allied health assistant framework self-audit tool · the allied health assistant framework...

Allied Health Assistant Framework Self-audit Tool

Allied Health Professions’ Office of Queensland

June 2017

Allied Health Assistant Framework Self-audit Tool

Published by the State of Queensland (Queensland Health), June 2017

This document is licensed under a Creative Commons Attribution 3.0 Australia licence. To view a copy of this licence, visit creativecommons.org/licenses/by/3.0/au

© State of Queensland (Queensland Health) 2017

You are free to copy, communicate and adapt the work, as long as you attribute the State of Queensland (Queensland Health).

For more information contact: Allied Health Professions’ Office of Queensland, Clinical Excellence Division, Department of Health, PO Box 2368, Fortitude Valley BC QLD 4006, email [email protected], phone (07) 3328 9298.

An electronic version of this document is available at https://www.health.qld.gov.au/ahwac/html/ahassist.asp Disclaimer: The content presented in this publication is distributed by the Queensland Government as an information source only. The State of Queensland makes no statements, representations or warranties about the accuracy, completeness or reliability of any information contained in this publication. The State of Queensland disclaims all responsibility and all liability (including without limitation for liability in negligence) for all expenses, losses, damages and costs you might incur as a result of the information being inaccurate or incomplete in any way, and for any reason reliance was placed on such information.

Allied Health Assistant Framework Self-audit Tool - ii -

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https://www.health.qld.gov.au/ahwac/html/ahassist.asp

ContentsAllied Health Assistant Framework Self-audit Tool ............................................. 1

Purpose ............................................................................................................... 1

AHA Framework components .............................................................................. 1

Applying the AHA Framework Self-audit Tool ...................................................... 2

Appendix 1 Questionnaire 1: Allied health assistants ..................................... 4

Appendix 2 Questionnaire 2: Allied health professionals ................................ 8

Appendix 3 Questionnaire 3: Team Leader or Allied Health Director ........... 13

Appendix 4 Action Plan template.................................................................. 18

Acknowledgement

The Allied Health Assistant Framework Self-audit Tool was developed by the Cairns & Hinterland Hospital and Health Service and has been adapted and reproduced by the Allied Health Professions’ Office of Queensland (AHPOQ) with permission from the Executive Director of Allied Health.

AHPOQ would also like to acknowledge the support of the many teams who trialled the tool and provided invaluable feedback.

Allied Health Assistant Framework Self-audit Tool - iii -

Allied Health Assistant Framework Self-audit Tool Purpose The Allied Health Assistant (AHA) Framework Self-audit Tool is designed to be used by allied health teams to enhance the role and work practices of AHAs within services.

The self-audit tool comprises a series of questionnaires and templates that map the eight components of the AHA Framework1 against the current status of AHA service delivery in a particular work unit, team, service or Hospital and Health Service (HHS).

The AHA Framework Self-audit Tool is recommended for use in line with the particular HHS’s nominated Performance Development Plan (PDP) or equivalent process2.

AHA Framework components Component 1: Scope of practice

• AHAs working in the Queensland public health system will have a defined scope of practice linked to service needs.

• The scope of practice includes tasks in which the AHA has been trained and is competent to safely perform.

• Flexibility to adapt the scope of practice is required in order to reflect the changing needs of the local service. The scope will vary depending on setting and profession needs e.g. paediatric, geriatric or mental health.

Component 2: Education, skills and competencies

• The Certificate IV in Allied Health Assistance has been identified as the qualification best aligned to enable the full scope of practice for AHAs.

• AHAs currently employed in the Queensland public sector are encouraged to participate in ‘recognition of prior learning’ (RPL) as part of meeting the relevant qualification requirements.

• AHAs should be encouraged to progress to attainment of the competencies and skill sets required for/or linked to the role.

• Some roles may have mandatory qualifications and/or skill sets that are determined by the requirements of the position.

Component 3: Role description AHAs working within the Queensland public health system will have a role description that reflects the role type and setting and links directly to the clinical service the role supports.

