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Accreditation Report

Quality Innovation Performance Accreditation Report

© QIP 2017 Torres and Cape Hospital and Health Service TCHHS – Accreditation Report

Thursday, 7 December 2017 | 1

Assessment Details

Health Service Name Torres and Cape Hospital and Health Service TCHHS

Health Service ID HP1007

Accreditation Contact Mr Leigh Broad

Standards NSQHS Standards (HOSPITAL)

Assessor

Mr Anastasios Kambouris Ms Nicole McKenzie Dr John Scott Phipps Mr David Stevens

Date of Assessment Monday, 4 September 2017

Assessment Location Level 9, Citi Central Building 45-48 Sheridan Street CAIRNS QLD 4870

Accreditation Status

Accreditation Decision Accredited

Accreditation Decision Maker Kate Lord

Decision Maker Signature

Date 7 December 2017

Accreditation Period 1 November 2017 – 1 November 2021

This assessment was conducted according to the requirements of the NSQHS Standards (HOSPITAL) and

Accreditation Program. The health service is required to maintain compliance with these standards

throughout the accredited period.

Disclaimer

The information contained in this report is based on evidence provided by the participating organisation and its representatives at the time of

the accreditation assessment and where applicable any further subsequent information that the organisation supplied through the reporting

process. Accreditation issued by Quality Innovation Performance (QIP) does not guarantee the safety, quality or acceptability of a participating

organisation or its services or programs, or that legislative and funding requirements are being, or will be, met.




Foreword

Accreditation is independent recognition that an organisation, practice, service, program or activity meets

the requirements of defined criteria or standards. Accreditation provides quality and performance

assurance for owners, managers, staff, funding bodies and consumers.

The achievement of accreditation is measured against the sector specific Standards which have been set as

the minimum benchmark for quality. Compliance with the Standards is demonstrated through an

independent assessment.

Accreditation can help an organisation to:

• Provide independent recognition that the organisation is committed to safety and quality

• Foster a culture of quality

• Provide consumers with confidence

• Build a more efficient organisation using a systematic approach to quality and performance

• Increase capability

• Reduce risk

• Provide a competitive advantage over organisations that are not accredited, and

• Comply with regulatory requirements, where relevant.

Continuous quality improvement (CQI) underpins all AGPAL/QIP accreditation programs and the

organisation/practice/service through:

• Looking for ways to improve as an essential activity of everyday practice

• Consistently achieving and maintaining quality care that meets consumer/patient needs

• Monitoring outcomes in consumer/patient care and seeking opportunities to improve both the care and

its results.

• Constantly striving for best practice by learning from others to increase the efficiency and effectiveness of

processes

The following report is based on an independent assessment of the service’s performance against NSQHS

Standards (HOSPITAL). The report includes compliance level ratings for each indicator, criteria and standard

and includes explanatory notes for key findings. Where an indicator is not rated as ‘met’, corrective action

is specified.




Executive Summary Formed through the amalgamation of two health districts in 2014, the Torres and Cape Hospital and Health

Service (TCHHS) provides services to over 26,000 people, most of whom live in areas that are remote from

standard services. With a predominantly indigenous population, the cultural influences are strong and the

organisation is working to incorporate those effects into the services provided. The TCHHS also has an

international involvement, with the PNG border at its northern boundary and health services provided to

PNG nationals through specific agreements between the countries, adopting a humanitarian approach to

those who present at the clinics.

Governance is well established and flows clearly across the organisation and at all levels of activity. Policies

and procedures are effective and accessible and the move to an electronic document management system

that is being considered would be most beneficial. The TCHHS operates two “regions” – Northern (Torres

Strait and the top of Cape York) and Southern (the bulk of the Cape north of Cairns). There remains some

level of division between the two regions at the points of service, which is probably inevitable, given that

the amalgamation of two health services is only 3 years old and that the two regions cover two different

cultural groups. The Board is considering a move to regionalisation of the workforce, which means having

more people living and working in the two regions rather than at the head office in Cairns. It will need

careful attention to ensure that such a move does not reinforce parochial thinking. Clinical governance is

robust and effective, with clear lines of reporting and responsibilities established. The introduction of the

Riskman software has improved the processes even further. Patients’ rights are well respected and the

employment of nurse navigators by the TCHHS has already seen improvements in the individual patient’s

lived experience as well as improving the efficiency of services.

Consumer involvement is evident across the organisation although somewhat patchy. Predominantly

stronger in the northern region, it could be refined further through better use of the local health groups in

both regions and effective use of the island cluster co-ordinators in the north. Interactions experienced by

the assessors with consumers revealed an essentially positive attitude plus an interest in being more

involved. Consumer input is considered by the board and there are board meetings held in the regions on

occasion, but there could be closer and clearer involvement by the communities particularly when

formulating the 4 year Strategic Plan. Whilst the board advised that they considered that strategic planning

is a whole-of-board activity, there may be merit in considering a strategy subcommittee of the board to

allow better involvement of communities and to allow the board members to review strategic issues more

thoroughly.

Infection control activities are effective and standardised across the TCHHS, with ample evidence of staff

education and assessments being undertaken. As with all organisations, there is a need to remain vigilant.

The organisation is managing a significant public health challenge with the high incidence of Tuberculosis

amongst PNG nationals seeking medical attention, many of whom have multi-drug resistant TB. It is most

important that accurate data is collected and collated to allow effective tracing and monitoring so

databases need to be effective and secure. It is recognised by the assessors that this issue is a cross-border

one, between Australia and PNG, but it is important that all efforts be made to co-ordinate care and

monitoring of these individuals. It is really a multi-agency effort that has to be in place.




Medication management is effective and follows the expected various governance approaches as required

by the National Standards and Queensland Health. There is always the issue of community medication

management but the TCHHS has a clear goal to ensure the best possible patient management. With the

acting chief Pharmacist currently based in the northern sector, it is important to ensure that his ability to

oversee the whole organisation is assured. Overall, the medical services are essentially that of general

practice, with procedures based at that level, along with some higher level services at the hospitals.

Identification and matching is orderly and effective. Transfer of care is a large part of the work undertaken

by the TCHHS and the processes are effective. Clinical handover is equally smooth and well established,

with a particular emphasis on discharge planning.

The organisation uses blood and blood products for a small number of regular patients; otherwise blood is

used only for emergencies. The systems in place are effective and well monitored. There are a number of

haemodialysis beds in operation and the appropriate supervision is undertaken, plus the organisation hosts

some patients who undertake their own haemodialysis.

Clinical care of patients is effective and concords with the National Standards with respect to both acute

and longer stay patients, carers and families. Prevention of pressure injuries and falls are high priorities,

with long stay patients regularly re-assessed for their individual risks. The use of allied health generalists is

likely to prove very effective in these issues both in the facilities and the communities. Managing the

deteriorating patient is standard and effort has been made to educate families and carers in this regard as

well, including those patients managed in the community.

Although somewhat outside the National Standards, the surveyors became aware that there are some

issues with the accommodation for relief staff in some remote communities. The situation can be that the

reliever has to share rooms with the person being relieved, which results in that person being constantly

disturbed by work-calls and thus, effectively, not being off duty. It is recognised that this is a potential

significant capital cost but it is one that needs to be reviewed since retention of remote staff is a major

challenge for the organisation.

In summary, the TCHHS has managed to combine two services into one quite well. Challenges remain to

maintain the balance between the competing interests, but the organisation has robust processes in

operation to adapt services to the needs of the various communities. Consumer involvement is underway

and will become more mature with time and effort. Clinical services are of a good standard and appear to

cope effectively with the challenges of remote medicine and clinical presentations that are often well

outside that seen in other areas of Australia.




Assessment Ratings

Four levels of attainment are used consistently throughout this report to give an overall rating for each

Standard. The levels of attainment are:

• Met

• Met with Merit

• Not Met

• Not Applicable

In order to meet accreditation requirements all the Standards must be met.

Summary of Ratings

Overall Assessment of Standards

Standard Rating

1 Governance for Safety and Quality in Health Service Organisations

Met

2 Partnering with Consumers Met

3 Preventing and Controlling Healthcare Associated Infections Met

4 Medication Safety Met

5 Patient Identification and Procedure Matching Met

6 Clinical Handover Met

7 Blood and Blood Products Met

8 Preventing and Managing Pressure Injuries Met

9 Recognising and Responding to Clinical Deterioration in Acute Health Care

Met

10 Preventing Falls and Harm from Falls Met




Summary of Quality Improvement Recommendations

Recommendations

Criterion Recommendations

1.1 Governance Systems Service Development, Delivery and Management Documents/Records: It is recommended that the organisation progresses towards an electronic system for the management of documents. Governance Documents/Records: It is recommended that, with the planned transfer to community controlled health centres, the organisation ensures that the information sharing and service agreements being developed are robust enough to ensure that the sharing of patient information continues both now and in the future.

1.2 Governance - patient safety and quality care

Board Interview: It is recommended that: 1. The Board and senior management ensure that workforce strategy and planning be more transparent so that all levels of the organisation have an opportunity to participate in planning. 2. The organisation develops a "map" of partnerships and collaborations for each region across the health service to facilitate better strategic planning. Governance Documents/Records: To improve timeliness and accuracy of reports, it is recommended that the organisation reviews the training provided to line managers and staff with respect to computer skills and review the administrative support available at the outlying clinics. Management Interview: It is recommended that: a) The Board and senior management ensure that workforce strategy and planning be more transparent so that all levels of the organisation have an opportunity to participate in planning. b) The organisation develops a "map" of partnerships and collaborations for each region across the health service to facilitate better strategic planning. c) To improve timeliness and accuracy of reports, it is recommended that the organisation reviews the training provided to line managers and staff with respect to computer skills and review the administrative support available at the outlying clinics. CEO Interview: It is recommended that the organisation create policies and





procedures that outline management of acute MH presentations whilst awaiting transfer. The policies and procedures will make it clear that isolation and seclusion are not to be initiated in TCHHS facilities as this would be in breach of the Mental Health Act 2016. Acutely unwell MH patients are specialled and under constant supervision to minimise the risk of self-harm. An audit of ligature points will be conducted in rooms designated for acutely unwell mental health patients. It is recommended that the organisation develop a research agenda that needs to be pro-active and reviewed periodically with the communities to ensure that it remains relevant to their needs as well as broader organisational objectives.

1.3 Workforce roles Clinical Interview: It is recommended that the organisation: a) Review workforce strategies and service planning and support with a view to making the process more transparent to all staff. b) Review line management arrangements to ensure that programs are appropriately sited within the organisation. c) Review workforce education to ensure that health workers are aware of support services available to them. d) Improve inter-agency interactions in the southern sector and review and improve the role of cluster co-ordinators in the northern sector. Review workforce strategies and service planning and support with a view to making the process more transparent to all staff. Review financial delegations to ensure that they are reasonable for each circumstance. Review line management arrangements to ensure that programs are appropriately sited within the organisation. Review workforce education to ensure that health workers are aware of support services available to them. Improve interagency interactions in the southern sector and review and improve the role of cluster co-ordinators in the northern sector. HRM Documents/Records: The organisation could consider developing training on each standard as an entire event to link clinical and theoretical aspects of the Standards together for the clinical and non-clinical workforce.





Management Interview: It is recommended that the organisation: a) Review workforce strategies and service planning and support with a view to making the process more transparent to all staff. b) Review financial delegations to ensure that they are reasonable for each circumstance. c) Review line management arrangements to ensure that programs are appropriately sited within the organisation. d) Review workforce education to ensure that health workers are aware of support services available to them. e) Improve inter-agency interactions in the southern sector and review and improve the role of cluster co-ordinators in the northern sector.

1.5 Risk management system Risk Management Documents/Records: It is recommended that: a) The organisation undertake a risk assessment of the location of the propane gas cylinders at Bamaga Hospital. b) The mental health team at Bamaga be provided with replacement satellite phones. c) There be a review of all power sources to ensure that site satisfactory power back-up is available. d) The main diesel storage supply on Thursday Island is returned to operation as soon as possible and that arrangements for other fuel supplies or generating capacity are reviewed and revised. e) The organisation review the communication systems for the fire wardens and ensure that they are adequate.

1.6 Quality management system Safety and Quality Documents/Records: The organisation should consider the use of one system for all quality management.

1.9 Clinical record Clinical Documents/Records: It is recommended that the organisation works with their software supplier to integrate the Primary Healthcare Manual into the new patient record and to ensure that the contents allow easy auditing against the requirements of the National Standards as well as aligning the data dictionary for research purposes.

1.10 Clinical workforce review HRM Documents/Records: The organisation should consider a Scope of Practice Matrix for each area to easier identify individuals with appropriate clinical skills and competencies.

1.12 Safety and quality education Clinical Interview: It is recommended that the organisation reviews the educational syllabus used by the training organisations to ensure that it meets the requirements of the TCHHS as well as being culturally appropriate.

1.17 Patient charter of rights Consumer Documents/Records:





The organisation should consider practical placement of the charter and develop a unique charter involving the community and consumer groups.

1.19 Confidentiality - patient clinical records

Facilities and Equipment: It is recommended that: a) The organisation reviews the sound proofing of the interview room of the mental health service at Bamaga or moves interviews to another room. b) Ensures that there are robust systems to secure the data held by the chronic disease project.

3.2 Surveillance healthcare infections Infection Control Documents/Records: It is recommended that the organisation review and revise the data management of patients with TB and that ways to share information appropriately with the local authorities be examined.

3.5 Auditing hand hygiene program HRM Documents/Records: The organisation should consider various levels of Hand Hygiene training dependant on roles and responsibilities e.g. General Hand Hygiene Training, Pre-procedure scrub training etc. Infection Control Documents/Records: The organisation should consider further auditing in high risk areas of theatre to match the Infection Control (hand hygiene) policy and procedure.

3.7 OHS programs Clinical Interview: It is recommended that: a) The organisation review signage across the sites to ensure that it is specific, uniform and appropriately sited and that all staff and VMO's receive education on the appropriate selection of PPE. b) The equipment and drainage at the mortuary at Bamaga are fit-for-purpose. Infection Control Documents/Records: It is recommended that: a) The organisation review the PPE and Hand Hygiene signage across the sites to ensure that it is specific, uniform and appropriately sited and that all staff and VMO's receive education on the appropriate selection of PPE. b) the equipment and drainage at the mortuary at Bamaga are fit-for-purpose

3.9 Invasive device procedures HRM Documents/Records: Hand Hygiene training should meet procedural requirements.

3.11 Standard precautions Facilities and Equipment: Ensure all signage is uniform throughout the organisation. It is advisable to create a signage audit to ensure uniformity e.g. Hand Wash Vs Hand Rub Signage, 5 moments of hand hygiene and PPE.





3.18 Competency-based training HRM Documents/Records: It is recommended that competency based training of peer review should also be developed for reprocessing area.

3.19 Consumer-specific information Consumer Documents/Records: It is recommended that consumer information covering the organisation's infection control activities be uniform for each site across the southern sector.

4.1 Medication safety Medicine Safety Documents/Records:

Recommend that the TCHHS pharmacists, take carriage for all

vaccine stocks across the organisation.

4.2 Medication use systems Medicine Safety Documents/Records:

It is recommended that the records for water testing for

haemodialysis are to include the lot number, batch number

and expiry of testing kits.

4.10 Medicine storage Medicine Safety Documents/Records: It is recommended that all refrigerators used to store temperature sensitive medicines comply with the national "Strive for 5" guidelines.

6.2 Clinical handover processes Clinical Interview: It is recommended that: a) The organisation review information sharing with other agencies when appropriate - specifically Offender Health services and TB services (see 3.2.1) - and review ways to allow easier exchange of information between the organisations own records. b) The organisation review the working relationships in the northern sector between the mental health team and the social and emotional wellbeing team, to seek better patient outcomes.




1 Governance for Safety and Quality in Health Service Organisations Criterion: 1.1 Governance Systems

There are integrated system of governance to actively manage patient safety and quality risks.

Implementing a governance system that sets out the policies, procedures and/or protocols for: • establishing and maintaining a clinical governance framework • identifying safety and quality risks • collecting and reviewing performance data • implementing prevention strategies based on data analysis • analysing reported incidents • implementing performance management procedures • ensuring compliance with legislative requirements and relevant industry standards • communicating with and informing the clinical and non-clinical workforce • undertaking regular clinical audits

Rating: Met

Indicators Description Assessment Rating

Assessment Comments Final Rating

1.1 .1 (C) An organisation-wide management system is in place for the development, implementation and regular review of policies, procedures and/or protocols

Met Board Interview: The Board members interviewed could describe how the policies and procedures are managed, reviewed and updated through the executive levels of the organisation. CEO Interview: The CEO could describe the system through which policies and procedures are managed, reviewed and updated. Governance Documents/Records: Review of the documentation provided adequately described the systems in place for policy management. Service Development, Delivery and Management Documents/Records: Review of documentation provided shows the development, implementation and regular review of policies, procedures and protocols is in place. However, the system is somewhat fragmented and moving to an electronic document management system

Met






would improve the situation and the surveyors understand that this move is under consideration. Improvement Opportunities Service Development, Delivery and Management Documents/Records: It is recommended that the organisation progresses towards an electronic system for the management of documents.

1.1 .2 (C) The impact on patient safety and quality of care is considered in business decision making

Met Board Interview: The Board members interviewed could describe how quality and safety information, through the various reports received by them, is used as a key consideration in business decision making. CEO Interview: The CEO could describe how quality and safety information is used in business decision making at the highest levels of the organisation. Governance Documents/Records: Review of governance documents shows evidence that the impact on patient safety and quality of care is being considered in business decision making. However, there is a plan to transfer some primary health care centres to community control, which presents a significant risk with respect to sharing of patient information - particularly in the areas of after-hours care, TB monitoring and contact tracing for various diseases. Improvement Opportunities Governance Documents/Records: It is recommended that, with the planned transfer to community controlled health centres, the organisation ensures that the information sharing and service agreements being developed are robust enough to ensure that the sharing of patient information continues both now and in the future.

Met




Criterion: 1.2 Governance - patient safety and quality care There are integrated systems of governance to actively manage patient safety and quality risks.

