and risks of harm identified in screening processes may be referred elsewhere if further assessment and care are required. Develop admission protocols or policies that clearly outline criteria for admission.

Identify expectations about the timing of initial screening and assessment processes, and indications for repeated screening and assessment, in relevant policies, guidelines and procedures.

Integrate screening and assessment

Integrate processes for screening and assessment, wherever possible. This means developing strategies to integrate:

  • The multiple tools used to screen for common conditions and risks
  • Screening activities with clinical assessment activities
  • The input of multiple clinicians.

Link screening activities to clinical decision-making and action when clinical risks are identified. This might mean ensuring that screening tools direct clinicians to the relevant assessments and interventions for managing an identified risk. For example, if a patient is identified as having cognitive impairment, specific assessments and clinical management strategies are recommended.1

Examples of evidence

Select only examples currently in use:

  • Organisational assessment of the risks relevant to the population serviced by the health service organisation
  • Policy documents or by-laws that outline processes for conducting screening for, and assessment of, identified clinical conditions and risks, including those outlined in the ‘Minimising patient harm’ criterion, if relevant
  • Resources and tools developed for pre-admission screening and assessment of clinical conditions and risks that are relevant to the health service organisation and risks outlined in the ‘Minimising patient harm’ criterion
  • Employment documents that describe the roles, responsibilities and accountabilities for the workforce in relation to screening and assessment
  • Training documents about the identification and assessment of at-risk patients
  • Audit of screening and, if necessary, assessment processes on admission and at appropriate intervals during an episode of care.
MPS & Small Hospitals

MPSs and small hospitals will need to:

  • Assess the risks and clinical requirements of the patients who use the health service organisation, and agree on relevant screening and assessment processes
  • Ensure that the risks of harm identified in the ‘Minimising patient harm’ criterion of this standard are addressed in these processes.

Screening is used to identify existing conditions or issues that may predispose a patient to further harm, and to identify the level of risk for potential new harms to occur. The conditions, issues and risks identified through screening need to be properly assessed to determine what actions should be taken to manage them. Screening should shape the care delivered to a patient.

Many different conditions, issues and risks can potentially be identified through screening. To develop appropriate screening processes for the health service organisation, consider:

  • The cognitive, behavioural, mental and physical conditions and risks encountered by the patient population served by the organisation
  • The risks of harm identified in the ‘Minimising patient harm’ criterion of this standard
  • Feedback from quality improvement processes
  • The capacity and type of services that the organisation provides.

Use this information to work with clinicians and consumers to develop screening and assessment processes that are appropriate to the needs of patients and the clinical service being provided, and are integrated into clinical workflow.

Identify expectations about the timing of initial screening and assessment processes, and indications for repeated screening and assessment, in relevant policies, procedures and protocols.

Processes may vary for different groups of patients who attend the health service organisation and in different services. In some cases, different emphasis will be placed on screening versus comprehensive assessment. For example, in the anaesthetic assessment service, a detailed preoperative screening process may be needed to identify anaesthetic and surgical risks. In the geriatric section, screening processes may be minimal because patients routinely receive a thorough clinical assessment of the common conditions, issues and risks associated with older hospitalised patients.

Integrate screening and assessment

Integrate processes for screening and assessment, wherever possible. This means developing strategies to integrate:

  • The multiple tools used to screen for common conditions and risks
  • Screening activities with clinical assessment activities
  • The input of multiple clinicians.

Link screening activities to clinical decision-making and action when clinical risks are identified. This might mean ensuring that screening tools direct clinicians to the relevant assessments and interventions for managing an identified risk. For example, if a patient is identified as having cognitive impairment, specific assessments and clinical management strategies are recommended.1

Integrate the screening and clinical assessment findings of multiple clinicians. This will reduce the need for patients, carers and families to repeat the same information multiple times to different care providers. It will also help to ensure that the information gained through different professional assessments is addressed in clinical decision-making and incorporated into the comprehensive care plan. Strategies to foster integrated multidisciplinary screening and assessment activities include the use of:

  • Shared electronic or paper-based screening and assessment tools and systems
  • Shared ward rounds and clinics, multidisciplinary rapid rounding and multidisciplinary case conferencing
  • Formalised communication strategies such as checklists, timeouts, multidisciplinary handover meetings and electronic patient journey boards.

Action 5.8

The health service organisation has processes to routinely ask patients if they identify as being of Aboriginal and/or Torres Strait Islander origin, and to record this information in administrative and clinical information systems

Intent

People who identify as being of Aboriginal and/or Torres Strait Islander origin are provided with tailored and culturally appropriate comprehensive care.

Reflective questions

What processes are in place for patients to identify as being of Aboriginal or Torres Strait Islander origin?

How is this information recorded in administrative information systems and transferred to clinical information systems?

Key tasks

  • Develop policies, protocols and processes for confirming Aboriginal and Torres Strait Islander identification status.

  • Train the workforce to build competence in working with diverse population groups and specifically for collecting identification information.

