Criterion: Patient safety and quality systems
Safety and quality systems are integrated with governance processes to enable organisations to actively manage and improve the safety and quality of health care for patients.
Effective clinical governance creates a learning environment and a comprehensive program of continuous quality improvement. The organisation’s safety and quality systems should ensure that patient safety and quality incidents are recognised, reported and analysed, and used to improve the care provided. It is important that these systems are integrated with governance processes to enable health service organisations to actively manage risk, and to improve the safety and quality of care.
The organisation’s approach to delivering and supporting clinical care should be described in policies, procedures and protocols, which may need to be endorsed by the governing body. Include the following topics:
- Developing policies, procedures and protocols
- Monitoring and reporting clinical performance
- Managing clinical risk
- Managing and reporting adverse events, including reporting on sentinel events
- Managing complaints and compliments
- Managing open disclosure
- Engaging clinicians in planned, systematic audits of clinical services following agreed protocols and schedules.