The board, chief executive officer and/or other higher level of governance within a health service organisation taking responsibility for patient safety and quality of care

Rating: Met



1.2 .1 (C) Regular reports on safety and quality indicators and other safety and quality performance data are monitored by the executive level of governance

Met Board Interview: Board members interviewed could describe the safety and quality reports as well as performance data that the board receives. However, it was not clear how the board was informed about the workforce planning and needs: vacancies, backfilling of positions, career pathways, traineeships, apprenticeships as well as having a collaboration/ partnership strategy for each region across the health service. Partnerships vary across the communities served and clarity about "mapping” and strategic planning is needed at the various sites to facilitate better community response, particularly in the southern sector. CEO Interview: The CEO interviewed could explain the variety of information that is provided to the executive level and how it is monitored and acted upon. Governance Documents/Records: Review of meeting minutes showed that safety and quality reporting occurs in all activities. However there was noted to be some delay in reports from the clinical areas being received and this appears to be mostly the result of issues pertaining to IT literacy and confidence in handling the software by the health workers, as well as low levels of administrative support at the outstations. Management Interview: Management staff interviewed were able to describe the range of information provided to the executive level, including that covering patient safety and quality, and how feedback on changes made to policies or procedures are implemented. Management staff interviewed were able to describe the types of information provided to the executive level on patient safety and quality and how feedback on changes are

Met






implemented through auditing and reports. Improvement Opportunities Board Interview: It is recommended that: 1. The Board and senior management ensure that workforce strategy and planning is more transparent so that all levels of the organisation have an opportunity to participate in planning. 2. The organisation develops a "map" of partnerships and collaborations for each region across the health service to facilitate better strategic planning. Governance Documents/Records: To improve timeliness and accuracy of reports, it is recommended that the organisation reviews the training provided to line managers and staff with respect to computer skills and review the administrative support available at the outlying clinics. Management Interview: It is recommended that: a) The Board and senior management ensure that workforce strategy and planning be more transparent so that all levels of the organisation have an opportunity to participate in planning. b) The organisation develops a "map" of partnerships and collaborations for each region across the health service to facilitate better strategic planning. c) To improve timeliness and accuracy of reports, it is recommended that the organisation reviews the training provided to line managers and staff with respect to computer skills and review the administrative support available at the outlying clinics.

1.2 .2 (C) Action is taken to improve the safety and quality of patient care

Met CEO Interview: The CEO interviewed could provide examples of improvements to safe practice and quality of patient care. Whilst it is recognised that the organisation does not usually provide continuing care for acute mental health episodes that require hospitalisation, there are times when the organisation has to provide temporary accommodation until transfer can be performed. Therefore, there is a need to have policies and protocols in place to manage this situation.

Met






The organisation is involved in a lot of research but this tends to be reactive to approaches from universities with the governing policies and procedures in place. However, community involvement in planning or choosing research involvement is weak. Safety and Quality Documents/Records: Review of meeting minutes found examples of actions taken to improve safety and quality of patient care within the organisation. Improvement Opportunities CEO Interview: It is recommended that the organisation create policies and procedures that outline management of acute MH presentations whilst awaiting transfer. The policies and procedures will make it clear that isolation and seclusion are not to be initiated in TCHHS facilities as this would be in breach of the Mental Health Act 2016. Acutely unwell MH patients are specialled and under constant supervision to minimise the risk of self-harm. An audit of ligature points will be conducted in rooms designated for acutely unwell mental health patients. It is recommended that the organisation develop a research agenda that is pro-active and reviewed periodically with the communities to ensure that it remains relevant to their needs as well as broader organisational objectives.

Criterion: 1.3 Workforce roles There are integrated systems of governance to actively manage patient safety and quality risks.

Assigning workforce roles, responsibilities and accountabilities to individuals for: • patient safety and quality in their delivery of health care • the management of safety and quality specified in each of these Standards

Rating: Met








1.3 .1 (C) Workforce are aware of their delegated safety and quality roles and responsibilities

Met Clinical Interview: The clinical staff interviewed could describe their safety and quality responsibilities within their roles. HRM Documents/Records: Review of human resource documents shows safety and quality roles and responsibilities are documented through the use of the term "quality" in position descriptions, orientation and on-going training. Staff interviewed could describe their safety and quality responsibilities through knowledge from orientation, on-going training and position descriptions. It is also reflected in policies and procedures.

Met

1.3 .2 (C) Individuals with delegated responsibilities are supported to understand and perform their roles and responsibilities, in particular to meet the requirements of these Standards

Met Clinical Interview: Clinical staff interviewed could describe how they are supported to understand and perform their responsibilities. However, there was a consistent lack of administrative support in the outstations, depending on site and workload, which meant that clinicians were losing clinical time with some finding it difficult to manage their time and risk. Recruitment plans and ways to share nearby staff were unclear to some staff. It is recognised that workforce planning is being done to try to address these matters. On occasion, the hosting of a program within the service seemed somewhat inappropriate - for instance, the northern sector maternal and child health program has responsibility for eye health which is overwhelmingly related to adult care. There was concern that this situation may result in other funding sources being missed. Indigenous health workers in the out stations had a variable awareness of the support services available to them. Interagency co-operation was less than optimal in the southern sector, with better quality meetings needed - the role of cluster co-ordinators in the northern sector appeared to be underdeveloped. HRM Documents/Records:

Met






Review of the human resource and training documents show evidence of workforce training in the NSQHS Standards. Management Interview: Management staff interviewed could describe how all staff are supported to understand their roles and responsibilities. Delegations are clear but in some instances they appear to be incongruent insofar that project management is on the same level as procurement delegations; a manager of a large project underway may benefit from a higher delegation. It is recognised by the assessors that the responsibility for this situation may lay outside the organisation at a State level. Management staff interviewed could describe how staff are supported to understand their safety and quality responsibilities through organisational and on-site orientation with on-going scheduled training events. Improvement Opportunities Clinical Interview: It is recommended that the organisation: a) Review workforce strategies and service planning and support with a view to making the process more transparent to all staff. b) Review line management arrangements to ensure that programs are appropriately sited within the organisation. c) Review workforce education to ensure that health workers are aware of support services available to them. d) Improve inter-agency interactions in the southern sector and review and improve the role of cluster co-ordinators in the northern sector. Review workforce strategies and service planning and support with a view to making the process more transparent to all staff. Review financial delegations to ensure that they are reasonable for each circumstance. Review line management arrangements to ensure that programs are appropriately sited






within the organisation. Review workforce education to ensure that health workers are aware of support services available to them. Improve interagency interactions in the southern sector and review and improve the role of cluster co-ordinators in the northern sector. HRM Documents/Records: The organisation could consider developing training on each standard as an entire event to link clinical and theoretical aspects of the Standards together for the clinical and non-clinical workforce. Management Interview: It is recommended that the organisation: a) Review workforce strategies and service planning and support with a view to making the process more transparent to all staff. b) Review financial delegations to ensure that they are reasonable for each circumstance. c) Review line management arrangements to ensure that programs are appropriately sited within the organisation. d) Review workforce education to ensure that health workers are aware of support services available to them. e) Improve inter-agency interactions in the southern sector and review and improve the role of cluster co-ordinators in the northern sector.

1.3 .3 (C) Agency or locum workforce are aware of their designated roles and responsibilities

Met Clinical Interview: The locum/agency staff interviewed could indicate that they received information about their role and responsibilities in their orientation. HRM Documents/Records: Review of human resource records shows locum or agency workforce has designated roles and responsibilities specified.

Met




Criterion: 1.4 Training There are integrated systems of governance to actively manage patient safety and quality risks.

Implementing training in the assigned safety and quality roles and responsibilities

Rating: Met



1.4 .1 (D) Orientation and ongoing training programs provide the workforce with the skill and information needed to fulfil their safety and quality roles and responsibilities

Met HRM Documents/Records: Review of the training records provide evidence of orientation and ongoing training programs provided to the workforce, whilst the role and training for isolated practice-endorsed health workers could be reviewed. However, the assessors were concerned that the training to manage violence in the workplace is limited. Given that many staff are working in remote and isolated sites, organisational training needs to occur, preferably face-to-face. Review of the training plan/attendance records provide adequate evidence of orientation and ongoing training programs provided to the workforce to fulfil their safety and quality roles and responsibilities. Improvement Opportunities HRM Documents/Records: It is recommended that the organisation undertake training for staff to manage violence in the workplace, preferably face-to-face.

Met

1.4 .2 (D) Annual mandatory training programs to meet the requirements of these Standards

Met HRM Documents/Records: Review of training program documents/records showed annual mandatory training programs to meet the requirements of the NSQHS Standards are conducted.

Met

1.4 .3 (D) Locum and agency workforce have the necessary information, training and orientation to the workplace to fulfil their safety and quality roles and responsibilities

Met HRM Documents/Records: Review of the locum training/orientation documents showed evidence of safety and quality training.

Met

1.4 .4 (D) Competency-based training is provided to the clinical workforce to improve safety and quality

Met Clinical Interview: Clinical staff interviewed could describe how the clinical workforce are provided with competency-based training to improve safety and quality.

Met






However, the assessors considered that there were several areas that need attention: a) To be focussed on the needs of individual communities, particularly in the southern sector. b) Ensure that staff have a common understanding of recovery pathways in mental health. c) To ensure that staff manage their own workloads effectively. d) To ensure that appropriate time-frames are applied to the need for staff re-orientation after extended leave. e) Training in sexual forensic examination and records. f) Training in issues around child safety, assessment and reporting (especially sexual issues under 16 - Gillick competency, authorised person, protocols when to treat an STI and report, or not report to child safety officers). g) Establish linkages between the NSQHS requirements to tasks, training, compliance and competency. HRM Documents/Records: Review of the competency-based training records/materials showed competency-based training is provided to the clinical workforce to improve safety and quality. Improvement Opportunities Clinical Interview: It is recommended that the organisation ensures that: a) Appropriate training and competency assessments be linked to specific community needs and programs. b) Appropriate staff are trained in sexual forensic examination and records. c) Staff receive clear training in child safety requirements with a specific focus on child sexual health issues. HRM Documents/Records: The organisation should consider: a) Appropriate training and competency assessments be linked to specific community needs and programs.






b) Appropriate staff are trained in sexual forensic examination and records. c) Staff receive clear training in child safety requirements with a specific focus on child sexual health issues.

Criterion: 1.5 Risk management system There are integrated systems of governance to actively manage patient safety and quality risks.

Establishing an organisation-wide risk management system that incorporates identification, assessment, rating, controls and monitoring for patient safety and quality

Rating: Met



1.5 .1 (C) An organisation-wide risk register is used and regularly monitored

Met CEO Interview: The CEO could describe how risk is managed across the organisation, including how the risk register is used within the organisation. Management Interview: Management staff interviewed could describe the risk management process and how the risk register is used through Riskman. Risk Management Documents/Records: Review of the risk registers shows evidence of their use and monitoring.

Met

1.5 .2 (C) Actions are taken to minimise risks to patient safety and quality of care

Met Risk Management Documents/Records: Review of risk documents found examples of actions taken to minimise risks to patient safety and quality of care. However, at Bamaga hospital, the cluster of large propane gas cylinders in use is located immediately adjacent to the single entry point to the helipad and they are stored in an open sided shed. Whilst the likelihood of an incident with a helicopter is low, the resulting explosion could be catastrophic. Discussions held on site suggested that relocating the cylinders should not be difficult. The mental health team at Bamaga are providing outreach services to sites that have

Met






poor or no mobile phone coverage. They had satellite phones which were taken away and not replaced and this situation is not satisfactory. In the northern sector, there has been a sudden jump from zero loss of temperature sensitive medications in recent years to over $8000.00 loss in 2016, predominantly as a result of the failure of several power backup sources (UPS batteries). Careful monitoring of the reliable lifespan of these devices should limit the risk. On Thursday Island, the main diesel storage tank has been isolated for over six months as a result of water contaminating the fuel, so the generator has only the day tank operating. Whilst there are informal agreements in place to supply fuel, the approaching wet season means that supply could be jeopardised. Further, there is no agreement in place for back-up if the hospital generator fails. Fire drills have been conducted with satisfactory outcomes but there is no radio communication between the fire wardens at the various evacuation assembly points, so it is not possible for the chief warden to quickly check the head counts and inform the fire authority of discrepancies. Improvement Opportunities Risk Management Documents/Records: It is recommended that: a) The organisation undertake a risk assessment of the propane gas cylinders at Bamaga Hospital. b) The mental health team at Bamaga be provided with replacement satellite phones. c) There be a review of all power sources to ensure that site satisfactory power back-up is available. d) The main diesel storage supply on Thursday Island is returned to operation as soon as possible and that arrangements for other fuel supplies or generating capacity are reviewed and revised. e) The organisation review the communication systems for the fire wardens and ensure that they are adequate.




Criterion: 1.6 Quality management system There are integrated systems of governance to actively manage patient safety and quality risks.

Establishing an organisation-wide quality management system that monitors and reports on the safety and quality of patient care and informs changes in practice

Rating: Met



1.6 .1 (C) An organisation-wide quality management system is used and regularly monitored

Met CEO Interview: The CEO could describe the quality management system, how it operates at all levels and how progress is monitored. Clinical Governance Documents/Records: Review of documents provided shows the organisation-wide quality management system is used and regularly monitored with reports flowing both up and down the lines of responsibility. Management Interview: Management staff interviewed could describe the organisations quality management system and how it is monitored across the range of activities undertaken. Safety and Quality Documents/Records: Review of the quality policy/framework showed there is a quality management system in use and regularly monitored at all levels of the organisation. Met With Merit Clinical Governance Documents/Records: Regional Clinical Governance committee with all partners within the Cape ensuring awareness of the need for processes within each community. Improvement Opportunities Safety and Quality Documents/Records: The organisation should consider the use of one system for all quality management.

Met

1.6 .2 (C) Actions are taken to maximise patient quality of care

Met CEO Interview: The CEO could describe how the senior management team structure and activities aims

Met






to ensure the highest quality of care for patients. Management Interview: Management staff interviewed could describe actions in place to ensure the highest quality of care for patients with ensuring validation of equipment, regular auditing and peer review of practice, orientation and training. Safety and Quality Documents/Records: Review of the action/improvement plan confirmed actions are taken to maximise patient quality of care through regular review of all registers and documents.

Criterion: 1.7 Clinical guidelines Care provided by the clinical workforce is guided by current best practice.

Developing and/or applying clinical guidelines or pathways that are supported by the best available evidence

Rating: Met



1.7 .1 (C) Agreed and documented clinical guidelines and/or pathways are available to the clinical workforce

Met Clinical Interview: Clinical staff interviewed could describe the how clinical guidelines are available to them including the Primary Care Manual and Chronic Conditions Manual. Facilities and Equipment: Observation of work sites confirmed that clinical guidelines and pathways are available to the workforce.

Met

1.7 .2 (C) The use of agreed clinical guidelines by the clinical workforce is monitored.

Met Clinical Governance Documents/Records: Review of the audit and monitoring results showed the use of clinical guidelines by the clinical workforce is monitored. The planned introduction of an electronic record to be shared across all providers of care in the region will assist in this process.

Met




Criterion: 1.8 Management - patient increased harm Care provided by the clinical workforce is guided by current best practice.

Adopting processes to support the early identification, early intervention and appropriate management of patients at increased risk of harm

Rating: Met



1.8 .1 (C) Mechanisms are in place to identify patients at increased risk of harm

Met Clinical Documents/Records: Review of the clinical records confirmed that there are mechanisms in place to identify patients at increased risk of harm through admission processes and on-going review of clients at each consultation. Clinical Interview: Clinical staff interviewed were able to describe how patients at an increased risk of harm are identified and managed. Refer to comments under 1.2.2 Clinical staff interviewed were able to describe how patients at an increased risk of harm are identified through patient admission processes and procedure risk assessments. Staff interviewed were able to describe how patients at an increased risk of harm are identified through review of new patient forms and reviewing client risk of harm on each occasion.

Met

1.8 .2 (C) Early action is taken to reduce the risks for at-risk patients

Met Clinical Documents/Records: Review of the clinical management plans shows that an evaluation of risks is undertaken and methods of eliminating or reducing identifiable risks is in place. The organisation recognises that it has a key role in deciding the appropriate level of care that is to be provided to each patient. Review of the risk profile or management plan shows an evaluation of risks and methods of eliminating or reducing identifiable risks is in place through a risk register outlining a flow of events, identifying potential consequences and contributing factors through root cause analysis.

Met

1.8 .3 (C) Systems exist to escalate the level of care when there is an unexpected

Met Clinical Interview: The clinical staff interviewed could describe the escalation action that they would take

Met






deterioration in health status when a patient's condition deteriorates unexpectedly through the use of Ryan's Rules which are known sector wide and promoted throughout the clinical and waiting areas. Facilities and Equipment: Observation of the facilities shows clearly displayed instructions on how to call for assistance. Service Development, Delivery and Management Documents/Records: Review of the clinical deterioration policy adequately described the systems in place for the management of clinical deterioration at all clinics and services. Staff interviewed could describe the escalation action that they would take when a patient's condition deteriorates unexpectedly knowing protocols for transferring patients out of communities to gain further assistance at aligned hospitals.

Criterion: 1.9 Clinical record Care provided by the clinical workforce is guided by current best practice.

Using an integrated patient clinical record that identifies all aspects of the patient’s care

Rating: Met



1.9 .1 (C) Accurate, integrated and readily accessible patient clinical records are available to the clinical workforce at the point of care

Met Clinical Documents/Records: Observation of the facilities shows the availability of patient clinical records to clinicians at the point of care through hard copy clinical records. Clinical Interview: The clinical staff interviewed indicated that patient clinical records are available at the point of care in hard copy form. Service Development, Delivery and Management Documents/Records: Review of policies shows procedures in place for ensuring patient clinical records are

Met






available at the point of care when a patient is transferred within the organisation and between organisations.

1.9 .2 (C) The design of the patient clinical record allows for systematic audit of the contents against the requirements of these Standards

Met Clinical Documents/Records: Review of the records showed that patient clinical records are designed to allow systematic audit of their contents. The organisation is presently designing a new electronic record and has the opportunity to improve the standards of care and to align the databases with the National Standards. The assessors considered that it would be appropriate to include the Primary Healthcare Manual into the new record and that research governance have input into the data dictionary. Improvement Opportunities Clinical Documents/Records: It is recommended that the organisation works with their software supplier to integrate the Primary Healthcare Manual into the new patient record and to ensure that the contents allow easy auditing against the requirements of the National Standards as well as aligning the data dictionary for research purposes.

Met

Criterion: 1.10 Clinical workforce review Managers and the clinical workforce have the right qualifications, skills and approach to provide safe, high quality health care.

Implementing a system that determines and regularly reviews the roles, responsibilities, accountabilities and scope of practice for the clinical workforce

Rating: Met



1.10 .1 (C) A system is in place to define and regularly review the scope of practice for the clinical workforce

Met HRM Documents/Records: Review of workforce performance appraisal and feedback records show a review of the scope of practice for clinicians. Management Interview: Management staff interviewed could describe how the scope of practice of clinical staff is defined, documented and reviewed.