  • Include Aboriginal and Torres Strait Islander identifiers in administrative and clinical datasets.

  • Monitor and report on the implementation of Aboriginal and Torres Strait Islander identification strategies.

Strategies for improvement

Hospitals

Confirming the identity of a person as being of Aboriginal or Torres Strait Islander origin at the beginning of their care will help health service organisations provide comprehensive tailored and culturally appropriate care, including better assessment of the risks that an individual may face.

If Aboriginal or Torres Strait Islander identity is established through an administrative process, ensure that there are mechanisms for this information to be transferred to the clinical information systems and, critically, the patient’s healthcare record.

Monitor trends in reporting, healthcare delivery and health outcomes for Aboriginal and Torres Strait Islander people, and use this to assess the effectiveness of improvement strategies for Aboriginal and Torres Strait Islander consumers.

The correct and consistent identification and recording of Aboriginal and Torres Strait Islander consumers are also important practices in upholding the rights of healthcare consumers. Encourage the workforce to collect information in a professional and respectful manner, without making assumptions about a consumer’s identity or about how they are likely to respond to any given question. Be aware that some Aboriginal and Torres Strait Islander consumers may not wish to declare their Aboriginal or Torres Strait Islander heritage.

To improve the willingness of Aboriginal and Torres Strait Islander people to identify themselves, health service organisations can:

  • Partner with Aboriginal and Torres Strait Islander consumers and local communities to improve the health service organisation’s understanding of reasons for declaring or not declaring their Aboriginal or Torres Strait Islander identity, and to improve processes for Aboriginal and Torres Strait Islander identification
  • Develop resources in formats that are easily accessible for Aboriginal and Torres Strait Islander consumers, to explain why the question of Aboriginal and Torres Strait Islander identity is being asked
  • Establish mechanisms to improve cultural competency and reflective practice of the workforce.

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

Day Procedure Services

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, a day procedure service cannot determine this without a system for identifying which of its patients identify as Aboriginal or Torres Strait Islander and what, if any, additional risks they face.

Encouraging Aboriginal and Torres Strait Islander people to be comfortable identifying themselves may require day procedure services to:

  • Provide patients with easy-to-understand information about why the service is asking them to identify themselves
  • Establish mechanisms to improve the cultural competency and reflective practice of the workforce that collects identifying information.

Evidence provided under this action will determine the applicability of other actions that relate to Aboriginal and Torres Strait Islander health (Actions 1.21.41.33 and 2.13).

Further strategies are available in NSQHS Standards Users Guide for Aboriginal and Torres Strait Islander Health.

Examples of evidence

Select only examples currently in use:

  • Policy documents or by-laws that outline processes for identifying Aboriginal and Torres Strait Islander patients, and recording this information in administrative and clinical information systems
  • Admission registration form on which patients can identify as being of Aboriginal or Torres Strait Islander origin
  • Comparison of patient healthcare and admission records that shows that Aboriginal and Torres Strait Islander patients are identified consistently
  • Communication material displayed in admission areas that provides patients with information about why they will be asked if they identify as being of Aboriginal or Torres Strait Islander origin
  • Training documents about obtaining information about Aboriginal and Torres Strait Islander patients
  • Communication with the workforce about the importance of identifying Aboriginal and Torres Strait Islander patients.
MPS & Small Hospitals

Confirming the identity of a person as being of Aboriginal or Torres Strait Islander origin at the beginning of their care will help health service organisations provide comprehensive tailored and culturally appropriate care, including better assessment of the risks that an individual may face.

MPSs and small hospitals should:

  • Develop policies, protocols and processes for confirming Aboriginal and Torres Strait Islander identification status
  • Train the workforce to build competence in working with diverse population groups and specifically for collecting identification information
  • Include Aboriginal and Torres Strait Islander identifiers in administrative and clinical datasets
  • Monitor and report on the implementation of Aboriginal and Torres Strait Islander identification strategies.

If Aboriginal or Torres Strait Islander identity is established through an administrative process, ensure that there are mechanisms for this information to be transferred to the clinical information systems and, critically, the patient’s healthcare record.

Monitor trends in reporting, healthcare delivery and health outcomes for Aboriginal and Torres Strait Islander people, and use this to assess the effectiveness of improvement strategies for Aboriginal and Torres Strait Islander consumers.

The correct and consistent identification and recording of Aboriginal and Torres Strait Islander consumers are also important practices in upholding the rights of healthcare consumers. Encourage the workforce to collect information in a professional and respectful manner, without making assumptions about a consumer’s identity or about how they are likely to respond to any given question. Be aware that some Aboriginal and Torres Strait Islander consumers may not wish to declare their Aboriginal and Torres Strait Islander heritage.