Component 4: Clinical supervision guidelines

• AHA positions are to be clinically supervised by an allied health professional. • AHA positions will have a designated clinical supervisor. • Formal supervision sessions will be documented in accordance with local requirements. • Clinical supervision may be direct, indirect and/or remote.

1 http://qheps.health.qld.gov.au/alliedhealth/docs/aha/ahaframework.pdf 2 Also known as Performance and Development (PaD), Performance Appraisal and Development (PAD) or Performance Planning and Appraisal (PPA) processes.

Allied Health Assistant Framework Self-audit Tool - 1 -

http://qheps.health.qld.gov.au/alliedhealth/docs/aha/ahaframework.pdf

Component 5: Delegation guidelines

• Allied health professionals will have a clear understanding of what can be delegated to AHAs and the related responsibilities and accountabilities.

• AHAs will have a clear understanding of their responsibilities when accepting delegated tasks from allied health professionals.

• Delegation will be documented.

Component 6: Evaluation and sustainability

• Evaluation forms an integral part of delegated practice. • Strategies for sustainability should be implemented to embed the inclusion of AHAs within

service teams.

Component 7: Integrating AHAs into allied health teams

• Allied health professionals are required to have knowledge and understanding of the roles and responsibilities of AHAs.

• Allied health professionals may require support to develop effective supervision and delegation skills when working with AHAs.

Component 8: Professional development Ongoing professional development is important for AHAs in order to maintain and enhance their skills and knowledge. This is a shared responsibility between the individual and their employer, aimed at optimising performance and enhancing patient care.

Applying the AHA Framework Self-audit Tool Applying the AHA Framework Self-audit Tool within a particular work unit, team, service or HHS should be considered a collaborative, team-based activity with contributions required from all AHAs, supervising allied health professionals (AHPs) and Team Leader or Allied Health Director.

The self-audit tool includes three questionnaires for completion by the different stakeholders and a template that assists in the development of an action plan:

Questionnaire 1: To be completed by the AHA Questionnaire 2: To be completed by the supervising AHP Questionnaire 3: To be completed by the Team Leader or Allied Health Director. Action Plan template: To be completed by the Team Leader or Allied Health Director

as a guide to developing an action plan3.

Each questionnaire comprises a series of audit questions to assist the user to identify the key component areas which have capacity for improvement (Appendices 1-3).

The Action Plan template provides a structured format for summarising the areas where action is required, and a process for recording key actions or strategies against an agreed timeframe (Appendix 4).

3 Adapted from iQIPP-AH Guides for quality improvement in allied health practice education (2012)


Instructions Answer every audit question by ticking the appropriate box (Yes, No, Unsure, N/A),

and/or adding a short answer in the free text section where indicated. When every question has been answered, list any deficits or areas of concern at the

bottom of the questionnaire. Where appropriate, transfer any deficits/areas of concern to the Action Plan. Timeframes identified in the Action Plan should be documented and actioned as

appropriate. Use the free text box at the end of each questionnaire to record any additional

thoughts or comments that you may wish to further discuss with the team. Where applicable, we have aligned the numbers in each questionnaire with those in the Action Plan template.


Appendix 1 Questionnaire 1: Allied health assistants

This questionnaire should be completed by all AHAs working in the work unit, team, service or HHS.

It is recommended that the AHA completes this questionnaire with the assistance of their primary supervisor and/or line manager. Discuss any deficits or areas of concern that become apparent after you have responded to all questions and consider key actions and potential timeframes that can be entered into the Action Plan.