Met






Service Development, Delivery and Management Documents/Records: Review of the service documents adequately described the systems in place for defining and reviewing the scope of practice for the clinical workforce. Improvement Opportunities HRM Documents/Records: The organisation should consider a Scope of Practice Matrix for each area to easier identify individuals with appropriate clinical skills and competencies.

1.10 .2 (C) Mechanisms are in place to monitor that the clinical workforce are working within their agreed scope of practice

Met Clinical Governance Documents/Records: The organisation has robust clinical governance systems of review to ensure that clinicians are working within their scope of practice. HRM Documents/Records: Review of performance review documents showed how the workforce is monitored to ensure they work within their agreed scope of practice through performance and peer reviews. Management Interview: Management staff interviewed could describe how the clinical staff are monitored to ensure that they are working within their scope of practice.

Met

1.10 .3 (C) Organisational clinical service capability, planning, and scope of practice is directly linked to the clinical service roles of the organisation

Met Governance Documents/Records: Review of the governance documents found that organisational capability, planning and scope of practice is directly linked to the clinical service roles. Management Interview: Management staff interviewed could describe how the organisation reviews needs and plans to ensure that the service has the clinical skills mix required to provide safe and effective care. Management staff interviewed could describe the process for ensuring the service has the clinical skills mix required to provide safe and effective care through each site having a Business Planning Framework.

Met






1.10 .4 (C) The system for defining the scope of practice is used whenever a new clinical service, procedure or other technology is introduced

Met Clinical Interview: Clinical staff interviewed were able to describe the system in place for training whenever a new clinical service, procedure or other technology is introduced. Service Development, Delivery and Management Documents/Records: Review of policies, procedures, protocols or planning documents to introduce new services shows a system is in place to ensure scope of practice is recognised and linked to positions.

Met

1.10 .5 (C) Supervision of the clinical workforce is provided whenever it is necessary for individuals to fulfil their designated role

Met HRM Documents/Records: Review of the clinical supervision records found examples of supervision provided to the clinical workforce to fulfil their role.

Met

Criterion: 1.11 Performance system Managers and the clinical workforce have the right qualifications, skills and approach to provide safe, high quality health care.

Implementing a performance development system for the clinical workforce that supports performance improvement within their scope of practice

Rating: Met



1.11 .1 (C) A valid and reliable performance review process is in place for the clinical workforce

Met HRM Documents/Records: Review of the performance review records showed the clinical workforce participates in performance reviews that supports development and improvement.

Met

1.11 .2 (C) The clinical workforce participates in regular performance reviews that support individual development and improvement

Met Clinical Interview: Clinical staff interviewed could describe what was involved in their last performance review and how that was used to plan their professional development. HRM Documents/Records: Review of the performance review records showed the clinical workforce participates in performance reviews that supports development and improvement.

Met




Criterion: 1.12 Safety and quality education Managers and the clinical workforce have the right qualifications, skills and approach to provide safe, high quality health care.

Ensuring that systems are in place for ongoing safety and quality education and training

Rating: Met



1.12 .1 (C) The clinical and relevant non-clinical workforce have access to ongoing safety and quality education and training for identified professional and personal development

Met Clinical Interview: Clinical staff interviewed could provide examples of training and CPD activities they had attended. HRM Documents/Records: Review of the training plan and/or CPD records showed the clinical and relevant non-clinical workforce have access to ongoing safety and quality education and training for identified professional and personal development. Staff interviewed could provide examples of training and CPD activities they had attended. Some staff raised questions about the syllabus for the basic training of health worker, expressing the opinion that there was not enough emphasis on the care of chronic disease and that there was concern about the cultural content. Staff interviewed could provide examples of training and CPD activities they had attended through on-line and face to face training events. Improvement Opportunities Clinical Interview: It is recommended that the organisation reviews the educational syllabus used by the training organisations to ensure that it meets the requirements of the TCHHS as well as being culturally appropriate.

Met




Criterion: 1.13 Workforce Managers and the clinical workforce have the right qualifications, skills and approach to provide safe, high quality health care.

Seeking regular feedback from the workforce to assess their level of engagement with, and understanding of, the safety and quality system of the organisation

Rating: Met



1.13 .1 (C) Analyse feedback from the workforce on their understanding and use of safety and quality systems

Met Management Interview: Management staff interviewed could describe how the organisation seeks feedback from staff on the safety and quality systems including training and induction. Management interviewed could describe how the organisation seeks feedback from staff on safety and quality systems through staff survey, training feedback and general staff feedback.

Met

1.13 .2 (C) Action is taken to increase workforce understanding and use of safety and quality systems

Met Safety and Quality Documents/Records: Review of documents provided showed evidence of actions taken to increase workforce understanding and use of safety and quality systems through orientation and on-going training events including staff communication from management.

Met

Criterion: 1.14 Incident management Patient safety and quality incidents are recognised, reported and analysed, and this information is used to improve safety systems.

Implementing an incident management and investigation system that includes reporting, investigating and analysing incidents (including near misses), which all result in corrective actions

Rating: Met



1.14 .1 (C) Processes are in place to support the workforce recognition and reporting of incidents and near misses

Met HRM Documents/Records: Review of the training plan/records showed the workforce is provided training in incident management with access to Riskman at all levels of the organisation. Management Interview: Management staff interviewed confirmed that the organisation has the "Riskman" software installed to support the workforce in the recognition and reporting of incidents

Met






and near misses. Risk Management Documents/Records: Review of policies, procedures and protocols shows processes in place for reporting, investigating and analysing incidents and near misses.

1.14 .2 (C) Systems are in place to analyse and report on incidents

Met Risk Management Documents/Records: Review of the incident reports showed systems are in place to analyse and report on incidents.

Met

1.14 .3 (C) Feedback on the analysis of reported incidents is provided to the workforce

Met Clinical Interview: The clinical staff interviewed confirmed that they receive feedback regarding incidents and incident trends through team meetings and publications by the organisation. Management Interview: Management interviewed could explain how feedback on the analysis of reported incidents is provided to the workforce. Risk Management Documents/Records: Review of documentation shows meetings include information on incidents, adverse events and near misses. Staff interviewed confirmed that they receive feedback regarding incidents and incident trends through communication from meetings and meeting minutes.

Met

1.14 .4 (C) Action is taken to reduce risks to patients identified through the incident management system

Met Risk Management Documents/Records: Review of the improvement plan shows evidence of action taken to reduce risks to patients identified through the incident management system.

Met

1.14 .5 (C) Incidents and analysis of incidents are reviewed at the highest level of governance in the organisation

Met Board Interview: Board members interviewed described how the Board reviews the incident management reports and how they initiate appropriate action. Risk Management Documents/Records: Review of meeting minutes shows evidence of incidents reviewed at the highest level of governance.

Met




Criterion: 1.15 Complaints management Patient safety and quality incidents are recognised, reported and analysed, and this information is used to improve safety systems.

Implementing a complaints management system that includes partnership with patients and carers

Rating: Met



1.15 .1 (C) Processes are in place to support the workforce to recognise and report complaints

Met Clinical Interview: Clinical staff interviewed could describe the complaint management process and how they manage a complaint both locally and through the "Riskman" software. Clinical staff interviewed could describe the complaint management process and the action they would take in the event of a patient complaint. Evaluation and Feedback Documents/Records: Review of the complaints register confirmed that there are processes in place to support the recognition and reporting of complaints. Management Interview: Management staff interviewed could describe the complaint management system from receiving to reporting. New Sub Indicator 1: The CEO was able to describe the training given to staff to report complaints and comments as well as the way that the information is managed at the senior levels. Staff interviewed could describe the complaint management system.

Met

1.15 .2 (C) Systems are in place to analyse and implement improvements in response to complaints

Met Evaluation and Feedback Documents/Records: Review of the improvement plan showed that there is a system in place to analyse and implement improvements in response to complaints.

Met

1.15 .3 (C) Feedback is provided to the workforce on the analysis of reported complaints

Met Clinical Interview: The clinical staff interviewed could provide examples of feedback or information provided to staff about complaints or trends.

Met






Management Interview: Management staff interviewed could provide examples of feedback or information provided to staff about complaint trends which is recorded in meeting agenda and templates. Staff interviewed indicated that they receive or have access to feedback on complaints through meetings and meeting minutes.

1.15 .4 (C) Patient feedback and complaints are reviewed at the highest level of governance in the organisation

Met Board Interview: Board members interviewed could describe the information that the Board receives about complaints and trends and how these issues are managed across the organisation. Governance Documents/Records: Review of meeting minutes found that patient feedback and complaints are reviewed at the highest level of governance.

Met

Criterion: 1.16 Open disclosure Patient safety and quality incidents are recognised, reported and analysed, and this information is used to improve safety systems.

Implementing an open disclosure process based on the national open disclosure standard

Rating: Met



1.16 .1 (D) An open disclosure program is in place and is consistent with the national open disclosure standard

Met CEO Interview: The CEO could explain the organisations policy and training in open disclosure. Management Interview: Management staff interviewed could explain the organisations policy on open disclosure and how staff have been suitably trained. Service Development, Delivery and Management Documents/Records: Review of the open disclosure policy shows consistency with the national open disclosure standard.

Met






1.16 .2 (D) The clinical workforce are trained in open disclosure processes

Met HRM Documents/Records: Review of the training plan/records showed the workforce is provided training in open disclosure on an on-going basis.

Met

Criterion: 1.17 Patient charter of rights Patient rights are respected and their engagement in their care is supported.

Implementing through organisational policies and practices a patient charter of rights that is consistent with the current national charter of healthcare rights

Rating: Met



1.17 .1 (C) The organisation has a charter of patient rights that is consistent with the current national charter of healthcare rights

Met Facilities and Equipment: Observation of the organisation shows the charter of patients' rights was displayed. Service Development, Delivery and Management Documents/Records: Review of policies shows how the use of a charter of patients’ rights in the organisation is implemented.

Met

1.17 .2 (C) Information on patient rights is provided and explained to patients and carers

Met Consumer Documents/Records: Review of consumer documents shows information on patients’ rights is available for patients and carers in all areas of the organisation. Consumer Interview: Consumers interviewed provided examples of information they have received about their rights and responsibilities. Improvement Opportunities Consumer Documents/Records: The organisation should consider practical placement of the charter and develop a unique charter involving the community and consumer groups.

Met

1.17 .3 (D) Systems are in place to support patients who are at risk of not understanding their healthcare rights

Met Staff Interview: Staff interviewed could provide examples of assistance given to consumers who may have difficulty understanding their rights. However in this organisation, there are several

Met






languages predominating with patients for whom English is a second or third language. The assessors recognise that it is not possible to have all organisational information in multiple languages, but they consider that having patient information on rights and responsibilities in the various languages would be worthwhile. Improvement Opportunities Staff Interview: It is recommended that the organisation consider offering brochures explaining patients' rights and responsibilities in the main indigenous languages of the TCHHS.

Criterion: 1.18 Informed consent Patient rights are respected and their engagement in their care is supported.

Implementing processes to enable partnership with patients in decisions about their care, including informed consent to treatment

Rating: Met



1.18 .1 (C) Patients and carers are partners in the planning for their treatment

Met Clinical Documents/Records: Review of the records of informed consent showed evidence of patients and carers involvement in planning for their treatment. Clinical Interview: Clinical staff interviewed could describe how they include patients and families in the planning process prior to commencing treatment. Clinical staff interviewed could describe how they include patients in the planning process prior to care/treatment through discussing treatment options and planning of care. Consumer Interview: The consumers interviewed indicated that they felt included in the planning of their care or treatment.

Met






1.18 .2 (C) Mechanisms are in place to monitor and improve documentation of informed consent

Met Clinical Documents/Records: Review of the action/improvement plans and audit/monitoring results showed mechanisms are in place for monitoring and improving informed consent documentation.

Met

1.18 .3 (D) Mechanisms are in place to align the information provided to patients with their capacity to understand

Met Consumer Documents/Records: Review of the patient information brochures showed that patients are provided information aligned with their capacity to understand. Management Interview: The management staff interviewed confirmed that the organisation provides services to many patients who have language or literacy problems and could provide examples of actions the organisation has taken to ensure that patient information is appropriate and easily understood.

Met

1.18 .4 (D) Patients and carers are supported to document clear advance care directives and/or treatment-limiting orders

Met Clinical Interview: Clinical staff interviewed could describe how they have supported patients in documenting clear advance care directives and/or treatment-limiting orders. Service Development, Delivery and Management Documents/Records: Review of the advance care planning/treatment limiting order policy adequately described the systems in place for supporting patients/carers to document clear advance care directives and/or treatment-limiting orders.

Met

Criterion: 1.19 Confidentiality - patient clinical records Patient rights are respected and their engagement in their care is supported.

Implementing procedures that protect the confidentiality of patient clinical records without compromising appropriate clinical workforce access to patient clinical information

Rating: Met



1.19 .1 (C) Patient clinical records are available at the point of care

Met Clinical Interview: Clinical staff interviewed indicated they have access to patient clinical records at the point of care.

Met






Facilities and Equipment: Observation of work sites confirmed that patient clinical records are available at the point of care.

1.19 .2 (C) Systems are in place to restrict inappropriate access to and dissemination of patient clinical information

Met Facilities and Equipment: Observation of the organisations work sites and health records storage showed that appropriate mechanisms are in place to restrict inappropriate access to and dissemination of patient clinical information. However, it was noted that there was no sound proofing of the interview room of the mental health service at Bamaga and that the room is immediately adjacent to the waiting room. This needs to be corrected. The organisation has a chronic disease project which manages a lot of patient's private information for cleaning and analysis with the security for managing this data unclear. Observation of the organisation's health records storage area showed appropriate mechanisms are in place to restrict inappropriate access to and dissemination of patient clinical information. Management Interview: Management staff interviewed could describe the organisations IT security systems and how it protects clinical information. Service Development, Delivery and Management Documents/Records: Review of the clinical records management policy adequately described the systems in place for records management. Improvement Opportunities Facilities and Equipment: It is recommended that: a) The organisation reviews the sound proofing of the interview room of the mental health service at Bamaga or moves interviews to another room. b) Ensures that there are robust systems to secure the data held by the chronic disease

Met






project.

Criterion: 1.20 Patient feedback Patient rights are respected and their engagement in their care is supported.

Implementing well designed, valid and reliable patient experience feedback mechanisms and using these to evaluate the health service performance

Rating: Met



1.20 .1 (C) Data collected from patient feedback systems are used to measure and improve health services in the organisation

Met CEO Interview: The CEO could describe how patient feedback is received and reviewed with reports going to the senior managers and Board. Evaluation and Feedback Documents/Records: Review of the feedback report confirmed that data is collected from patients and then used to measure and improve health services. Management Interview: Management staff interviewed could describe how the organisation seeks and collates feedback from patients. Management staff interviewed could describe patient feedback management systems.

Met




2 Partnering with Consumers Criterion: 2.1 Consumer partnerships

Governance structures are in place to form partnerships with consumers and/or carers.

Establishing governance structures to facilitate partnerships with consumers and/or carers

Rating: Met



2.1 .1 (D) Consumers and/or carers are involved in the governance of the health service organisation

Met Board Interview: Board members interviewed could describe how they strive to include consumer feedback in the governance of the organisation and confirmed that the Board has community representatives. CEO Interview: The CEO could describe how consumers are engaged in the governance of the organisation, through the consumer engagement framework. Governance Documents/Records: Review of meeting minutes showed that consumers and carers are included in the governance of the organisation. However, the communities are undergoing changes that need to be addressed on an individual basis. It may be prudent for the organisation to have a Growth Management plan to align with the operational plan for each community, to manage periods of change, particularly to support a stepped approach to the plan for regionalisation of staff and thereby allow periods of consolidation as well as manage changes in key senior staff. Service Development, Delivery and Management Documents/Records: Review of documentation provided shows a policy in place relating to engaging consumers and carers in the governance of the organisation. Improvement Opportunities Governance Documents/Records: It is recommended that the organisation consider the development of a Growth Management plan to align with the operational plan for each community.

Met






2.1 .2 (D) Governance partnerships are reflective of the diverse range of backgrounds in the population served by the health service organisation, including those people that do not usually provide feedback

Met Governance Documents/Records: Review of the consumer engagement framework shows consumers are asked to provide feedback and input about the governance of the organisation. There is work to be done in the southern sector to improve the level of engagement.

Met

Criterion: 2.2 Partnering with patients Governance structures are in place to form partnerships with consumers and/or carers.

Implementing policies, procedures and/or protocols for partnering with patients, carers and consumers in: • strategic and operational/services planning • decision making about safety and quality initiatives • quality improvement activities

Rating: Met



2.2 .1 (D) The health service organisation establishes mechanisms for engaging consumers and/or carers in the strategic and/or operational planning for the organisation

Met Governance Documents/Records: Review of strategic planning records and the consumer engagement framework shows the mechanisms for engaging consumers and carers in both strategic and operational planning. The organisation is seeking feedback across the range of services but could be more robust, particularly in the southern sector. The rural generalist allied health program holds hope for better access to services but it needs to be included in feedback. Improvement Opportunities Governance Documents/Records: Recommend that the organisation ensures that the generalist allied health program seeks feedback from patients at the completion of their services.

Met

2.2 .2 (D) Consumers and/or carers are actively involved in decision making about safety and quality

Met Safety and Quality Documents/Records: The organisation has several ways of engaging consumers including the nurse navigators who are working to streamline admission and discharge processes from Cairns hospital. Their role could be expanded further to engage consumers to provide feedback. Several communities have health action teams that are actively involved in decision making and

Met






desire to do more whilst other ones need more support to move into this role. These groups are seeking a role in feedback about staff performance as well as acceptability along with the physical standard of the hospital - Bamaga has had the television sets removed from the wards many months ago and they want them back. Some communities considered that they received inadequate information about the planned visits of the various rotating clinical services Review of the consumer engagement framework shows that consumers and/or carers are included in decision making about safety and quality. Improvement Opportunities Safety and Quality Documents/Records: It is recommended that the organisation: a) Consider ways to expand the nurse navigator role to receive more feedback from consumers. b) Consider ways to better support the community health action teams. c) Supply television sets to the wards in Bamaga hospital. d) Review the processes used to disseminate to communities the calendar of services provided.

Criterion: 2.3 Consumer orientation and training Governance structures are in place to form partnerships with consumers and/or carers.