To improve the willingness of Aboriginal and Torres Strait Islander people to identify themselves, health service organisations can:

  • Partner with Aboriginal and Torres Strait Islander consumers and local communities to improve the health service organisation’s understanding of reasons for declaring or not declaring their Aboriginal and Torres Strait Islander identity, and to improve processes for Aboriginal and Torres Strait Islander identification
  • Develop resources in formats that are easily accessible for Aboriginal and Torres Strait Islander consumers, to explain why the question of Aboriginal and Torres Strait Islander identity is being asked
  • Set up mechanisms to improve cultural competency and reflective practice of the workforce.

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

Action 5.9

Patients are supported to document clear advance care plans

Intent

Patients are supported to document clear advance care plans.

Reflective question

What processes are in place to support patients to document an advance care plan?

Key task

Develop processes to support patients to document clear advance care plans.

Strategies for improvement

Hospitals

Advance care planning is a process of preparing for likely future healthcare scenarios. Documented advance care plans or directives come into effect when a patient no longer has the capacity to make decisions for themselves.

The laws that govern advance care plans and directives differ across Australian states and territories. Consider relevant legislation and guidelines when developing advance care planning processes for the health service organisation. The Advance Care Planning Australian website includes links to information and resources, specific to each state and territory, for different populations (including children) in different settings (for example, mental health or intensive care).

Ensure that the advance care planning process includes discussion of a patient’s values, preferences, and personal and family circumstances, and occurs in the context of their medical history and condition.

When undertaking advance care planning, patients need to consider many issues, including:

  • How their previous experiences of health care influence their preferences for future care
  • The quality of life that would be acceptable to them
  • Who they would want to speak for them if they lack the capacity to take part in decision-making
  • How they will maintain the relevance and currency of their advance care plan.

Outcomes of advance care planning may include nomination of a substitute decision-maker, or documentation of an advance care plan or directive. Patients may want to consider a number of different scenarios through advance care planning, such as their wishes and preferences for future care when:

  • An episode of acute deterioration in mental state occurs
  • Progressive cognitive decline associated with dementia occurs
  • Decisions about end-of-life care are needed.

Advance care planning is an iterative process, and multiple discussions may be needed. Documented advance care plans need to be updated over time.

Include the following in the system for supporting patients to document advance care plans:

  • Promotion of advance care planning as an important tool in providing care that aligns with patient preferences
  • Consistency with legislative, common law and state or territory requirements
  • A senior clinical lead to oversee implementation, evaluation and improvement of advance care planning processes
  • Policies and procedures that describe the roles and responsibilities of patients, carers, witnesses, substitute decision-makers and clinicians in advance care planning, and the process for documenting and updating advance care plans
  • Information resources, forms and other tools for patients and carers to consider, and document advance care plans in accordance with their wishes.
Day Procedure Services

Given the very short length of stay for most patients using day procedure services, this action will not be applicable for most services.

Action 5.17 regarding receiving and documenting advance care plans remains applicable. Further strategies and examples of evidence are available in the hospitals tab.

MPS & Small Hospitals

Advance care planning is a process of preparing for likely future healthcare scenarios. Documented advance care plans or directives come into effect when a patient no longer has the capacity to make decisions for themselves.

The laws that govern advance care plans and directives differ across Australian states and territories. Consider relevant legislation and guidelines when developing advance care planning processes for the health service organisation. The Advance Care Planning Australia website includes links to information and resources for different populations (including children) in different settings (for example, mental health or intensive care).

Ensure that the advance care planning process includes discussion of a patient’s values, preferences, and personal and family circumstances, and occurs in the context of their medical history and condition.

When undertaking advance care planning, patients need to consider many issues, including:

  • How their previous experiences of health care influence their preferences for future care
  • The quality of life that would be acceptable to them
  • Who they would want to speak for them if they lack capacity to take part in decision-making
  • How they will maintain the relevance and currency of their advance care plan.

Outcomes of advance care planning may include nomination of a substitute decision-maker, or documentation of an advance care plan or directive. Patients may want to consider a number of different scenarios through advance care planning, such as their wishes and preferences for future care when:

  • An episode of acute deterioration in mental state occurs
  • Progressive cognitive decline associated with dementia occurs
  • Decisions about end-of-life care are needed.

Advance care planning is an iterative process, and multiple discussions may be needed. Documented advance care plans need to be updated over time.

Include the following in the system for supporting patients to document advance care plans:

  • Promotion of advance care planning as an important tool in providing care that aligns with patient preferences
  • Consistency with legislative, common law and state or territory requirements
  • A senior clinical lead to oversee implementation, evaluation and improvement of advance care planning processes
  • Policies and procedures that describe the roles and responsibilities of patients, carers, witnesses, substitute decision-makers and clinicians in advance care planning, and the process for documenting and updating advance care plans
  • Information resources, forms and other tools for patients and carers to consider, and documentation of advance care plans in accordance with their wishes.
Last updated 5th July, 2018 at 04:48pm
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References

Redley B. Risk screening and assessment for avoiding preventable harm to older people in hospitals. Melbourne: Centre for Quality and Patient Safety Research, Deakin University; 2016.