In order to answer questions in Component 4 (Clinical supervision guidelines); please refer to the following definitions for the different types of clinical supervision:

Direct clinical supervision Indirect clinical supervision Remote clinical supervision Occurs when the supervising AHP: • works alongside the AHA

Occurs when the supervising AHP: • works on-site and is easily

accessible but not in direct view of the AHA while the activity is being performed – the AHA must rely on clear communication from the supervising AHP

Occurs when the supervising AHP: • is located some distance

from the AHA

• observes and directs the AHA’s activities

• is readily available within the same physical area or easily contactable (i.e. by phone or pager) should the need for consultation arise

• is contactable and accessible to provide direction, support and guidance as required e.g. telephone or video conferencing

• provides immediate guidance, feedback and intervention as required

• designates an alternative contact person (should the need arise) if they will be unavailable


AHA Framework Self-audit Questionnaire 1: Allied health assistants Name: Team:

Line manager: Location:

Questions Response

Yes No Unsure N/A

Component 1: Scope of practice

1. 1 Do you have a role description for your current position?

1. 2 Does the role description include a statement about scope of practice?

1. 3 Is your scope of practice reviewed regularly to ensure it remains relevant to service needs?


2.1 Do you hold a qualification? If so, what is it?

2.2 Are you currently studying? If so, what course?

2.4 Is on-the-job training provided to you? If so, how is this training provided?

2.5 Does the training provided to you cover the tasks required for your position?

2.6 Are skill assessments (of the clinical tasks in which you have been trained) undertaken and the results documented? If so, how often and by whom?

2.10 Have you undertaken delegation training? If so, what type of training?

2.11 Are the training activities you have completed recorded? If so, who manages these records? How often are these records reviewed?

Component 3: Role description

3.3 Are you performing all the functions listed in your role description?

3.4 Are you performing any clinical tasks not included within the scope of practice described in your role description?


Questions Response

Yes No Unsure N/A

Component 4: Clinical supervision guidelines [Refer to definitions provided]

4.1 Do you have a primary clinical supervisor?

4.2 Do you have a formal (written) supervision plan in place?

4.3 What is the frequency of your clinical supervision?

4.4 Has your supervisor provided you with a clear statement of duties?

4.5 How is your supervision provided? Please tick all that apply.

Direct Indirect Remote

4.6 If remote supervision is required for your position (e.g. you do home visits) how is this managed?


5.3 Do the AHPs document the tasks they delegate to you?

5.4 Do you update the patient’s medical record after completing the delegated task or activity?

5.5 Have you received training in recognising ‘when to stop’ delegated tasks and/or escalate concerns to your supervisor?


6.3 Did you participate in an induction program when you commenced your role?

Component 8: Professional development

8.1 How do you access and fund your professional development (PD) activities?

8.2 Do you participate in workplace-based learning activities such as in-services?

8.3 Do you have a Performance and Development Plan (PDP)?

8.4 Are the PD activities you have completed recorded? If so, who manages and monitors these records? How often are these records reviewed?


Questionnaire 1

List any deficits/areas of concern:

Please use this space to add any comments or suggestions regarding AHA roles and governance arrangements:


Appendix 2 Questionnaire 2: Allied health professionals

This questionnaire should be completed by all AHPs providing clinical supervision to AHAs working in the work unit, team, service or HHS.



Occurs when the supervising AHP: • works on-site and is

accessible but not in direct view of the AHA while the activity is being performed – the AHA must rely on clear communication from the supervising AHP


from the AHA

• observes and directs the AHAs activities

• is readily available within the same physical area or easily contactable (i.e. by phone or pager) should the need for consultation arise

• is contactable and accessible to provide direction, support and guidance as required e.g. telephone or video conferencing

• provides immediate guidance, feedback and intervention as required

• designates an alternative contact person (should the need arise) if they will be unavailable

In order to answer Question 7.2 please refer to the draft Operational Services Manual available at: http://qheps.health.qld.gov.au/hr/employment-conditions/streams/op-serv-manual.pdf.

Discuss with your line manager any deficits or areas of concern that become apparent after you have completed the questionnaire. Consider key actions and potential timeframes that can be entered into the Action Plan.


http://qheps.health.qld.gov.au/hr/employment-conditions/streams/op-serv-manual.pdf


AHA Framework Self-audit Questionnaire 2: Allied health professionals Name: Team:

Line manager: Location:

Questions Response

Yes No Unsure N/A


1.3 Is a scope of practice statement included in role descriptions for AHA positions?

1.4 What systems or processes are in place to ensure the AHA works within the specified scope of practice?


2.1 Do OO4 (or higher) AHA positions require a mandatory qualification e.g. minimum Cert IV in Allied Health Assistance or equivalent level qualification?