Facilitating access to relevant orientation and training for consumers and/or carers partnering with the organisation

Rating: Met



2.3 .1 (D) Health service organisations provide orientation and ongoing training for consumers and/or carers to enable them to fulfil their partnership role

Met HRM Documents/Records: Review of the consumer engagement documents found consumers are provided some orientation. However, it is patchy across the communities. 2.2.2

Met






Create strategy/guidelines on supporting carers of people with mental health issues. (NMHS 7.6) NSQHS 2.2.2 2.3.1 The organisation needs to ensure a systemic approach when orientating consumers to each service. Review of the consumer orientation documents found consumers are provided orientation and ongoing training to fulfil their partnership role. Improvement Opportunities HRM Documents/Records: It is recommended that the organisation review its processes to educate consumers in their roles.

Criterion: 2.4 Consumer consultation Governance structures are in place to form partnerships with consumers and/or carers.

Consulting consumers on patient information distributed by the organisation

Rating: Met



2.4 .1 (C) Consumers and/or carers provide feedback on patient information publications prepared by the health service organisation (for distribution to patients)

Met Evaluation and Feedback Documents/Records: Review of the consumer engagement framework and feedback shows how feedback from consumers and/or carers is sought about patient information/publications with evidence of community and cultural specific health information. Management Interview: Management staff interviewed could provide examples of improvements and modifications made when patient information has been reviewed by a consumer group. Management staff interviewed could provide examples of improvements made when

Met






patient information has been reviewed by a consumer such as brochures and health promotional material.

2.4 .2 (C) Action is taken to incorporate consumer and/or carers feedback into publications prepared by the health service organisation for distribution to patients

Met Evaluation and Feedback Documents/Records: Review of the information/publications shows consumers and/or carers’ feedback is incorporated into publications prepared by the health service organisation.

Met

Criterion: 2.5 Delivery of care Consumers and/or carers are supported by the health service organisation to actively participate in the improvement of the patient experience and patient health outcomes.

Partnering with consumers and/or carers to design the way care is delivered to better meet patient needs and preferences

Rating: Met



2.5 .1 (D) Consumers and/or carers participate in the design and redesign of health services

Met CEO Interview: The CEO could describe how the opinions of consumers are involved in changes or re-design of the health services. Management Interview: Management staff interviewed could describe how consumers are involved in changes or re-design of the health services. However some new facilities in the southern sector have had little input concerning decoration from the communities. Improvement Opportunities Management Interview: It is recommended that the organisation reviews processes to ensure that appropriate consultation occurs with communities when preparing new facilities.

Met




Criterion: 2.6 Consumer engagement training Consumers and/or carers are supported by the health service organisation to actively participate in the improvement of the patient experience and patient health outcomes.

Implementing training for clinical leaders, senior management and the workforce on the value of and ways to facilitate consumer engagement and how to create and sustain partnerships

Rating: Met



2.6 .1 (C) Clinical leaders, senior managers and the workforce access training on patient-centred care and the engagement of individuals in their care

Met HRM Documents/Records: Review of the training plan/records shows the workforce is provided training in patient engagement/patient-centred care.

Met

2.6 .2 (D) Consumers and/or carers are involved in training the clinical workforce

Met Management Interview: Management staff interviewed could describe how input is sought from consumers and then used to inform training programs for clinicians, particularly in cultural appropriateness. More training for the clinical workforce to review the patient lived experience. Improvement Opportunities Management Interview: It is recommended that the organisation educate staff on how to review and understand that patient's lived experience.

Met

Criterion: 2.7 Informing consumers on safety performance Consumers and/or carers receive information on the health service organisation’s performance and contribute to the ongoing monitoring, measurement and evaluation of performance for continuous quality improvement.

Informing consumers and/or carers about the organisation’s safety and quality performance in a format that can be understood and interpreted independently

Rating: Met



2.7 .1 (C) The community and consumers are provided with information that is

Met Consumer Documents/Records: Review of consumer information showed that consumers and the community are

Met






meaningful and relevant on the organisation’s safety and quality performance

provided with safety and quality performance information through meetings and discussions.

Criterion: 2.8 Safety and quality performance Consumers and/or carers receive information on the health service organisation’s performance and contribute to the ongoing monitoring, measurement and evaluation of performance for continuous quality improvement.

Consumers and/or carers participating in the analysis of safety and quality performance information and data, and the development and implementation of action plans

Rating: Met



2.8 .1 (D) Consumers and/or carers participate in the analysis of organisational safety and quality performance

Met Management Interview: Management staff interviewed could describe how consumers are engaged in analysing safety and quality data.

Met

2.8 .2 (D) Consumers and/or carers participate in the planning and implementation of quality improvements

Met Management Interview: Management staff interviewed could describe how consumers are engaged in planning and implementing quality improvements through feedback and community engagement.

Met

Criterion: 2.9 Patient feedback evaluation Consumers and/or carers receive information on the health service organisation’s performance and contribute to the ongoing monitoring, measurement and evaluation of performance for continuous quality improvement.

Consumers and/or carers participating in the evaluation of patient feedback data and development of action plans.

Rating: Met



2.9 .1 (D) Consumers and/or carers participate in the evaluation of patient feedback data

Met Management Interview: Management staff interviewed could describe how input is sought from consumers when evaluating patient feedback data from the various sites of service.

Met

2.9 .2 (D) Consumers and/or carers participate in the implementation of quality activities

Met Management Interview: Management staff interviewed could describe how consumers are engaged when

Met






relating to patient feedback data determining and implementing improvements resulted from patient feedback.




3 Preventing and Controlling Healthcare Associated Infections Criterion: 3.1 Infection prevention governance system

Effective governance and management systems for healthcare associated infections are implemented and maintained.

Developing and implementing governance systems for effective infection prevention and control to minimise the risks to patients of healthcare associated infections

Rating: Met



3.1 .1 (C) A risk management approach is taken when implementing policies, procedures and/or protocols for: • standard infection control precautions • transmission-based precautions • aseptic non-touch technique • safe handling and disposal of sharps • prevention and management of occupational exposure to blood and body substances • environmental cleaning and disinfection • antimicrobial prescribing • outbreaks or unusual clusters of communicable infection • processing of reusable medical devices • single-use devices • surveillance and reporting of data where relevant • reporting of communicable and notifiable diseases • provision of risk assessment guidelines to workforce • exposure-prone procedures

Met CEO Interview: The CEO could describe how infection control policies and procedures are managed in the organisation, in part by using a risk assessment processes as well as ensuring that the guidelines and protocols concur with national standards. Facilities and Equipment: Observation of facilities shows staff have access to the Australian Guidelines on the Prevention and Control of Infection in Healthcare through signage and availability of equipment. Infection Control Documents/Records: Review of the policy/procedure showed a risk management approach is taken when implementing policies and procedures for infection prevention and control throughout the organisation. Management Interview: Management staff interviewed could describe how risk assessment processes are used to determine the scope of infection control policies and procedures and how those policies and procedures are managed. Clinical staff interviewed could describe how risk assessment processes are used to determine the scope of infection control policies and procedures and how those policies and procedures are managed. Risk Management Documents/Records: Review of organisational risk management plan shows a mechanism in place for

Met






identifying, escalating and reviewing healthcare associated infections risks.

3.1 .2 (C) The use of policies, procedures and/or protocols is regularly monitored

Met Infection Control Documents/Records: Review of the documents provided shows policies, procedures and/or protocols are regularly monitored at all levels of the organisation. Management Interview: Management staff interviewed could describe how infection control policies and procedures are monitored for both effectiveness and compliance. Clinical staff interviewed could describe how use and adherence to infection control policies and procedures are monitored.

Met

3.1 .3 (C) The effectiveness of the infection prevention and control systems is regularly reviewed at the highest level of governance in the organisation

Met Board Interview: Board members interviewed could describe the infection control performance data that is routinely reported to Board and then used to assist in decision making. CEO Interview: The CEO could describe the reports about infection control program performance that are routinely received by the Board and senior management team. Governance Documents/Records: Review of meeting minutes shows that control performance data is considered at the highest level of governance.

Met

3.1 .4 (C) Action is taken to improve the effectiveness of infection prevention and control policies, procedures and/or protocols

Met Infection Control Documents/Records: Review of the documents provided shows evidence of actions taken to improve the effectiveness of infection prevention and control policies, procedures and/or protocols.

Met




Criterion: 3.2 Surveillance healthcare infections Effective governance and management systems for healthcare associated infections are implemented and maintained.

Undertaking surveillance of healthcare associated infections

Rating: Met



3.2 .1 (C) Surveillance systems for healthcare associated infections are in place

Met Infection Control Documents/Records: Review of the documents supplied showed evidence of surveillance systems for healthcare associated infections. Tuberculosis is the significant public health threat and it is very important that treatment records and contact tracing is efficient and effective. At present, there is some difficulty aligning local data bases and interaction with the state-wide TARDIS system is reported as difficult. With patients crossing from PNG and returning there, arrangements to monitor treatments is difficult. Further, these patients sometimes cross the border several times so tracking them is more difficult. It may be useful if the Australian Border Force authority and the Torres Strait Council could be involved in information sharing about identified cases if appropriate. Review of the documents supplied showed evidence of surveillance systems for healthcare associated infections with follow-up of patient post invasive procedure. Management Interview: Management interviewed could describe the organisations surveillance systems for healthcare associated infections and how the data derived is analysed and used. Improvement Opportunities Infection Control Documents/Records: It is recommended that the organisation review and revise the data management of patients with TB and that ways to share information appropriately with the local authorities be examined.

Met

3.2 .2 (C) Healthcare associated infections surveillance data are regularly monitored by the delegated workforce and/or committees

Met Infection Control Documents/Records: Review of healthcare associated infections surveillance data shows it is regularly monitored by the delegated workforce and/or committees.

Met






Management Interview: Management interviewed could describe how infection surveillance data is monitored, reviewed and used to plan changes as required, with the outcomes reported to staff. Management interviewed could describe how infection surveillance data is monitored, how frequently it is reviewed and how the results are reported.

Criterion: 3.3 Infection systems and process Effective governance and management systems for healthcare associated infections are implemented and maintained.

Developing and implementing systems and processes for reporting, investigating and analysing healthcare associated infections, and aligning these systems to the organisation’s risk management strategy

Rating: Met



3.3 .1 (C) Mechanisms to regularly assess the healthcare associated infection risks are in place

Met Infection Control Documents/Records: Review of risk assessment records described the mechanisms for assessing healthcare associated infection risks at point of entry into each service through new patient/client forms. Management Interview: Management interviewed could describe the risk management process is used in relation to infection control and how the information is promulgated across the organisation. Management interviewed could describe the risk management process is used in relation to infection control which is documented in the risk register.

Met

3.3 .2 (C) Action is taken to reduce the risks of healthcare associated infection

Met Infection Control Documents/Records: Review of the action/improvement plans/records confirmed that actions are taken to minimise the risks of associated infections through the organisational wide risk register.

Met




Criterion: 3.4 Quality improvement activities Effective governance and management systems for healthcare associated infections are implemented and maintained.

Undertaking quality improvement activities to reduce healthcare associated infections through changes to practice

Rating: Met



3.4 .1 (C) Quality improvement activities are implemented to reduce and prevent healthcare associated infections

Met Infection Control Documents/Records: Review of the quality improvement records confirm quality improvement activities are implemented to reduce and prevent healthcare associated infections. Management Interview: Management interviewed could describe quality improvement activities that have been implemented to reduce and prevent healthcare associated infections such as new staff vaccination procedure, Clinell wall mounted brackets and Central CSSD for oral health.

Met

3.4 .2 (C) Compliance with changes in practice are monitored

Met Infection Control Documents/Records: Review of audit/monitoring results show evidence of infection control compliance monitoring in the event of changes within the organisation such as Hand Hygiene, Post procedure reviews etc.

Met

3.4 .3 (D) The effectiveness of changes to practice are evaluated

Met Infection Control Documents/Records: Review of the improvement evaluation records show the effectiveness of infection control changes to the organisation are evaluated. Management Interview: Management interviewed could explain how infection control quality activities are implemented and evaluated across the various sites. Management interviewed demonstrated an awareness of how infection control quality activities are implemented and evaluated through review processes and feedback.

Met




Criterion: 3.5 Auditing hand hygiene program Strategies for the prevention and control of healthcare associated infection are developed and implemented.

Developing, implementing and auditing a hand hygiene program consistent with the current national hand hygiene initiative

Rating: Met



3.5 .1 (C) Workforce compliance with current national hand hygiene guidelines is regularly audited

Met Clinical Governance Documents/Records: Review of audit results shows compliance with current national hand hygiene guidelines is regularly conducted. HRM Documents/Records: Review of training records shows records of workforce attendance at hand hygiene training. Infection Control Documents/Records: Review of the hand hygiene information indicated that hand hygiene audits are regularly conducted. Improvement Opportunities HRM Documents/Records: The organisation should consider various levels of Hand Hygiene training dependant on roles and responsibilities e.g. General Hand Hygiene Training, Pre-procedure scrub training etc. Infection Control Documents/Records: The organisation should consider further auditing in high risk areas of theatre to match the Infection Control (Hand Hygiene) policy and procedure.

Met

3.5 .2 (C) Compliance rates from hand hygiene audits are regularly reported to the highest level of governance in the organisation

Met Board Interview: The governance representatives interviewed could describe the information that the Board routinely receives covering hygiene compliance across the organisation. CEO Interview: The CEO could describe the information pertaining to hygiene compliance that the Board

Met






receives regularly. Governance Documents/Records: Review of governance documents shows that reports from committees and meetings includes information from hand hygiene audits.

3.5 .3 (C) Action is taken to address non-compliance, or the inability to comply, with the requirements of the current national hand hygiene guidelines

Met Infection Control Documents/Records: Review of the improvement plans supplied show evidence of actions taken to address non-compliance with hand hygiene requirements.

Met

Criterion: 3.6 Workforce immunisation program Strategies for the prevention and control of healthcare associated infection are developed and implemented.

Developing, implementing and monitoring a risk-based workforce immunisation program in accordance with the current National Health and Medical Research Council Australian immunisation guidelines

Rating: Met



3.6 .1 (C) A workforce immunisation program that complies with current national guidelines is in use

Met Clinical Interview: Clinical staff interviewed could describe the immunisations offered to them by the organisation and that they comply with the Australian Immunisation Handbook. HRM Documents/Records: Review of the staff immunisation policy adequately described the systems in place for workforce immunisation management that complies with current national guidelines. Management Interview: Management interviewed could describe the organisations workforce immunisation program. Staff interviewed could describe the immunisation program and provide examples of immunisations offered to them.

Met




Criterion: 3.7 OHS programs Strategies for the prevention and control of healthcare associated infection are developed and implemented.

Promoting collaboration with occupational health and safety programs to decrease the risk of infection or injury to healthcare workers

Rating: Met



3.7 .1 (C) Infection prevention and control consultation related to occupational health and safety policies, procedures and/or protocols are implemented to address: • communicable disease status • occupational management and prophylaxis • work restrictions • personal protective equipment • assessment of risk to healthcare workers for occupational allergies • evaluation of new products and procedures

Met Clinical Interview: Clinical staff interviewed could provide examples of consultations undertaken with staff relating to the WHS aspects of infection control. The assessors noted that infection control signage was variable in its distribution in the various sites, plus some procedural staff and VMO's need further education in the selection of appropriate PPE. Issues were noted in the mortuary at Bamaga with respect to appropriate trolleys being supplied as well as some conjecture as to whether the drainage meets current standards. Infection Control Documents/Records: Review of infection prevention and control records shows evidence of consultation related to occupational health and safety policies, procedures and/or protocols. Improvement Opportunities Clinical Interview: It is recommended that: a) The organisation review the PPE and Hand Hygiene signage across the sites to ensure that it is specific, uniform and appropriately sited and that all staff and VMO's receive education on the appropriate selection of PPE. b) The equipment and drainage at the mortuary at Bamaga are fit-for-purpose. Infection Control Documents/Records: It is recommended that: a) The organisation review signage across the sites to ensure that it is specific, uniform and appropriately sited and that all staff and VMO's receive education on the appropriate selection of PPE.

Met






b) the equipment and drainage at the mortuary at Bamaga are fit-for-purpose

Criterion: 3.8 Invasive devices systems Strategies for the prevention and control of healthcare associated infection are developed and implemented.

Developing and implementing a system for use and management of invasive devices based on the current national guidelines for preventing and controlling infections in health care

Rating: Met



3.8 .1 (C) Compliance with the system for the use and management of invasive devices is monitored

Met Clinical Governance Documents/Records: Review of audit results shows compliance with the system for the use and management of invasive devices is monitored. Clinical Interview: Clinical staff interviewed could describe how invasive devices are monitored by the service through tracking systems and documentation within the clinical record. Infection Control Documents/Records: Review of the monitoring/audit results confirmed the use and management of invasive devices are monitored.

Met

Criterion: 3.9 Invasive device procedures Implementing protocols for invasive device procedures regularly performed within the organisation

Rating: Met



3.9 .1 (C) Education and competency-based training in invasive devices protocols and use is provided for the workforce

Met Clinical Interview: Clinical staff interviewed could describe the training undertaken in the protocols and use of invasive devices along with the competency reviews.

Met






who perform procedures with invasive devices

HRM Documents/Records: Review of the competency based training records showed the workforce who perform procedures with invasive devices is provided with training in invasive devices protocols and use. Management Interview: Management interviewed could describe education and training provided to staff that use invasive devices. Improvement Opportunities HRM Documents/Records: Hand Hygiene training should meet procedural requirements.

Criterion: 3.10 Aseptic techniques Strategies for the prevention and control of healthcare associated infection are developed and implemented.

Developing and implementing protocols for aseptic technique

Rating: Met



3.10 .1 (C) The clinical workforce is trained in aseptic technique

Met Clinical Interview: Clinical staff interviewed indicated that they have received training and review in aseptic non-touch techniques. HRM Documents/Records: Review of the training records/qualifications showed the clinical workforce is trained in aseptic technique.

Met

3.10 .2 (C) Compliance with aseptic technique is regularly audited

Met Clinical Governance Documents/Records: Review of the audit/monitoring results showed compliance with aseptic technique is regularly audited and used as a basis for continuing education as required.

Met






3.10 .3 (C) Action is taken to increase compliance with the aseptic technique protocols

Met Infection Control Documents/Records: Review of the action plan showed action is taken to increase compliance with the aseptic technique protocols. ANNT is audited in October and also included in IV cannulation audits in August.

Met

Criterion: 3.11 Standard precautions Patients presenting with, or acquiring an infection or colonisation during their care are identified promptly and receive the necessary management and treatment.

Implementing systems for using standard precautions and transmission based precautions

Rating: Met



3.11 .1 (C) Standard precautions and transmission-based precautions consistent with the current national guidelines are in use

Met Clinical Interview: Clinical staff interviewed demonstrated an awareness of the service's transmission based precautions and what PPE is provided to staff, when to use it and where it is stored. Facilities and Equipment: Observation of facilities shows signage and other information resources that are consistent with the current national guidelines for standard and transmission-based precautions. Infection Control Documents/Records: Review of the policy and procedure shows that the organisation uses standard and transmission based precautions that are consistent with the current national guidelines. Staff interviewed demonstrated an awareness of the service's transmission based precautions and the PPE is provided to staff. Improvement Opportunities Facilities and Equipment: Ensure all signage is uniform throughout the organisation. It is advisable to create a signage audit to ensure uniformity e.g. Hand Wash Vs Hand Rub Signage, 5 moments of

Met






hand hygiene and PPE.

3.11 .2 (C) Compliance with standard precautions is monitored

Met Clinical Governance Documents/Records: Review of the audit results showed that compliance with standard precautions is monitored.

Met

3.11 .3 (C) Action is taken to improve compliance with standard precautions

Met Infection Control Documents/Records: Review of the action/improvement plan showed action is taken to improve compliance with standard precautions through the NHMRC Prevention and Control of Infection in Healthcare guidelines (2010).

Met

3.11 .4 (C) Compliance with transmission-based precautions is monitored

Met Clinical Governance Documents/Records: Review of the audit results confirmed that compliance with transmission-based precautions is monitored and the results used for continuing education.

Met

3.11 .5 (C) Action is taken to improve compliance with transmission based precautions

Met Infection Control Documents/Records: Review of the improvement plans showed actions are taken to improve compliance with transmission-based precautions.

Met

Criterion: 3.12 Patient placement Patients presenting with, or acquiring an infection or colonisation during their care are identified promptly and receive the necessary management and treatment.

Assessing the need for patient placement based on the risk of infection transmission

Rating: Met



3.12 .1 (C) A risk analysis is undertaken to consider the need for transmission-based precautions including: • accommodation based on the mode of transmission • environmental controls through air flow • transportation within and outside the facility

Met Infection Control Documents/Records: Review of the risk analysis showed the need for transmission-based precautions is considered. Management Interview: Management staff interviewed could describe the risk assessment process used to determine which transmission based precautions are used.

Met






• cleaning procedures • equipment requirements

Criterion: 3.13 Patient infection protocols Patients presenting with, or acquiring an infection or colonisation during their care are identified promptly and receive the necessary management and treatment.

Developing and implementing protocols relating to the admission, receipt and transfer of patients with an infection

Rating: Met



3.13 .1 (C) Mechanisms are in use for checking for pre-existing healthcare associated infections or communicable disease on presentation for care

Met Infection Control Documents/Records: Review of the documentation shows mechanisms are used to check for pre-existing infections or diseases when a person presents for care. Further, a review of the discharge or transfer documents showed that a patient's infectious status is communicated when care is transferred between service providers or facilities.

Met

3.13 .2 (C) A process for communicating a patient’s infectious status is in place whenever responsibility for care is transferred between service providers or facilities

Met Infection Control Documents/Records: Review of the clinical handover policy adequately described the systems in place for communicating a patient's infectious status in the handover process.

Met

Criterion: 3.14 Antimicrobial stewardship system Safe and appropriate antimicrobial prescribing is a strategic goal of the clinical governance system.

Developing, implementing and regularly reviewing the effectiveness of the antimicrobial stewardship system

Rating: Met



3.14 .1 (C) An antimicrobial stewardship program is in place

Met Infection Control Documents/Records: Review of the antimicrobial stewardship policy adequately described the organisations antimicrobial stewardship program.

Met






Management Interview: Management interviewed could describe the organisations antimicrobial stewardship program.

3.14 .2 (C) The clinical workforce prescribing antimicrobials have access to current endorsed therapeutic guidelines on antibiotic usage

Met Clinical Interview: Clinical staff interviewed could provide examples of clinical guidelines they refer to when requiring information about antibiotics. Facilities and Equipment: Observation of the facilities shows the clinical workforce have access to current endorsed therapeutic guidelines on antibiotic usage at the point of care and clinical areas.

Met

3.14 .3 (C) Monitoring of antimicrobial usage and resistance is undertaken

Met Clinical Governance Documents/Records: Review of the monitoring results showed that antimicrobial resistance is monitored, including by using biograms, and that the usage of antibiotics is monitored to ensure that they are appropriate and follow the guidelines in place.

Met

3.14 .4 (C) Action is taken to improve the effectiveness of antimicrobial stewardship

Met Infection Control Documents/Records: Review of the action/improvement plans showed that action is taken to improve the effectiveness of antimicrobial stewardship through training and is a standard item during orientation.

Met

Criterion: 3.15 Hygienic environment Healthcare facilities and the associated environment are clean and hygienic. Reprocessing of equipment and instrumentation meets current best practice guidelines.

Using risk management principles to implement systems that maintain a clean and hygienic environment for patients and healthcare workers

Rating: Met



3.15 .1 (C) Policies, procedures and/or protocols for environmental cleaning that address the principles of infection prevention and control are implemented, including: • maintenance of building facilities

Met Infection Control Documents/Records: Review of the environmental cleaning policy adequately described the systems in place for maintaining a clean environment through daily, weekly and monthly cleaning schedules.

Met






• cleaning resources and services • risk assessment for cleaning and disinfection based on transmission-based precautions and the infectious agent involved • waste management within the clinical environment • laundry and linen transportation, cleaning and storage • appropriate use of personal protective equipment

3.15 .2 (C) Policies, procedures and/or protocols for environmental cleaning are regularly reviewed

Met Infection Control Documents/Records: Review of the policy revisions shows the procedures and protocols for environmental cleaning are regularly reviewed.

Met

3.15 .3 (C) An established environmental cleaning schedule is in place and environmental cleaning audits are undertaken regularly

Met Clinical Governance Documents/Records: Review of the cleaning records shows the organisation uses established environmental cleaning schedules and that cleaning audits are regularly undertaken.

Met

Criterion: 3.16 Reprocessing reusable medical equipment Healthcare facilities and the associated environment are clean and hygienic. Reprocessing of equipment and instrumentation meets current best practice guidelines.

Reprocessing reusable medical equipment, instruments and devices in accordance with relevant national or international standards and manufacturers’ instructions

Rating: Met



3.16 .1 (C) Compliance with relevant national or international standards and manufacturer’s instructions for cleaning, disinfection and sterilisation of reusable instruments and devices is regularly monitored

Met Clinical Governance Documents/Records: Review of audit results shows that validation and compliance reviews of systems for sterilisation of reusable instruments and devices is monitored to ensure that they comply with Standards and manufacturers recommendations. Infection Control Documents/Records: Review of the monitoring/audit results showed that instructions on cleaning, disinfection

Met






and sterilisation of reusable instruments and devices is regularly monitored and available for all staff to review.

Criterion: 3.17 Patient identification Healthcare facilities and the associated environment are clean and hygienic. Reprocessing of equipment and instrumentation meets current best practice guidelines.

Implementing systems to enable the identification of patients on whom the reusable medical devices have been used

Rating: Met



3.17 .1 (C) A traceability system that identifies patients who have a procedure using sterile reusable medical instruments and devices is in place

Met Infection Control Documents/Records: Review of the tracking records showed there is a traceability system in place that identifies patients who have a procedure using sterile reusable medical instruments and devices.

Met

Criterion: 3.18 Competency-based training Healthcare facilities and the associated environment are clean and hygienic. Reprocessing of equipment and instrumentation meets current best practice guidelines.

Ensuring workforce who decontaminate reusable medical devices undertake competency-based training in these practices.

Rating: Met



3.18 .1 (C) Action is taken to maximise coverage of the relevant workforce trained in a competency-based program to decontaminate reusable medical devices

Met HRM Documents/Records: Review of the training records or materials showed action is taken to maximise coverage of the relevant workforce trained in a competency-based program to decontaminate reusable medical devices. Improvement Opportunities HRM Documents/Records: It is recommended that competency based training of peer review should also be developed for reprocessing area.

Met




Criterion: 3.19 Consumer-specific information Information on healthcare associated infection is provided to patients, carers, consumers and service providers.

Ensuring consumer-specific information on the management and reduction of healthcare associated infections is available at the point of care.

Rating: Met



3.19 .1 (C) Information on the organisation’s corporate and clinical infection risks and initiatives implemented to minimise patient infection risks is provided to patients and/or carers

Met Consumer Documents/Records: Review of consumer information showed that consumers and carers are provided with information on clinical infection risks. However, in the southern sector consumer involvement is variable across the sites and the information provided is also variable. Improvement Opportunities Consumer Documents/Records: It is recommended that consumer information covering the organisation's infection control activities be uniform for each site across the southern sector.

Met

3.19 .2 (D) Patient infection prevention and control information is evaluated to determine if it meets the needs of the target audience

Met Infection Control Documents/Records: Review of evaluation results show patient infection prevention and control information is evaluated through consumer advisory committee. Improvement Opportunities Infection Control Documents/Records: The organisation should promote their infection prevention and control information to give consumers an understanding of processes undertaken to maintain best practice.

Met




4 Medication Safety Criterion: 4.1 Medication safety

Health service organisations have mechanisms for the safe prescribing, dispensing, supplying, administering, storing, manufacturing, compounding and monitoring of the effects of medicines.

Developing and implementing governance arrangements and organisational policies, procedures and/or protocols for medication safety, which are consistent with national and jurisdictional legislative requirements, policies and guidelines

Rating: Met



4.1 .1 (C) Governance arrangements are in place to support the development, implementation and maintenance of organisation wide medication safety systems

Met CEO Interview: Interview with the CEO confirmed that the organisation has sound medication governance arrangements in place. HRM Documents/Records: Review of HRM records shows roles, responsibilities and accountabilities for clinical and organisational medication management activities is documented in position descriptions or employment contracts. Medicine Safety Documents/Records: Review of documentation from committees and meetings shows that organisation wide medication safety systems are implemented and reviewed by the governing body. However, the (acting) chief pharmacist is based on Thursday Island and has no direct oversight of the immunisation program in the southern sector, despite having ultimate responsibility for the stocks of vaccines. Improvement Opportunities Medicine Safety Documents/Records: Recommend that the TCHHS pharmacists take carriage for all vaccine stocks across the organisation.

Met

4.1 .2 (C) Policies, procedures and/or protocols are in place that are consistent with legislative requirements, national, jurisdictional and professional guidelines

Met Medicine Safety Documents/Records: Review of the medication safety policy adequately described the systems in place for medication safety and showed consistency with legislative requirements.

Met




Criterion: 4.2 Medication use systems Health service organisations have mechanisms for the safe prescribing, dispensing, supplying, administering, storing, manufacturing, compounding and monitoring of the effects of medicines.

Undertaking a regular, comprehensive assessment of medication use systems to identify risks to patient safety and implementing system changes to address the identified risks

Rating: Met



4.2 .1 (C) The medication management system is regularly assessed

Met Clinical Governance Documents/Records: Review of the monitoring/audit results shows medication management systems are regularly assessed, including bedside audits and participation in the national inpatient medication chart audits.

Met

4.2 .2 (C) Action is taken to reduce the risks identified in the medication management system

Met Medicine Safety Documents/Records: Review of the improvement plan shows action is taken to reduce the risks identified in the medication management system. However at two sites where haemodialysis is performed, the materials being used to test chlorine levels in the water were out of date and that the testing records were unsatisfactory. Improvement Opportunities Medicine Safety Documents/Records: It is recommended that the records for water testing for haemodialysis are to include the lot number, batch number and expiry of testing kits.

Met

Criterion: 4.3 Medication authorisation Health service organisations have mechanisms for the safe prescribing, dispensing, supplying, administering, storing, manufacturing, compounding and monitoring of the effects of medicines.

Authorising the relevant clinical workforce to prescribe, dispense and administer medications

Rating: Met








4.3 .1 (C) A system is in place to verify that the clinical workforce have medication authorities appropriate to their scope of practice

Met HRM Documents/Records: Review of medicines authorisation records found systems are in place to ensure the clinical workforce have medication authorities appropriate to their scope of practice. Medicine Safety Documents/Records: Review of policies, procedures and protocols shows that roles, responsibilities and accountabilities of clinicians for medication management processes are clear.

Met

4.3 .2 (C) The use of the medication authorisation system is regularly monitored

Met Clinical Governance Documents/Records: Review of the audit results shows that the medication authorisation systems are regularly monitored.

Met

4.3 .3 (C) Action is taken to increase the effectiveness of the medication authority system

Met Medicine Safety Documents/Records: Review of the action/improvement plan shows that action is taken to improve the effectiveness of the medication authority system.

Met

Criterion: 4.4 Medication incidents Health service organisations have mechanisms for the safe prescribing, dispensing, supplying, administering, storing, manufacturing, compounding and monitoring of the effects of medicines.

Using a robust organisation-wide system of reporting, investigating and managing change to respond to medication incidents

Rating: Met



4.4 .1 (C) Medication incidents are regularly monitored, reported and investigated

Met CEO Interview: The CEO could describe how the organisation monitors, reports and investigates all medication incidents. Clinical Governance Documents/Records: Review of the incident reports shows that all medication incidents are reported and investigated through the clinical safety and audit pathways. Clinical Interview: Clinical staff interviewed could describe how medication incidents are regularly

Met






monitored, reported and investigated. Management Interview: Management staff could describe how the organisation monitors, reports and investigates medication incidents supported by policy and procedures.

4.4 .2 (C) Action is taken to reduce the risk of an adverse medication incidents

Met Medicine Safety Documents/Records: Review of the improvement plans shows that actions are taken to reduce the risk of adverse medication incidents.

Met

Criterion: 4.5 Quality improvement Health service organisations have mechanisms for the safe prescribing, dispensing, supplying, administering, storing, manufacturing, compounding and monitoring of the effects of medicines.

Undertaking quality improvement activities to enhance the safety of medicines use

Rating: Met



4.5 .1 (C) The performance of the medication management system is regularly assessed

Met Clinical Governance Documents/Records: Review of the safety and quality governance pathways shows that the performance of the medication management system is regularly assessed.

Met

4.5 .2 (C) Quality improvement activities are undertaken to reduce the risk of patient harm and increase the quality and effectiveness of medicines use

Met Medicine Safety Documents/Records: Review of the improvement plans shows evidence of activities undertaken to minimise patient risk and increase quality and effective use of medicines.

Met

Criterion: 4.6 Patient medication history The clinical workforce accurately records a patient’s medication history and this history is available throughout the episode of care.

The clinical workforce taking an accurate medication history when a patient presents to a health service organisation, or as early as possible in the episode of care, which is then available at the point of care

Rating: Met






4.6 .1 (C) A best possible medication history is documented for each patient

Met Clinical Documents/Records: Review of the medical records confirmed that a comprehensive medication history is documented. Review of the assessment records shows the best possible medication history is documented on each presentation.

Met

4.6 .2 (C) The medication history and current clinical information is available at the point of care

Met Clinical Interview: Clinical staff interviewed confirmed that they have access to a patient's medication history at the point of care. Medicine Safety Documents/Records: Review of policies shows that medication history is accessible on admission and at the point of care.

Met

Criterion: 4.7 Adverse medicine reactions The clinical workforce accurately records a patient’s medication history and this history is available throughout the episode of care.

The clinical workforce documenting the patient’s previously known adverse medicines reactions on initial presentation and updating this if an adverse reaction to a medicine occurs during the episode of care

Rating: Met



4.7 .1 (C) Known medication allergies and adverse drug reactions are documented in the patient clinical record

Met Clinical Documents/Records: Review of the patient clinical record shows that known medication allergies and adverse drug reactions are documented in the patient clinical records.

Met

4.7 .2 (C) Action is taken to reduce the risk of adverse reactions

Met Medicine Safety Documents/Records: Review of the adverse reaction alerts shows that actions are taken to reduce the risk of adverse reactions across the organisation.

Met

4.7 .3 (C) Adverse drug reactions are reported within the organisation and to the Therapeutic Goods Administration

Met Clinical Governance Documents/Records: Review of the reports shows that adverse drug reactions within the organisation are reviewed as well as reported to the Therapeutic Goods Administration.

Met




Criterion: 4.8 Current medication orders The clinical workforce accurately records a patient’s medication history and this history is available throughout the episode of care.

The clinical workforce reviewing the patient’s current medication orders against their medication history and prescriber’s medication plan, and reconciling any discrepancies

Rating: Met



4.8 .1 (D) Current medicines are documented and reconciled at admission and transfer of care between healthcare settings

Met Clinical Documents/Records: Review of the medication management system shows that current medicines are documented and recorded upon admission and at time of transfer of care to another healthcare facility. Review of the admission/discharge/transfer reports shows current medicines are documented and recorded at admission and transfer of care between healthcare settings.

Met

Criterion: 4.9 Medicines information The clinical workforce is supported for the prescribing, dispensing, administering, storing, manufacturing compounding and monitoring of medicines.

Ensuring that current and accurate medicines information and decision support tools are readily available to the clinical workforce when making clinical decisions related to medicines use

Rating: Met



4.9 .1 (C) Information and decision support tools for medicines are available to the clinical workforce at the point of care

Met Clinical Interview: Clinical staff interviewed could provide examples of medicines information available at the point of care that support effective prescribing through Therapeutic Guidelines. Medicine Safety Documents/Records: Observation of the location of the medicines decision tools confirms that they are available to the clinicians at the point of care.

Met

4.9 .2 (C) The use of the information and decision support tools are regularly reviewed

Met Clinical Governance Documents/Records: Review of the governance records shows that the use of information and decision

Met






support tools is reviewed. Clinical Interview: Clinical staff interviewed confirmed that current medicines information and references are available at the point of care.

4.9 .3 (C) Action is taken to improve the availability and effectiveness of information and decision support tools

Met Medicine Safety Documents/Records: Review of the improvement plans shows that actions are taken to improve the availability and effectiveness of information and decision support tools.

Met

Criterion: 4.10 Medicine storage The clinical workforce is supported for the prescribing, dispensing, administering, storing, manufacturing compounding and monitoring of medicines.

Ensuring that medicines are distributed and stored securely, safely and in accordance with the manufacturer’s directions, legislation, jurisdictional orders and operational directives

Rating: Met



4.10 .1 (C) Risks associated with secure storage and safe distribution of medicines are regularly reviewed

Met Clinical Governance Documents/Records: Review of the monitoring records shows that regular review of the risks associated with secure storage and safe distribution of medicines is undertaken. Risk Management Documents/Records: Review of the assessment/audit/monitoring records shows regular review of risks associated with secure storage and safe distribution of medicines.