2.4 Is on-the-job training provided to AHAs? If so, how is this training provided?

2.5 Does the training provided to AHAs cover the tasks detailed in their role descriptions?

2.6 Is the AHA’s competence in performing clinical tasks regularly assessed and documented? If so, how often and by whom?

2.9 Have you undertaken delegation training? If so, what type of training?

2.11 Are the training activities completed by the AHA recorded? If so, who manages and monitors these records? How often are these records reviewed?


3.1 Are there generic role descriptions for OO3 and OO4 AHAs?

3.2 Does the AHA role description clearly document:

• scope of practice?

• accountabilities and responsibilities?

• details for professional supervision?

• details of line management?

• an adequate balance of clinical,administrative and operational functions?


Questions Response Yes No Unsure N/A

3.3 Are AHAs performing all the functions listed in the role description?

3.4 Are AHAs performing clinical tasks that are inconsistent with the scope of practice in the role description?


4.1 Do all AHAs have a primary clinical supervisor?

4.2 Do AHAs have a formal (written) clinical supervision plan in place?

4.3 How do you determine the frequency of supervision you provide to AHAs?

4.4 Have you provided a clear statement of duties to the AHA?

4.5 Is clinical supervision delivered appropriate to the practice setting (i.e. direct, indirect and/or remote)?

4.6 If remote supervision is required for an AHA position how is this managed?

4.7 Have you had training in providing clinical supervision to AHAs? If so, what type of training?


5.1 Do you consider the following three risk areas at the point of delegation: • patient complexity and stability • task setting and context • AHA competence in that task?

5.2 Do you follow the principles of effective delegation?

5.3 Do you document all the tasks that you delegate to AHAs?

5.4 Do AHAs update the patient’s medical record after completing the delegated task or activity?

5.5 Have AHAs received training in recognising ‘when to stop’ delegated tasks and/or escalate concerns to you?


6.1 Are audits of the following regularly performed:

• delegation practices?

• clinical task instructions (or equivalent)?

• supervision and training arrangements?


Questions Response

Yes No Unsure N/A

If yes, how frequently do these audits occur?

6.2 Do you help develop Performance and Development Plans (PDPs) for new and existing AHA staff?

6.3 Do AHAs participate in an induction program when commencing a new role? 6.4 Is there a formal process in place for managing, monitoring and evaluating AHA roles? Component 7: Integrating AHAs into allied health teams

7.1 Do work units have protocols and guidelines in place to govern clinical decision-making for AHAs? If yes, please describe?

7.2 Do you ensure AHAs follow the objectives and duties outlined in the Queensland Health Operational Services Manual? If so, how?

7.3 Are there any AHA roles that have responsibility for providing support, guidance, direction and/or operational management to other AHA staff or AHA trainees? If yes, please describe?


8.2 Do AHAs participate in workplace-based learning activities such as in-services?

8.3 Do AHAs use their PDP to plan PD activities?

8.4 Are the PD activities completed by the AHA recorded? If so, who manages and monitors these records? How frequently are these records reviewed?

Questionnaire 2



Appendix 3 Questionnaire 3: Team Leader or Allied Health Director

This questionnaire should be completed by the Team Leader or Allied Health Director of the work unit, team, service or HHS.



Occurs when the supervising AHP: • works on-site and is easily

accessible but not in direct view of the AHA while the activity is being performed – the AHA must rely onclear communication from the supervising AHP


from the AHA

• observes and directs theAHAs activities

• is readily available withinthe same physical area oreasily contactable (i.e. byphone or pager) should theneed for consultation arise

• is contactable andaccessible to providedirection, support andguidance as required e.g.telephone or videoconferencing

• provides immediateguidance, feedback andintervention as required

• designates an alternativecontact person (should theneed arise) if they will beunavailable

In order to answer Question 7.2 please refer to the draft Operational Services Manual available at: http://qheps.health.qld.gov.au/hr/employment-conditions/streams/op-serv-manual.pdf.