Met

4.10 .2 (C) Action is taken to reduce the risks associated with storage and distribution of medicines

Met Medicine Safety Documents/Records: Review of the improvement plans shows that actions are taken to reduce the risks associated with storage and distribution of medicines. At one site, some temperature sensitive medicines are stored in the refrigerator in cardboard boxes touching the walls whereas it is recommended that there is a 40 mm gap (Strive for Five p12) from all walls. Improvement Opportunities Medicine Safety Documents/Records:

Met






It is recommended that all refrigerators used to store temperature sensitive medicines comply with the national "Strive for 5" guidelines.

4.10 .3 (C) The storage of temperature-sensitive medicines is monitored

Met Clinical Governance Documents/Records: Review of audit results shows that compliance reviews with processes for daily checks of medicines and vaccines refrigerators is undertaken. Medicine Safety Documents/Records: Review of the records shows that the storage of temperature-sensitive medicines is monitored.

Met

4.10 .4 (C) A system that is consistent with legislative and jurisdictional requirements for the disposal of unused, unwanted or expired medications is in place

Met Clinical Interview: Clinical staff interviewed were able to describe how surplus or expired medicines are disposed through clinical waste management processes. Management Interview: Management interviewed could describe the system for the disposal of unused, unwanted or expired medications and how it meets all legislative and jurisdictional requirements. Medicine Safety Documents/Records: Review of the medicines management policy adequately described the systems in place for the safe disposal of medications.

Met

4.10 .5 (C) The system for disposal of unused, unwanted or expired medications is regularly monitored

Met Clinical Governance Documents/Records: Review of audit results shows that compliance checks with the policies, procedures and protocols for disposal of medicines is undertaken. Medicine Safety Documents/Records: Review of the audit records shows that the medicine disposal systems are regularly monitored.

Met

4.10 .6 (C) Action is taken to increase compliance with the system for storage, distribution and disposal of medications

Met Medicine Safety Documents/Records: Review of the improvement plan shows that action is taken to increase compliance with the system for storage, distribution and disposal of medications.

Met




Criterion: 4.11 High risk medicines The clinical workforce is supported for the prescribing, dispensing, administering, storing, manufacturing compounding and monitoring of medicines.

Identifying high-risk medicines in the organisation and ensuring they are stored, prescribed, dispensed and administered safely

Rating: Met



4.11 .1 (C) The risks for storing, prescribing, dispensing and administration of high-risk medicines are regularly reviewed

Met Clinical Governance Documents/Records: Review of audit results shows that the processes for storing, prescribing, dispensing and administration of high-risk medicines are regularly reviewed. Management Interview: Management interviewed could explain how the risks for storing, prescribing, dispensing and administration of high-risk medicines are regularly reviewed through audit processes. Medicine Safety Documents/Records: Review of the assessment records shows that regular review is conducted of the risks for storing, prescribing, dispensing and administration of high-risk medicines.

Met

4.11 .2 (C) Action is taken to reduce the risks of storing, prescribing, dispensing and administering high-risk medicines

Met Medicine Safety Documents/Records: Review of the improvement plan shows actions are taken to reduce the risks of storing, prescribing, dispensing and administering high-risk medicines.

Met

Criterion: 4.12 Current comprehensive medicines list The clinician provides a complete list of a patient’s medicines to the receiving clinician and patient when handing over care or changing medicines.

Ensuring a current comprehensive list of medicines, and the reason(s) for any change, is provided to the receiving clinician and the patient during clinical handovers

Rating: Met



4.12 .1 (C) A system is in use that generates and distributes a current and comprehensive list of medicines and explanation of changes in medicines

Met Medicine Safety Documents/Records: Review of the medication charts/medicines list shows there is a system in place for generating and distributing current and comprehensive lists of medicines and explanations of changes in medicines.

Met






4.12 .2 (C) A current and comprehensive list of medicines is provided to the patient and/or carer when concluding an episode of care

Met Consumer Interview: The consumers interviewed confirmed that they received a list of medicines when discharged.

Met

4.12 .3 (C) A current comprehensive list of medicines is provided to the receiving clinician during clinical handover

Met Clinical Documents/Records: Review of the transfer records shows that the organisation ensures that clinicians receive a current and comprehensive list of medicines during clinical handover. Review of the transfer records shows clinicians receive a current and comprehensive list of medicines during clinical handover.

Met

4.12 .4 (C) Action is taken to increase the proportion of patients and receiving clinicians that are provided with a current comprehensive list of medicines during clinical handover

Met Medicine Safety Documents/Records: Review of the improvement plans shows that actions are taken to increase the proportion of patients and receiving clinicians that are provided with a current comprehensive list of medicines during clinical handover.

Met

Criterion: 4.13 Medication treatment options The clinical workforce informs patients about their options, risks and responsibilities for an agreed medication management plan.

The clinical workforce informing patients and carers about medication treatment options, benefits and associated risks

Rating: Met



4.13 .1 (D) The clinical workforce provides patients with patient specific medicine information, including medication treatment options, benefits and associated risks

Met Clinical Interview: Clinical staff interviewed could describe the CMI and other medicines information available to support patients with medication regimes. Consumer Documents/Records: Review of consumer documentation shows patient and carer education material such as brochures, fact sheets, posters and links to trusted web sites is available.

Met

4.13 .2 (D) Information that is designed for distribution to patients is readily

Met Medicine Safety Documents/Records: Review of materials used in patient and carer education such as brochures, fact sheets,

Met






available to the clinical workforce posters and consumer medicines information is available to the clinical workforce.

Criterion: 4.14 Medication management plan The clinical workforce informs patients about their options, risks and responsibilities for an agreed medication management plan.

Developing a medication management plan in partnership with patients and carers

Rating: Met



4.14 .1 (D) An agreed medication management plan is documented and available in the patient’s clinical record

Met Clinical Documents/Records: Review of clinical records shows that patients are provided with information about new medicines. Review of clinical records shows written information was provided on new medicines and medicines to be continued by patient post-discharge. Medicine Safety Documents/Records: Review of the medication management plans shows that medication management plans are available in patient clinical records.

Met

Criterion: 4.15 Medicines information The clinical workforce informs patients about their options, risks and responsibilities for an agreed medication management plan.

Providing current medicines information to patients in a format that meets their needs whenever new medicines are prescribed or dispensed

Rating: Met



4.15 .1 (D) Information on medicines is provided to patients and carers in a format that is understood and meaningful

Met Consumer Documents/Records: Review of consumer documentation shows that information about medicines is provided to patients in a format that is understood and meaningful.

Met






Consumer Interview: Consumers interviewed confirmed that they were provided with information on their medicines and could understand what they needed to do.

4.15 .2 (D) Action is taken in response to patient feedback to improve medicines information distributed by the health service organisation to patients

Met Medicine Safety Documents/Records: Review of the consumer information provided shows that medicines information is revised following patient feedback.

Met




5 Patient Identification and Procedure Matching Criterion: 5.1 Patient identification system

At least three approved patient identifiers are used when providing care, therapy or services.

Developing, implementing and regularly reviewing the effectiveness of a patient identification system including the associated policies, procedures and/or protocols that: • define approved patient identifiers • require at least three approved patient identifiers on registration or admission • require at least three approved patient identifiers when care, therapy or other services are provided • require at least three approved patient identifiers whenever clinical handover, patient transfer or discharge documentation is generated

Rating: Met



5.1 .1 (C) Use of an organisation-wide patient identification system is regularly monitored

Met CEO Interview: The CEO could confirm that the organisation monitors the use of the patient identification system. Management Interview: Management staff interviewed could describe how the organisation monitors the use of the patient identification system through training and policy. Service Development, Delivery and Management Documents/Records: Review of the monitoring/audit results shows the use of an organisation wide patient identification system is regularly monitored.

Met

5.1 .2 (C) Action is taken to improve compliance with the patient identification matching system

Met Service Development, Delivery and Management Documents/Records: Review of the action/improvement plan shows action is taken to improve compliance with the patient identification matching system.

Met

Criterion: 5.2 Patient mismatching events At least three approved patient identifiers are used when providing care, therapy or services.

Implementing a robust organisation wide system of reporting, investigation and change management to respond to any patient care mismatching events

Rating: Met








5.2 .1 (C) The system for reporting, investigating and analysis of patient care mismatching events is regularly monitored

Met CEO Interview: The CEO could describe how the system for reporting, investigating and analysis of any patient care mismatching events is monitored and reported to the executive and Board. Clinical Governance Documents/Records: Review of the incident reports showed that the system for reporting, investigating and analysis of any patient care mismatching events is regularly monitored. Management Interview: Clinical staff interviewed could describe how the system for reporting, investigating and analysis of patient care mismatching events is monitored through constant checking of patient ID and procedure matching.

Met

5.2 .2 (C) Action is taken to reduce mismatching events

Met Risk Management Documents/Records: Review of the risk register showed that action is taken to reduce mismatching events.

Met

Criterion: 5.3 National specifications At least three approved patient identifiers are used when providing care, therapy or services.

Ensuring that when a patient identification band is used, it meets the national specifications for patient identification bands

Rating: Met



5.3 .1 (C) Inpatient bands are used that meet the national specifications for patient identification bands

Met Service Development, Delivery and Management Documents/Records: Review of policies, procedures and protocols for patient identification and procedure matching shows they are consistent with the Specifications for a Standard Patient Identification Band.

Met

Criterion: 5.4 Effective patient identification A patient’s identity is confirmed using three approved patient identifiers when transferring responsibility for care.

Developing, implementing and regularly reviewing the effectiveness of the patient identification and matching system at patient handover, transfer and discharge

Rating: Met






5.4 .1 (C) A patient identification and matching system is implemented and regularly reviewed as part of structured clinical handover, transfer and discharge processes

Met Clinical Governance Documents/Records: Review of audit results shows that the patient identification and matching checks at transfer of care is monitored and regularly reviewed. Service Development, Delivery and Management Documents/Records: Review of audit results shows a patient identification and matching system is in place and used as part of structured clinical handover, transfer and discharge processes.

Met

Criterion: 5.5 Patient procedure matching Health service organisations have explicit processes to correctly match patients with their intended care.

Developing and implementing a documented process to match patients to their intended procedure, treatment or investigation and implementing the consistent national guidelines for patient procedure matching protocol or other relevant protocols

Rating: Met



5.5 .1 (C) A documented process to match patients and their intended treatment is in use

Met Service Development, Delivery and Management Documents/Records: Review of the patient identification and procedure matching policy confirms there is a documented process in place to match patients to their intended treatment.

Met

5.5 .2 (C) The process to match patients to any intended procedure treatment or investigation is regularly monitored

Met Clinical Governance Documents/Records: Review of the monitoring/audit results shows evidence to confirm that the process to match patients to any intended procedure, treatment or investigation is regularly monitored.

Met

5.5 .3 (C) Action is taken to improve the effectiveness of the process for matching patients to their intended procedure, treatment or investigation

Met Service Development, Delivery and Management Documents/Records: Review of the improvement plan shows action is taken to improve the effectiveness of the process for matching patients to their intended procedure, treatment or investigation.

Met




6 Clinical Handover Criterion: 6.1 Clinical handover

Health service organisations implement effective clinical handover systems.

Developing and implementing an organisational system for structured clinical handover that is relevant to the healthcare setting and specialities, including: • documented policy, procedures and/ or protocols • agreed tools and guides

Rating: Met



6.1 .1 (C) Clinical handover policies, procedures and/or protocols are used by the workforce and regularly monitored

Met CEO Interview: The CEO was able to describe the process in place for the regular review of clinical handover policies, procedures and protocols. Management Interview: Management staff interviewed could describe how clinical handover policies, procedures and/or protocols are regularly monitored. Service Development, Delivery and Management Documents/Records: Review of the clinical handover policy confirms clinical handover policies, procedures and/or protocols are used by the workforce and regularly monitored.

Met

6.1 .2 (C) Action is taken to maximise the effectiveness of clinical handover policies, procedures and/or protocols

Met Service Development, Delivery and Management Documents/Records: Review of the action/improvement plan shows action is taken to maximise the effectiveness of clinical handover policies, procedures and/or protocols.

Met

6.1 .3 (C) Tools and guides are periodically reviewed

Met Service Development, Delivery and Management Documents/Records: Review of the safety and quality improvement documentation shows tools and guides are periodically reviewed to ensure they are up to date and meet the requirements of the organisation.

Met

Criterion: 6.2 Clinical handover processes Health service organisations have documented and structured clinical handover processes in place.

Establishing and maintaining structured and documented processes for clinical handover

Rating: Met






6.2 .1 (C) The workforce has access to documented structured processes for clinical handover that include: • preparing for handover, including setting the location and time while maintaining continuity of patient care • organising relevant workforce members to participate • being aware of the clinical context and patient needs • participating in effective handover resulting in transfer of responsibility and accountability for care

Met Clinical Interview: Clinical staff interviewed could describe the patient handover process. The assessors were apprised of occasions where clinical information was difficult to retrieve from Offender Health Services in prisons, where there was difficulty exchanging information between dental and medical services in the organisation and within the TB services (see recommendations 3.2.1). With the expected move to the organisations new medical record it may be possible to develop an interface between the state-wide dental record. In the northern sector, there was evidence of a breakdown in communication between the mental health team and the social and emotional wellbeing team which could jeopardise patient care. Service Development, Delivery and Management Documents/Records: Review of the clinical handover policy confirmed the workforce has access to a documented structured process for clinical handover. Improvement Opportunities Clinical Interview: It is recommended that: a) The organisation review information sharing with other agencies when appropriate - specifically Offender Health services and TB services (see 3.2.1) - and review ways to allow easier exchange of information between the organisations own records. b) The organisation review the working relationships in the northern sector between the mental health team and the social and emotional wellbeing team, to seek better patient outcomes.

Met




Criterion: 6.3 Monitoring and evaluation Health service organisations have documented and structured clinical handover processes in place.

Monitoring and evaluating the agreed structured clinical handover processes, including: • regularly reviewing local processes based on current best practice in collaboration with clinicians, patients and carers • undertaking quality improvement activities and acting on issues identified from clinical handover reviews • reporting the results of clinical handover reviews at executive level of governance

Rating: Met



6.3 .1 (C) Regular evaluation and monitoring processes for clinical handover are in place

Met Clinical Governance Documents/Records: Review of the governance audit results showed that there are regular evaluation and monitoring processes in place for clinical handover.

Met

6.3 .2 (D) Local processes for clinical handover are reviewed in collaboration with clinicians, patients and carers

Met Service Development, Delivery and Management Documents/Records: Review of the feedback documents shows local processes for clinical handover are reviewed in collaboration with clinicians, patients and carers. The nurse navigators are very useful in this area.

Met

6.3 .3 (C) Action is taken to increase the effectiveness of clinical handover

Met Service Development, Delivery and Management Documents/Records: Review of the action/improvement plan showed action is taken to increase the effectiveness of clinical handover through orientation, training and peer review audits.

Met

6.3 .4 (C) The actions taken and the outcomes of local clinical handover reviews are reported to the executive level of governance

Met Governance Documents/Records: Review of minutes of meetings showed that the outcomes and actions of local clinical handover reviews are reported to the executive level of governance.

Met

Criterion: 6.4 Reporting, investigation and change management Health service organisations have documented and structured clinical handover processes in place.

Implementing a robust organisation wide system of reporting, investigation and change management to respond to any clinical handover incidents

Rating: Met








6.4 .1 (C) Regular reporting, investigating and monitoring of clinical handover incidents is in place

Met CEO Interview: The CEO could describe the organisations process in place for regular reporting, investigating and monitoring of clinical handover processes and any incidents that occur. Clinical Interview: Clinical staff interviewed could describe the process in place for reporting, investigating and monitoring of clinical handover incidents, through "Riskman" software. Management Interview: Management staff interviewed could describe the organisations process in place for regular reporting, investigating and monitoring of clinical handover incidents. Service Development, Delivery and Management Documents/Records: Review of the incident reports showed regular reporting, investigation and monitoring of clinical handover incidents are in place.

Met

6.4 .2 (C) Action is taken to reduce the risk of an adverse clinical handover incidents

Met Service Development, Delivery and Management Documents/Records: Review of the action/improvement plan showed action is taken to reduce the risk of an adverse clinical handover incidents.

Met

Criterion: 6.5 Patient and carer involvement Health service organisations establish mechanisms to include patients and carers in clinical handover processes.

Developing and implementing mechanisms to include patients and carers in the clinical handover process that are relevant to the healthcare setting

Rating: Met



6.5 .1 (D) Mechanisms to involve a patient and, where relevant, their carer in clinical handover are in use

Met Clinical Interview: Clinical staff interviewed could describe how they involve a patient or their carer in the clinical handover process. Consumer Interview: Consumers interviewed confirmed they were provided with a report or other information

Met






when they were involved in a clinical handover but in the southern sector considered that their involvement in the process could have been more structured. Consumers interviewed confirmed they were provided with a report or other information to pass onto their usual health practitioner. Service Development, Delivery and Management Documents/Records: Review of the clinical handover policy adequately describes the systems in place for involving patients in the clinical handover process. Improvement Opportunities Clinical Interview: Recommend that the organisation review the transfer processes to ensure that the patient or carer are better involved in the process where it is appropriate.




7 Blood and Blood Products Criterion: 7.1 Governance systems

Health service organisations have systems in place for the safe and appropriate prescribing and clinical use of blood and blood products.

Developing, governance systems for safe and appropriate prescription, administration and management of blood and blood products

Rating: Met



7.1 .1 (C) Blood and blood product policies, procedures and/or protocols are consistent with national evidence-based guidelines for pre-transfusion practices, prescribing and clinical use of blood and blood products

Met Blood and Blood Products Documents/Records: Review of the blood/blood product policies and procedures confirmed that they are aligned to the national Blood Management Guidelines. CEO Interview: The CEO could describe how the organisation ensures that blood and blood product policies, procedures and protocols are consistent with national evidence-based guidelines. Management Interview: Management staff interviewed could describe how the organisation ensures that all blood and blood product policies, procedures and/or protocols are consistent with national evidence-based guidelines.

Met


Met Blood and Blood Products Documents/Records: Review of the blood/blood product policies and procedures showed evidence of review and monitoring.

Met

7.1 .3 (C) Action is taken to increase the safety and appropriateness of prescribing and clinically using blood and blood products

Met Blood and Blood Products Documents/Records: Review of the haemovigilence committee minutes showed evidence of actions taken to increase the safety and appropriateness of blood/blood products management.

Met

Criterion: 7.2 System assessment Health service organisations have systems in place for the safe and appropriate prescribing and clinical use of blood and blood products.

Undertaking a regular, comprehensive assessment of blood and blood product systems to identify risks to patient safety and taking action to reduce risks

Rating: Met






7.2 .1 (C) The risks associated with transfusion practices and clinical use of blood and blood products are regularly assessed

Met Clinical Governance Documents/Records: Review of the clinical governance structures showed that risks are identified and that the practices associated with blood/blood product transfusion are regularly assessed and revised to comply with national standards. Risk Management Documents/Records: Review of audit results shows that the risks associated with transfusion practices and clinical use of blood and blood products are regularly assessed.

Met

7.2 .2 (C) Action is taken to reduce the risks associated with transfusion practices and the clinical use of blood and blood products

Met Blood and Blood Products Documents/Records: Review of the organisations documents confirmed that actions are taken to reduce risks associated with blood/blood product transfusion practices.

Met

Criterion: 7.3 Adverse events Health service organisations have systems in place for the safe and appropriate prescribing and clinical use of blood and blood products.

Ensuring blood and blood product adverse events are included in the incidents management and investigation system

Rating: Met



7.3 .1 (C) Reporting on blood and blood product incidents is included in regular incident reports

Met Blood and Blood Products Documents/Records: Review of the incident reports showed that any incidents concerning blood/blood products are reported through the regular incident reporting system. CEO Interview: The CEO could describe how any incidents related to blood and blood products are managed and reported to senior staff and the Board. Clinical Governance Documents/Records: Review of incident reports and procedures shows that any blood and blood product incidents are included in the incident reports.

Met






Management Interview: Management staff interviewed could describe the reporting process for any blood and blood product incidents. Met With Merit CEO Interview: The organisation reported that the only occasions of loss of blood and blood products occurred as a result of factors beyond their control. This is to be commended for an organisation that is providing services in remote areas.

7.3 .2 (C) Adverse blood and blood product incidents are reported to and reviewed by the highest level of governance in the health service organisation

Met Blood and Blood Products Documents/Records: Review of the meeting minutes showed adverse blood and blood product incidents are reported and reviewed by the highest level of governance.

Met

7.3 .3 (C) Health service organisations participate in relevant haemovigilance activities conducted by the organisation or at state or national level

Met Blood and Blood Products Documents/Records: Review of the reports confirmed that the organisation participates in the relevant haemovigilance activities at the state and national level.

Met

Criterion: 7.4 Quality improvement activities Health service organisations have systems in place for the safe and appropriate prescribing and clinical use of blood and blood products.

Undertaking quality improvement activities to improve the safe management of blood and blood products

Rating: Met



7.4 .1 (C) Quality improvement activities are undertaken to reduce the risks of patient harm from transfusion practices and the clinical use of blood and blood products

Met Blood and Blood Products Documents/Records: Review of the policies and procedure shows evidence of actions taken to reduce risks of patient harm related to blood/blood product management, including specific pathways for services provided without laboratory support.

Met




Criterion: 7.5 Patient treatment plan The clinical workforce accurately records a patient’s blood and blood product transfusion history and indications for use of blood and blood products.

As part of the patients treatment plan, the clinical workforce accurately documenting: • relevant medical conditions • indications for transfusion • any special product or transfusion requirements • known patient transfusion history type and volume of product transfusion patient response to transfusion

Rating: Met



7.5 .1 (C) A best possible history of blood product usage and relevant clinical and product information is documented in the patient clinical record

Met Blood and Blood Products Documents/Records: Review of the assessment records showed that blood product usage is documented in the patient clinical record. Clinical Documents/Records: Review of the clinical records shows that appropriate blood product usage is documented in the patient clinical record.

Met

7.5 .2 (C) The patient clinical records of transfused patients are periodically reviewed to assess the proportion of records completed

Met Clinical Documents/Records: Review of the audit results shows that the clinical records of transfused patients are reviewed to determine the proportion of records satisfactorily completed.

Met

7.5 .3 (C) Action is taken to increase the proportion of patient clinical records of transfused patients with a complete patient clinical record

Met Blood and Blood Products Documents/Records: Review of the policies and procedures confirmed that actions are taken to assess the proportion of appropriately completed patient clinical records for transfused patients. Clinical Documents/Records: Review of quality improvement plan shows actions taken to improve the transfusion records. Review of quality improvement plan shows actions to address issues identified and evidence of activities that have been implemented and evaluated.

Met




Criterion: 7.6 Documenting adverse reactions The clinical workforce accurately records a patient’s blood and blood product transfusion history and indications for use of blood and blood products.

The clinical workforce documenting any adverse reactions to blood or blood products

Rating: Met



7.6 .1 (C) Adverse reactions to blood or blood products are documented in the patient clinical record

Met Clinical Documents/Records: Review of the records shows that any adverse reactions to blood and blood products are recorded in the patient clinical record.

Met

7.6 .2 (C) Action is taken to reduce the risk of adverse events from administering blood or blood products

Met Blood and Blood Products Documents/Records: Review of the policies and procedures showed the actions taken to reduce the risks of adverse events resulting from the administration of blood/blood products.

Met

7.6 .3 (C) Adverse events are reported internally to the appropriate governance level and externally to the pathology service provider, blood service or product manufacturer whenever appropriate

Met Blood and Blood Products Documents/Records: Review of the incident reporting system shows that any adverse events are reported to the appropriate level of authority. Governance Documents/Records: Review of the governance reports shows that any adverse events are reported to the appropriate level of authority.

Met

Criterion: 7.7 Receipt, storage, collection and transport Health services organisations have systems to receive, store, transport and monitor wastage of blood and blood products safely and efficiently.

Ensuring the receipt, storage, collection and transport of blood and blood products within the organisation are consistent with best practice and/or guidelines

Rating: Met



7.7 .1 (C) Regular review of the risks associated with receipt, storage, collection and transport of blood and blood products is undertaken

Met Clinical Governance Documents/Records: Review of risk assessments shows that the risks associated with the blood management process are regularly reviewed.

Met

7.7 .2 (C) Action is taken to reduce the risk of incidents arising from the use of blood

Met Blood and Blood Products Documents/Records: Review of the incident management system shows that actions are taken to reduce the

Met






and blood product control systems risks of any incidents arising from the use of blood/blood product control systems.

Criterion: 7.8 Minimising unnecessary wastage Health services organisations have systems to receive, store, transport and monitor wastage of blood and blood products safely and efficiently.

Minimising unnecessary wastage of blood and blood products

Rating: Met



7.8 .1 (C) Blood and blood product wastage is regularly monitored

Met Clinical Governance Documents/Records: Review of the monitoring results shows that any blood and blood product wastage is reviewed and investigated.

Met

7.8 .2 (C) Action is taken to minimise wastage of blood and blood products

Met Blood and Blood Products Documents/Records: The only wastage has occurred from equipment problems or transport issues, not as a result of inadequate management of supplies and stores. Met With Merit Blood and Blood Products Documents/Records: The organisation is to be commended for the fact that there has been no blood wastage through inadequate management, despite providing services in remote areas.

Met

Criterion: 7.9 Informing patients and carers Patients and carers are informed about the risks and benefits of using blood and blood products and about the available alternatives when a plan for treatment is developed.

The clinical workforce informing patients and carers about blood and blood product treatment options, and the associated risks and benefits

Rating: Met








7.9 .1 (C) Patient information relating to blood and blood products, including risks, benefits and alternatives, is available for distribution by the clinical workforce

Met Clinical Interview: Clinical staff interviewed could describe examples of blood/blood products information provided to patients. Consumer Documents/Records: Review of consumer documents shows that brochures, fact sheets and posters available are provided in plain language.

Met

7.9 .2 (D) Plans for care that include the use of blood and blood products are developed in partnership with patients and carers

Met Blood and Blood Products Documents/Records: Review of the blood management process shows that consultation with patients is undertaken to plan and deliver effective treatment.

Met

Criterion: 7.10 Patient information Patients and carers are informed about the risks and benefits of using blood and blood products and about the available alternatives when a plan for treatment is developed.

Providing information to patients about blood and blood product use and possible alternatives in a format that can be understood by patients and carers

Rating: Met



7.10 .1 (D) Information on blood and blood products is provided to patients and their carers in a format that is understood and meaningful

Met Consumer Documents/Records: Review of the information supplied confirmed that meaningful blood and blood products information is provided to patients and their carers in a way that is understood.

Met

Criterion: 7.11 Informed consent Patients and carers are informed about the risks and benefits of using blood and blood products and about the available alternatives when a plan for treatment is developed.

Implementing an informed consent process for all blood and blood product use

Rating: Met








7.11 .1 (D) Informed consent is undertaken and documented for all transfusions of blood or blood products in accordance with the informed consent policy of the health service organisation

Met Blood and Blood Products Documents/Records: Review of the patient records shows that informed consent is collected and recorded for all transfusions of blood and blood products when clinically possible. Clinical Documents/Records: Review of the informed consent records showed informed consent is collected and recorded for all transfusions of blood and blood products. Clinical Interview: Clinical staff interviewed could describe the process involved in obtaining informed consent from patients prior to transfusion.

Met




8 Preventing and Managing Pressure Injuries Criterion: 8.1 Policies, procedures and/or protocols

Developing and implementing policies, procedures and/or protocols that are based on current best practice guidelines

Rating: Met



8.1 .1 (C) Policies, procedures and/or protocols are in use that are consistent with best practice guidelines and incorporate screening and assessment tools

Met Service Development, Delivery and Management Documents/Records: Review of the pressure injury prevention policy adequately described the systems in place for screening and assessing pressure injury risk.

Met

8.1 .2 (C) The use of policies, procedures and/or protocols are regularly monitored

Met Service Development, Delivery and Management Documents/Records: Review of the monitoring/audit results showed policy, procedure and/or protocol use is regularly monitored.

Met

Criterion: 8.2 Risk assessment framework Using a risk assessment framework and reporting systems to identify, investigate and take action to reduce the frequency and severity of pressure injuries

Rating: Met



8.2 .1 (C) An organisation-wide system for reporting pressure injuries is in use

Met CEO Interview: The CEO could describe the system for reporting pressure injuries, including the use of standardised tools for skin assessment. Clinical Interview: Clinical staff interviewed could describe the process in place across the organisation for reporting pressure injuries. Service Development, Delivery and Management Documents/Records: Review of the incident reports showed an organisation-wide system for reporting pressure injuries is in use.

Met

8.2 .2 (C) Administrative and clinical data are used to regularly monitor and investigate the frequency and severity of pressure

Met Clinical Governance Documents/Records: Review of the pressure injury reports showed that pressure injury data is used to monitor and investigate the frequency and severity of pressure injuries.

Met






injuries

8.2 .3 (C) Information on pressure injuries is regularly reported to the highest level of governance in the health service organisation

Met Governance Documents/Records: Review of the minutes of meetings showed that information on pressure injuries is regularly reported to the highest level of governance.

Met

8.2 .4 (C) Action is taken to reduce the frequency and severity of pressure injuries

Met Service Development, Delivery and Management Documents/Records: Review of the action/improvement plan showed evidence of actions taken to reduce the frequency and severity of pressure injuries through orientation and on-going training, reporting of pressure injuries and assessment prior to transfer of patients.

Met

Criterion: 8.3 Quality improvement activities Undertaking quality improvement activities to address safety risks and monitor the systems that prevent and manage pressure injuries

Rating: Met



8.3 .1 (C) Quality improvement activities are undertaken to prevent pressure injuries and/or improve the management of pressure injuries

Met Clinical Interview: Clinical staff interviewed could describe activities that are undertaken to prevent pressure injuries and/or improve the management of pressure injuries. Service Development, Delivery and Management Documents/Records: Review of the action/improvement plan showed evidence of actions taken to improve pressure injury management through audits and pre-transfer assessments.

Met

Criterion: 8.4 Equipment and devices Providing or facilitating access to equipment and devices to implement effective prevention strategies and best practice management plans

Rating: Met



8.4 .1 (C) Equipment and devices are available to effectively implement prevention

Met Clinical Interview: The nursing staff interviewed could describe the pressure injury prevention equipment

Met






strategies for patients at risk and plans for the management of patients with pressure injuries

available. Facilities and Equipment: Observation of the pressure management devices/equipment shows they are available for staff to access.

Criterion: 8.5 Identifying risk factors Patients are screened on presentation and pressure injury prevention strategies are implemented when clinically indicated.

Identifying risk factors for pressure injuries using an agreed screening tool for all presenting patients within timeframes set by best practice guidelines

Rating: Met



8.5 .1 (C) An agreed tool to screen for pressure injury risk is used by the clinical workforce to identify patients at risk of a pressure injury

Met Clinical Documents/Records: Review of the patient records showed that the clinical workforce is using a screening tool to identify patients at risk of pressure injuries.

Met

8.5 .2 (C) The use of the screening tool is monitored to identify the proportion of at-risk patients that are screened for pressure injuries on presentation

Met Clinical Documents/Records: Review of the monitoring/audit results showed the use of the screening tool is monitored to determine the proportion of patients screened for pressure injury on presentation.

Met

8.5 .3 (C) Action is taken to maximise the proportion of patients who are screened for pressure injury on presentation

Met Service Development, Delivery and Management Documents/Records: Review of the action/improvement plan showed evidence of actions taken to increase the proportion of patients screened for pressure injury on presentation when newly presented to the service and when transferred patients out and back into the service.

Met

Criterion: 8.6 Conducting skin inspections Patients are screened on presentation and pressure injury prevention strategies are implemented when clinically indicated.

Conducting a comprehensive skin inspection in timeframes set by best practice guidelines on patients with a high risk of developing pressure injuries at presentation, regularly as clinically indicated during a patient's admission, and before discharge

Rating: Met






8.6 .1 (C) Comprehensive skin inspections are undertaken using an agreed assessment tool and documented in the patient clinical record for patients at risk of pressure injuries

Met Clinical Documents/Records: Review of the clinical records notes showed comprehensive skin inspections are undertaken and documented for patients at risk of pressure injuries.

Met

8.6 .2 (C) Patient clinical records, transfer and discharge documentation are periodically audited to identify at-risk patients with documented skin assessments

Met Clinical Governance Documents/Records: Review of audit results shows that patient clinical records, transfer and discharge documentation are periodically audited to identify at-risk patients with documented skin assessments. Service Development, Delivery and Management Documents/Records: Review of the monitoring/audit results showed patient clinical records are being monitored to determine the proportion of skin assessments on patients at risk of pressure injuries.

Met

8.6 .3 (C) Action is taken to increase the proportion of skin assessments documented on patients at risk of pressure injuries

Met Service Development, Delivery and Management Documents/Records: Review of the action/improvement plan showed evidence of actions taken to increase the proportion of skin assessments documented on patients at risk of pressure injuries.

Met

Criterion: 8.7 Implementing and monitoring pressure injury prevention plans Patients are screened on presentation and pressure injury prevention strategies are implemented when clinically indicated.

Implementing and monitoring pressure injury prevention plans and reviewing when clinically indicated

Rating: Met



8.7 .1 (C) Prevention plans for all patients at risk of a pressure injury are consistent with best practice guidelines and are documented in the patient clinical record

Met Clinical Documents/Records: Review of the pressure injury prevention plans showed consistency with best practice guidelines.

Met






8.7 .2 (C) The effectiveness and appropriateness of pressure injury prevention plans are regularly reviewed

Met Clinical Documents/Records: Review of the pressure injury prevention plans showed that the effectiveness and appropriateness is regularly reviewed.

Met

8.7 .3 (D) Patient clinical records are monitored to determine the proportion of at-risk patients that have an implemented pressure injury prevention plan

Met Clinical Documents/Records: Review of the monitoring/audit results showed patient clinical records are being monitored to determine the proportion of implemented prevention plans for patients at risk of pressure injuries.

Met

8.7 .4 (D) Action is taken to increase the proportion of patients at risk of pressure injuries who have an implemented prevention plan

Met Service Development, Delivery and Management Documents/Records: Review of the action/improvement plan showed evidence of actions taken to increase the proportion of implemented prevention plans for patients at risk of pressure injuries.

Met

Criterion: 8.8 Implementing best practice management Patients who have pressure injuries are managed according to best practice guidelines.

Implementing best practice management and ongoing monitoring as clinically indicated

Rating: Met



8.8 .1 (D) An evidence-based wound management system is in place within the health service organisation

Met Service Development, Delivery and Management Documents/Records: Review of the wound management policy adequately described the evidence based wound management systems in place.

Met

8.8 .2 (D) Management plans for patients with pressure injuries are consistent with best practice and documented in the patient clinical record

Met Clinical Documents/Records: Review of clinical records shows management plans for patients with pressure injuries are in place. Service Development, Delivery and Management Documents/Records: Review of the pressure injury management tool showed consistency with best practice guidelines and evidence to confirm management plans are documented in the patient clinical record.

Met

8.8 .3 (D) Patient clinical records are monitored to determine compliance with evidence-

Met Clinical Documents/Records: Review of the monitoring/audit results showed compliance with pressure injury

Met






based pressure injury management plans

management plans is monitored.

8.8 .4 (D) Action is taken to increase compliance with evidence based pressure injury management plans

Met Service Development, Delivery and Management Documents/Records: Review of the action/improvement plan showed evidence of actions taken to increase compliance with evidence-based pressure injury management plans through staff orientation, on-going training and assessment through peer review.

Met

Criterion: 8.9 Informing patients Patients and carers are informed of the risks, prevention strategies and management of pressure injuries.

Informing patients with a high risk of pressure injury, and their carers, about the risks, prevention strategies and management of pressure injuries

Rating: Met



8.9 .1 (D) Patient information on prevention and management of pressure injuries is provided to patients and carers in a format that is understood and is meaningful

Met Consumer Documents/Records: Review of the information supplied confirmed that meaningful prevention and management of pressure injuries products information is provided to patients and their carers.

Met

Criterion: 8.10 Management plan Patients and carers are informed of the risks, prevention strategies and management of pressure injuries.

Developing a plan of management in partnership with patients and carers

Rating: Met



8.10 .1 (D) Pressure injury management plans are developed in partnership with patients and carers

Met Service Development, Delivery and Management Documents/Records: Review of the pressure injury management plan showed consultation with patients.

Met




9 Recognising and Responding to Clinical Deterioration in Acute Health Care Criterion: 9.1 Effectiveness of governance arrangements

Organisation-wide systems consistent with the National Consensus Statement are used to support and promote recognition of, and response to, patients whose condition deteriorates in an acute health care facility.

Developing, implementing and regularly reviewing the effectiveness of governance arrangements and the policies, procedures and/or protocols that are consistent with the requirements of the National Consensus Statement

Rating: Met



9.1 .1 (C) Governance arrangements are in place to support the development, implementation, and maintenance of organisation-wide recognition and response systems

Met CEO Interview: The CEO could describe the organisation supports the development, implementation, and maintenance of organisation-wide recognition and response systems. HRM Documents/Records: Review of position descriptions shows a person has responsibility for development, implementation and ongoing maintenance of organisation-wide recognition and response systems. Management Interview: Clinical staff interviewed could describe how staff are educated to identify and respond to clinical deterioration.