AHA Framework Self-audit Questionnaire 3: Team Leader or Allied Health Director Name: Team:

Location:

Questions Response

Yes No Unsure N/A


1.3 Is a scope of practice statement included in role descriptions for all new and existing AHA positions?

1.4 What systems or processes are in place to ensure that AHAs work within a specified scope of practice?


2.1 Do OO4 (or higher) AHA positions require a mandatory qualification e.g. minimum Cert IV in Allied Health Assistance or equivalent level qualification?

2.2 Are AHAs encouraged to undertake further study? 2.3 Are qualifications attained from outside Australia assessed for equivalency? If so, how are they assessed?

2.4 Is on-the-job training provided to AHAs? If so, how is this training provided?

2.5 Does the training provided to AHAs cover the tasks detailed in their role descriptions?

2.6 Is the AHA’s competence in performing clinical tasks regularly assessed and documented? If so, how often and by whom?

2.7 Are there team members available who can deliver or coordinate delegation training to your team/s?

2.8 Are trained Calderdale Framework Facilitators available in the HHS? If so, who are they?

2.9-2.10 Where relevant, have AHPs and AHAs undertaken training in delegation practices? If so, what type of training?


Questions Response

Yes No Unsure N/A

2.11 Are the training activities completed by AHAs recorded? If so, who manages and monitors these records? How frequently are these records reviewed?


3.1 Are there generic role descriptions for OO3, OO4 and OO5 AHAs?

3.2 Does the AHA role description clearly document:

• scope of practice?

• accountabilities and responsibilities?

• details for professional supervision?

• details of line management?

• an adequate balance of clinical,administrative and operational functions?

3.3 Are AHAs performing all the functions listed in the role description?

3.4 Are AHAs performing any clinical tasks that are inconsistent with the scope of practice described in role description?


4.1 Do all AHAs have a primary clinical supervisor?

4.2 Do AHAs have a formal (written) clinical supervision plan in place?

4.3 How is the frequency of clinical supervision provided to AHAs determined?

4.4 Has the supervisor provided a clear statement of duties to the AHA?

4.5 Is clinical supervision delivered appropriate to the practice setting (i.e. direct, indirect and/or remote)?

4.6 Where relevant, do AHPs have training in providing clinical supervision to AHAs? If so, what type of training?


5.5 Have AHAs received training in recognising ‘when to stop’ delegated tasks and/or escalate concerns to their supervisor?


Questions Response

Yes No Unsure N/A


6.1 Are audits of the following regularly performed:

• delegation practices?

• clinical task instructions (or equivalent)?

• supervision and training arrangements?

If yes, how frequently do these audits occur?

6.2 Do operational and/or clinical managers help develop a Performance and Development Plan (PDP) with new and existing AHA staff?

6.3 Do AHAs participate in an induction program when commencing a new role?

6.4 Are there formal processes in place for managing, monitoring and evaluating AHA roles? If yes, please describe


7.1 Do work units have protocols and guidelines in place to govern clinical decision-making for AHAs? If yes, please describe?

7.2 Do line managers ensure AHAs follow the objectives and duties outlined in Queensland Health Operational Services Manual? If so, how?

7.3 Are there any AHA roles that have responsibility for providing support, guidance, direction and/or operational management to other AHA staff or AHA trainees? If yes, please describe?


8.1 How do AHAs access and fund professional development (PD) activities?

8.2 Do AHAs participate in workplace-based learning activities such as in-services?

8.3 Do AHAs use their PDP to plan PD activities?

8.4 Are the PD activities completed by AHAs recorded? If so, who manages and monitors these records? How frequently are these records reviewed?


Questionnaire 3




Appendix 4 Action Plan template Once the responses have been tallied for each of the three questionnaires the results can be entered into the Action Plan template. This provides a structured format for summarising the areas where action is required and provides users with a process for recording key actions (based on the audit statements) against an agreed timeframe.

Action Plan Template Audit Statements Action

Required Key Actions Timeframe

Yes No


1.1-1.3 There is a scope of practice statement included in the role description for all AHA positions in the work unit, team, service or HHS that is regularly updated to ensure ongoing relevance.

1.4 Systems or processes are in place to ensure that AHAs work within a specified scope of practice.


2.1 All OO4 (or higher) AHAs hold a minimum Cert IV in Allied Health Assistance or equivalent level qualification.

2.2 AHAs are encouraged to undertake additional study.

2.3 Qualifications attained from outside Australia are assessed for equivalency

2.4 On-the-job training is provided to AHAs.

2.5 Training provided to AHAs covers the tasks detailed in the role description.

2.6 AHA competence in performing clinical tasks is regularly assessed and documented.

2.7 There are team members available who can deliver or coordinate delegation training to teams.

2.8 There are trained Calderdale Framework Facilitators available in the HHS.

2.9-2.10 Where relevant, all AHPs and AHAs have undertaken training in delegation practices.


Audit Statements Action Required

Key Actions Timeframe

Yes No

2.11 Records of training activities completed by AHAs are regularly updated and reviewed.


3.1 There are generic role descriptions for OO3, OO4 and OO5 AHA positions.

3.2 AHA role descriptions clearly document: • scope of practice• accountabilities and responsibilities• details for professional supervision• details of line management• an adequate balance of clinical,

administrative and operationalfunctions.

3.3 AHAs perform all functions listed in the role description.

3.4 AHAs perform only those clinical tasks that are consistent with the scope of practice described in the role description.

Component 4: Clinical supervision guidelines

4.1 AHAs have a primary clinical supervisor.

4.2 AHAs have a formal (written) clinical supervision plan in place.

4.3 The frequency of clinical supervision provided is determined by: • the nature of the delegated task• complexity of caseload• supervisory experience (AHP)• developmental level (AHA)• practice setting.

4.4 The supervisor provides a clear statement of duties to the AHA.

4.5 Clinical supervision is delivered appropriate to the practice setting (i.e. direct, indirect and/or remote).

4.6 Remote supervision is provided where the AHA works: • in a clients’ home• when the supervising AHP is not on

duty (e.g. weekend)• in a different facility to the supervising

AHP.




Yes No

4.7 Where relevant, AHPs have training in providing clinical supervision to AHAs.


5.1 AHPs consider three risk areas at the point of delegation: • patient complexity and stability• task setting and context• AHA competence in that task.

5.2 AHPs and AHAs follow the principles of effective delegation.

5.3 AHPs document the tasks they delegate to AHAs.

5.4 AHAs update the patient’s medical record after completing the delegated task or activity.

5.5 AHAs receive training in recognising when to stop delegated tasks and/or escalate concerns to their supervisors?


6.1 Audits are regularly performed on: • delegation practices• clinical task competency• supervision and training

arrangements.

6.2 AHAs receive advice and assistance when developing their PDPs.

6.3 AHAs participate in an induction program when commencing a new role.

6.4 There is a formal process in place for managing, monitoring and evaluating AHA roles.


7.1 Work units have protocols and guidelines in place to govern clinical decision-making for AHAs.

7.2 AHAs follow the objectives and duties outlined in the Queensland Health Operational Services Manual.

7.3 A number of AHA roles have responsibility for providing support, guidance, direction and/or operational management to other AHA staff or AHA trainees.




Yes No


8.1 AHAs have access to PD activities and funding to support attendance.

8.2 AHAs participate in workplace- based learning activities such as in-services.

8.3 AHAs use their PDP to plan PD activities.

8.4 Records of PD activities completed by AHAs are regularly updated and reviewed.


Department of Health Allied Health Assistant Framework Self-audit Tool https://www.health.qld.gov.au/ahwac/html/ahassist.asp

https://www.health.qld.gov.au/ahwac/html/ahassist.asp

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