Met

9.1 .2 (C) Policies, procedures and/or protocols for the organisation are implemented in areas such as: • measurement and documentation of observations • escalation of care • establishment of a rapid response system • communication about clinical deterioration

Met Service Development, Delivery and Management Documents/Records: Review of the clinical deterioration policy adequately described the systems in place for the documentation of observations, communication about deterioration along with a rapid response system to escalate care when required. Review of the clinical deterioration policy adequately described the systems in place for: Measurement and documentation of observation, Establishment of rapid response system and Communication about clinical deterioration.

Met




Criterion: 9.2 Collecting information Organisation-wide systems consistent with the National Consensus Statement are used to support and promote recognition of, and response to, patients whose condition deteriorates in an acute health care facility.

Collecting information about the recognition and response systems, providing feedback to the clinical workforce, and tracking outcomes and changes in performance over time

Rating: Met



9.2 .1 (C) Feedback is actively sought from the clinical workforce on the responsiveness of the recognition and response systems

Met Clinical Governance Documents/Records: Review of the staff reports showed that the clinical workforce feedback is sought on the responsiveness and effectiveness of the clinical deterioration recognition and response systems.

Met

9.2 .2 (C) Deaths or cardiac arrests for a patient without an agreed treatment-limiting order (such as not for resuscitation or do not resuscitate) are reviewed to identify the use of the recognition and response systems, and any failures in these systems

Met CEO Interview: The CEO could describe the systems in place to review deaths or cardiac arrests for a patient without an agreed treatment-limiting order, including the review to identify the use of the recognition and response systems, and any failures in these systems. Clinical Governance Documents/Records: Review of audit results shows that any unexpected death of a patient is reviewed to identify the use and effectiveness of the recognition and response systems. Service Development, Delivery and Management Documents/Records: Review of policies, procedures and protocols describe processes for collecting data on deaths and cardiac arrests.

Met

9.2 .3 (C) Data collected about recognition and response systems are provided to the clinical workforce as soon as practicable

Met Clinical Interview: Clinical staff interviewed could provide examples of feedback about the management of clinical deterioration that they have received. Service Development, Delivery and Management Documents/Records: Review of the clinical deterioration investigations/reviews/reports indicated that the data collected about recognition and response systems is provided to the clinical workforce as soon as practical.

Met






9.2 .4 (C) Action is taken to improve the responsiveness and effectiveness of the recognition and response systems

Met Service Development, Delivery and Management Documents/Records: Review of the action/improvement plan showed evidence of actions taken to improve responsiveness and effectiveness of the recognition and response systems.

Met

Criterion: 9.3 Implementing mechanisms Patients whose condition is deteriorating are recognised and appropriate action is taken to escalate care.

Implementing mechanism(s) for recording physiological observations that incorporates triggers to escalate care when deterioration occurs

Rating: Met



9.3 .1 (D) When using a general observation chart, ensure that it: • is designed according to human factors principles • includes the capacity to record information about respiratory rate, oxygen saturation, heart rate, blood pressure, temperature and level of consciousness that is recorded graphically over time • includes thresholds for each physiological parameter or combination of parameters that indicate abnormality • specifies the physiological abnormalities and other factors that trigger the escalation of care • includes actions required when care is escalated

Met Service Development, Delivery and Management Documents/Records: Review of the observation record provided confirmed that it complies with the requirements for observation charts as set out in the NSQHS Standards.

Met

9.3 .2 (C) Mechanisms for recording physiological observations are regularly audited to determine the proportion of patients that have complete sets of observations

Met Clinical Governance Documents/Records: Review of audit results shows that the recordings of physiological observations are regularly undertaken and the results used for training and education purposes for the staff.

Met






recorded in agreement with their monitoring plan

Service Development, Delivery and Management Documents/Records: Review of the audit results showed observation tools are monitored to determine the proportion of patient clinical records of observation as specified in the patient's monitoring plan.

9.3 .3 (C) Action is taken to increase the proportion of patients with complete sets of recorded observations, as specified in the patient's monitoring plan

Met Service Development, Delivery and Management Documents/Records: Review of the action/improvement plan showed evidence of actions taken to increase proportion of patient clinical records of observation as specified in the patient's monitoring plan.

Met

Criterion: 9.4 Mechanisms to escalate care Patients whose condition is deteriorating are recognised and appropriate action is taken to escalate care.

Developing and implementing mechanisms to escalate care and call for emergency assistance where there are concerns that a patient's condition is deteriorating

Rating: Met



9.4 .1 (C) Mechanisms are in place to escalate care and call for emergency assistance

Met Clinical Interview: Clinical staff interviewed could describe the appropriate actions taken to escalate the level of care if a patient was deteriorating clinically. Facilities and Equipment: Observation of facilities shows mechanisms such as signs, posters, or stickers describing how to call for assistance are in place. Service Development, Delivery and Management Documents/Records: Review of policies, procedures and protocols describe the process for escalation of care.

Met

9.4 .2 (C) Use of escalation processes, including failure to act on triggers for seeking emergency assistance, are regularly audited

Met Clinical Governance Documents/Records: Review of audit results shows that the use and effectiveness of escalation processes are reviewed.

Met






Service Development, Delivery and Management Documents/Records: Review of the monitoring/audit results showed the use of the escalation process is regularly audited.

9.4 .3 (C) Action is taken to maximise the appropriate use of escalation processes

Met Service Development, Delivery and Management Documents/Records: Review of the action/improvement plan shows evidence of actions taken to increase the appropriate use of escalation processes.

Met

Criterion: 9.5 Responding to clinical deterioration Appropriate and timely care is provided to patients whose condition is deteriorating.

Using the system in place to ensure that specialised and timely care is available to patients whose condition is deteriorating

Rating: Met



9.5 .1 (C) Criteria for triggering a call for emergency assistance are included in the escalation policies, procedures and/or protocols

Met Service Development, Delivery and Management Documents/Records: Review of the emergency call policy adequately described the systems in place for triggering a call for emergency assistance.

Met

9.5 .2 (C) The circumstances and outcome of calls for emergency assistance are regularly reviewed

Met Clinical Governance Documents/Records: Review of the monitoring results showed that emergency calls, including the circumstances and outcome, are regularly reviewed.

Met

Criterion: 9.6 Clinical workforce Appropriate and timely care is provided to patients whose condition is deteriorating.

Having a clinical workforce that is able to respond appropriately when a patient's condition is deteriorating

Rating: Met



9.6 .1 (C) The clinical workforce is trained and proficient in basic life support

Met HRM Documents/Records: Review of the CPR certificates found that they are current certificates and that the clinical workforce are trained in basic life support.

Met






9.6 .2 (C) A system is in place for ensuring access at all times to at least one clinician, either on-site or in close proximity, who can practise advanced life support

Met Clinical Interview: Clinical staff interviewed could describe the services policy related to the availability of clinicians able to perform CPR/ALS and indicated that there is a qualified person available at all times.

Met

Criterion: 9.7 Informing patients, families and carers Patients, families and carers are informed of recognition and response systems and can contribute to the processes of escalating care.

Ensuring patients, families and carers are informed about, and are supported so that they can participate in, recognition and response systems and processes

Rating: Met



9.7 .1 (D) Information is provided to patients, families and carers in a format that is understood and meaningful. The information should include: • the importance of communicating concerns and signs/symptoms of deterioration, which are relevant to the patient's condition, to the clinical workforce • local systems for responding to clinical deterioration, including how they can raise concerns about potential deterioration

Met Consumer Documents/Records: Review of consumer documents confirmed that information about how to handle clinical deterioration is available to patients, and their carers, in a way that is understood. Consumer Interview: Consumers/patients interviewed indicated that they were provided with information about communicating concerns and signs/symptoms of deterioration.

Met

Criterion: 9.8 Advance care plans and treatment-limiting orders Patients, families and carers are informed of recognition and response systems and can contribute to the processes of escalating care.

Ensuring that information about advance care plans and treatment-limiting orders is in the patient clinical record, where appropriate

Rating: Met






9.8 .1 (D) A system is in place for preparing and/or receiving advance care plans in partnership with patients, families and carers

Met Clinical Interview: Clinical staff interviewed could describe how they identify a patient who has an advanced care plan or treatment limiting order. Service Development, Delivery and Management Documents/Records: Review of the advance care planning or treatment limiting order policy adequately described the systems in place for preparing and/or receiving advance care plans in partnership with patients, families and carers.

Met

9.8 .2 (D) Advance care plans and other treatment-limiting orders are documented in the patient clinical record

Met Clinical Documents/Records: Review of clinical record shows that advance care plans or treatment limiting orders are documented.

Met

Criterion: 9.9 Enabling patients, families and carers Patients, families and carers are informed of recognition and response systems and can contribute to the processes of escalating care.

Enabling patients, families and carers to initiate an escalation of care response

Rating: Met



9.9 .1 (D) Mechanisms are in place for a patient, family member or carer to initiate an escalation of care response

Met Clinical Interview: Clinical staff interviewed could describe how patients and carers are equipped to initiate escalation of care. Service Development, Delivery and Management Documents/Records: Review of the clinical deterioration/escalation policy adequately described the systems in place for a patient, family member or carer to initiate an escalation of care response.

Met

9.9 .2 (D) Information about the system for family escalation of care is provided to patients, families and carers

Met Consumer Documents/Records: Review of the consumer documentation confirmed that information about escalation of care is available for patients and their carers. Consumer Interview:

Met






Consumers interviewed indicated that they were provided with information on how to raise alarm if they felt something was wrong following their treatment.

9.9 .3 (D) The performance and effectiveness of the system for family escalation of care is periodically reviewed

Met Clinical Governance Documents/Records: Review of the monitoring results showed that the process for a family to escalate care is regularly reviewed.

Met

9.9 .4 (D) Action is taken to improve the system performance for family escalation of care

Met Service Development, Delivery and Management Documents/Records: Review of the action/improvement plan showed evidence of actions taken to improve the system performance for family escalation of care.

Met




10 Preventing Falls and Harm from Falls Criterion: 10.1 Policies, procedures and/or protocols

Health service organisations have governance structures and systems in place to reduce falls and minimise harm from falls.

Developing, implementing and reviewing policies, procedures and/or protocols, including the associated tools, that are based on the current national guidelines for preventing falls and harm from falls

Rating: Met



10.1 .1 (C) Policies, procedures and/or protocols are in use that are consistent with best practice guidelines (where available) and incorporate screening and assessment tools

Met Service Development, Delivery and Management Documents/Records: Review of the falls prevention policy showed consistency with the best practice guidelines and adequately described the systems in place for screening and assessing patients at risk of falls.

Met


Met Clinical Governance Documents/Records: Review of the audit results confirmed policies, procedures and protocols are regularly monitored and revised as required. Management Interview: Management staff interviewed could describe how policies, procedures and/or protocols are regularly monitored.

Met

Criterion: 10.2 Reporting, investigation and change management Health service organisations have governance structures and systems in place to reduce falls and minimise harm from falls.

Using a robust organisation-wide system of reporting, investigation and change management to respond to falls incidents

Rating: Met



10.2 .1 (C) Regular reporting, investigating and monitoring of falls incidents is in place

Met Clinical Governance Documents/Records: Review of the incident reports showed that incidents relating to falls are regularly reported, investigated and monitored with the results provided to the workforce. Clinical Interview:

Met






Clinical staff interviewed could describe the systems in place for reporting, investigating and monitoring of falls incidents.

10.2 .2 (C) Administrative and clinical data are used to monitor and investigate regularly the frequency and severity of falls in the health service organisation

Met Clinical Governance Documents/Records: Review of the falls incident reports showed that the data is used to monitor and investigate the frequency and severity of falls.

Met

10.2 .3 (C) Information on falls is reported to the highest level of governance in the health service organisation

Met Board Interview: Board members interviewed could describe the information that the board routinely receives concerning falls. CEO Interview: The CEO confirmed that reports regarding the investigating and monitoring of falls incidents are sent to senior management and the Board. Governance Documents/Records: Review of the meeting minutes showed that information on falls is reported to the highest level of governance.

Met

10.2 .4 (C) Action is taken to reduce the frequency and severity of falls in the health service organisation

Met Service Development, Delivery and Management Documents/Records: Review of the falls prevention program/falls prevention quality activities shows action is taken to reduce falls frequency and severity.

Met

Criterion: 10.3 Quality improvement activities Health service organisations have governance structures and systems in place to reduce falls and minimise harm from falls.

Undertaking quality improvement activities to address safety risks and ensure the effectiveness of the falls prevention system

Rating: Met



10.3 .1 (C) Quality improvement activities are undertaken to prevent falls and minimise patient harm

Met Clinical Interview: Clinical staff interviewed could describe activities that are undertaken to prevent falls and minimise patient harm.

Met






Service Development, Delivery and Management Documents/Records: Review of the action/improvement plan showed evidence of actions taken to prevent falls and minimise patient harm.

Criterion: 10.4 Falls prevention plans Health service organisations have governance structures and systems in place to reduce falls and minimise harm from falls.

Implementing falls prevention plans and effective management of falls

Rating: Met



10.4 .1 (C) Equipment and devices are available to implement prevention strategies for patients at risk of falling and management plans to reduce the harm from falls

Met Clinical Interview: Clinical staff interviewed could describe what equipment and resources are available to minimise the risk of falls for patients at risk of falling. Facilities and Equipment: Observation of the falls prevention equipment/devices shows they are available to implement prevention strategies for patients at risk of falling and management plans to reduce the harm from falls.

Met

Criterion: 10.5 Screening tools Patients on presentation, during admission, and when clinically indicated, are screened for risk of a fall and the potential to be harmed from falls.

Using a best practice-based tool to screen patients on presentation, during admission and when clinically indicated for the risk of falls

Rating: Met



10.5 .1 (C) A best practice screening tool is used by the clinical workforce to identify the risk of falls

Met Clinical Interview: Clinical staff interviewed could describe the tools used for screening patients who may be at risk of falling, on admission as well as on review later in the period of admission. Service Development, Delivery and Management Documents/Records:

Met






Review of the falls risk screening tool shows evidence of use by the clinical workforce to identify the risks of falls.

10.5 .2 (C) Use of the screening tool is monitored to identify the proportion of at-risk patients that were screened for falls

Met Clinical Governance Documents/Records: Review of the audit results shows that the use of a screening tool to identify the proportion of at-risk patients is monitored.

Met

10.5 .3 (C) Action is taken to increase the proportion of at-risk patients who are screened for falls upon presentation and during admission

Met Service Development, Delivery and Management Documents/Records: Review of the action/improvement plan shows evidence of actions taken to increase the proportion of at-risk patients being screened for falls during admission.

Met

Criterion: 10.6 Risk assessment Patients on presentation, during admission, and when clinically indicated, are screened for risk of a fall and the potential to be harmed from falls.

Conducting a comprehensive risk assessment for patients identified at risk of falling in initial screening processes

Rating: Met



10.6 .1 (C) A best practice assessment tool is used by the clinical workforce to assess patients at risk of falling

Met Clinical Interview: Clinical staff interviewed could describe what risk assessment tools they use for patients identified as being at risk of falling. Service Development, Delivery and Management Documents/Records: Review of the falls risk assessment tool shows evidence of use by the clinical workforce to assess patients at risk of falling.

Met

10.6 .2 (C) The use of the assessment tool is monitored to identify the proportion of at-risk patients with a completed falls assessment

Met Clinical Governance Documents/Records: Review of the audit results showed that the use of an assessment tool is monitored to identify the proportion of at-risk patients who have had a completed falls assessment.

Met

10.6 .3 (C) Action is taken to increase the proportion of at-risk patients undergoing a comprehensive falls risk assessment

Met Service Development, Delivery and Management Documents/Records: Review of the improvement plan showed evidence of actions taken to increase the proportion of at-risk patients undergoing a comprehensive falls risk assessment.

Met




Criterion: 10.7 Multifactorial falls prevention plan Prevention strategies are in place for patients at risk of falling.

Developing and implementing a multifactorial falls prevention plan to address risks identified in the assessment

Rating: Met



10.7 .1 (C) Use of best practice multifactorial falls prevention and harm minimisation plans is documented in the patient clinical record

Met Clinical Documents/Records: Review of patient clinical records show falls management plans are documented. Clinical Interview: Clinical staff interviewed could describe the tools/processes they use when developing and documenting falls prevention plans.

Met

10.7 .2 (C) The effectiveness and appropriateness of the falls prevention and harm minimisation plan are regularly monitored

Met Clinical Governance Documents/Records: Review of the clinical governance processes showed that the effectiveness and appropriateness of falls prevention plans is monitored.

Met

10.7 .3 (C) Action is taken to reduce falls and minimise harm for at-risk patients

Met Service Development, Delivery and Management Documents/Records: Review of multifactorial falls prevention plans showed action is taken to reduce falls and minimise harm for at-risk patients.

Met

Criterion: 10.8 Referrals Prevention strategies are in place for patients at risk of falling.

Patients at risk of falling are referred to appropriate services, where available, as part of the discharge process

Rating: Met



10.8 .1 (C) Discharge planning includes referral to appropriate services, where available

Met Service Development, Delivery and Management Documents/Records: Review of the discharge records showed evidence of referral to appropriate services, where applicable.

Met




Criterion: 10.9 Informing patients and carers Patients and carers are informed of the identified risks from falls and are engaged in the development of a falls prevention plan.

Informing patients and carers about the risk of falls, and falls prevention strategies

Rating: Met



10.9 .1 (D) Patient information on falls risks and prevention strategies is provided to patients and their carers in a format that is understood and meaningful

Met Consumer Documents/Records: Review of consumer documentation confirmed that information about falls risks and prevention strategies is provided to patients and their carers. Consumer Interview: Consumers interviewed stated they were provided with falls prevention information.

Met

Criterion: 10.10 Partnering with patients Patients and carers are informed of the identified risks from falls and are engaged in the development of a falls prevention plan.

Developing falls prevention plans in partnership with patients and carers

Rating: Met



10.10 .1 (D) Falls prevention plans are developed in partnership with patients and carers

Met Clinical Governance Documents/Records: Review of documents shows that falls prevention plans are developed in partnership with patients and carers. Clinical Interview: Clinical staff interviewed could describe how patients are included in developing their falls prevention plan. Consumer Interview: Consumers interviewed indicated that they felt included in the development of their falls prevention plan.

Met

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