ACHS EQuIP6 Book 1 Final 2016

The ACHS EQuIP6 GUIDE
BOOK 1
Accreditation, Standards and Guidelines
Clinical Function
Safety
Quality
Performance
The ACHS EQuIP6 Guide:
Part 1 - Accreditation, standards, guidelines
Published by The Australian Council on Healthcare Standards (ACHS)
Copies available from the ACHS Publications Service
Phone: + 61 2 9281 9955
Fax: + 61 2 9211 9633
Copyright © The Australian Council on Healthcare Standards (ACHS)
This work is copyright. Apart from any use as permitted under the Copyright Act 1968,
no part may be reproduced by any process without prior written permission from
The Australian Council on Healthcare Standards. Requests and enquiries concerning
reproduction and rights should be addressed to the Chief Executive, The Australian
Council on Healthcare Standards, 5 Macarthur Street, ULTIMO NSW 2007 Australia.
Recommended citation: The Australian Council on Healthcare Standards (ACHS),
The ACHS EQuIP6 Guide, Part 1 - Accreditation, standards, guidelines.
2016, Sydney, Australia.
The EQuIP Guide:
First published 1996
Second edition 1998
Second edition revised 1999
Third edition 2002
Fourth edition 2006
Fifth edition 2010
Sixth edition 2016
6th Edition
ISBN-13: 978-1-921806-66-7 (paperback)
ISBN-13: 978-1-921806-67-4 (web)
2 The ACHS EQuIP6 Guide | Book 1 | Accreditation, Standards and Guidelines | Clinical Function
FOREWORD
On behalf of the Board of Directors, it is my pleasure

to present the 6th edition of the Australian Council on
Healthcare Standards’ (ACHS) Evaluation and Quality
Improvement Program (EQuIP6).
EQuIP6 will be implemented from 1 July 2016, over
a transition period of 6 months, where organisations
scheduled for an accreditation event can elect to
be assessed to either the EQuIP5 or the EQuIP6
Standards. As of 1 January 2017, all EQuIP accredited
organisations must be assessed against EQuIP6.
During the review of the EQuIP5 Standards, ACHS
engaged widely across the health industry seeking
strategic and technical input. The generous response
of time and expertise both across Australia and
internationally is indicative of the esteem held within the
health industry for ACHS. For this we are
very grateful.
Principles guiding the review process included an
emphasis on consumer / patient outcomes, the
importance of measuring performance and the national
agenda for safety and quality.
Alterations to the Standards, criteria and elements
for achievement have been largely editorial in nature,
although the new provisions relating to internal
emergencies and the merging of evaluation of
individual consumer / patient outcomes with
effectiveness of care are significant.
On behalf of the Board and Council, I commend to you
the Evaluation and Quality Improvement Program
6th edition.
Mr John Smith, PSM

President, ACHS
March 2016
March 2016 3
CONTENTS
Book 1 Book 2
Foreword 3 Section 7
Introduction 6 The Standards (Support Function) 215
Section 1 The Standards (Corporate Function) 319
ACHS and Accreditation 7 Section 8

1.1 The Australian Council on Healthcare Standards 7 Glossary 400
1.2 What is accreditation? 7
Section 9
1.3 The EQuIP principles 8
1.4 What is EQuIP? 8 Acknowledgements 414
1.5 The review of EQuIP 9
Section 2
Overview of EQuIP 10
2.1 The EQuIP framework 10
2.2 The EQuIP criterion ratings 14
2.3 Mandatory criteria 14
2.4 Not Applicable (NA) criteria 15
2.5 Expectations for ratings 15
2.6 The EQuIP accreditation cycle 18
Section 3
The EQuIP6 Guide 19
3.1 Terminology and definitions 19
Section 4
Further Information 20
4.1 Healthcare regulators 20
4.2 Policies, procedures, protocols, guidelines and
codes of practice 20
4.3 Vulnerable / At-risk populations and individuals 20
Section 5
The Standards (Clinical Function) 23
Section 6
Glossary 194
March 2016 5
INTRODUCTION
The ACHS Evaluation and Quality Improvement Program The ACHS EQuIP6 Guide is presented as three books
(EQuIP) was launched in 1996. EQuIP was developed with content as follows:
by ACHS to assist healthcare organisations to strive for
Book 1: Hard copy and online resource
excellence and was designed to be used by all types
of organisations which provide health care. ACHS has The EQuIP Guide introduction
now reviewed EQuIP5 to ensure that the next edition,
Clinical Function standards and guidelines
EQuIP6, is up-to-date, evidence-based, and relevant to
member organisations. Glossary
In response to our members’ requests, The ACHS Book 2: Hard copy and online resource
EQuIP6 Guide has new features. This printed guide
contains the standards, criteria, elements and guidelines Support Function standards and guidelines
for EQuIP6. The guidelines have been arranged under Corporate Function standards and guidelines
topic subheadings to assist users to navigate through
the information, and information has been formatted Glossary
in dot points where possible, to provide concise Acknowledgements
information about a topic. The ‘prompt points’ are still
provided under the information in each subheading. Book 3: Online resource
These are ‘enabling’ questions, to assist organisations
to consider the elements from a quality improvement The EQuIP accreditation program
perspective; they are not a checklist.
To address the elements, an organisation describes its
systems, processes, people and actions - which is really,
“what the organisation does”. True understanding that
will guide organisational quality improvement will come
from asking, “How does it happen?”, “Why was this
approach used?” and “What was the outcome?” These
‘how’, ‘why’ and ‘what’ questions are reflected in the
prompt points, and are key steps before an organisation
decides, “Perhaps we can do this better.”
In this section of the guide, there is information about
the EQuIP program and the factors that may influence
the way EQuIP6 is implemented and assessed. These
include an explanation of the meaning behind some
additions, such as vulnerable consumers / patients and
the meaning of policy requirements.
ACHS has also developed expanded versions of
the guidelines for each criterion. These are available
to members as an EQuIP6 resource that can be
accessed from the ACHS website. The expanded
guidelines contain more background information, and
were developed for those instances where further
information would assist users to better understand the
requirements of the criterion or specific elements, and
may provide more ideas for addressing the elements.
SECTION 1 ACHS and Accreditation
1.1 The Australian Council on 1.2 What is accreditation?

Healthcare Standards Healthcare accreditation is an external review of the
The Australian Council on Healthcare Standards (ACHS) quality of care and services. It is “an internationally
is an independent, not-for-profit organisation, dedicated recognised evaluation process used to assess and
to improving quality in health care. Having been at the improve the quality, efficiency, and effectiveness of
forefront of Australian healthcare accreditation since healthcare organisations; it is also a way to publicly
its inception in 1974, ACHS has maintained its strong recognise that a healthcare organisation has met
culture of developing relevant accreditation products national quality standards.”1
and services. For organisations striving to provide high quality care
With a 40 year history, ACHS has an unrivalled and services within a culture of safety and quality
understanding of healthcare accreditation and is improvement, accreditation will be the natural outcome.
committed to ensuring that its healthcare standards An accreditation system usually consists of the
are current, comprehensive and in alignment with best following components2,3:
practice, and that furthermore, the standards are able
to be assessed in a way that generates useful, accurate stablishment of agreed standards expected of
e
information to improve safety and quality for consumers. healthcare organisations
The processes ACHS use to develop healthcare evelopment of a process for evaluation of the
d
standards have been tested, evaluated and modified provision of services by organisations wishing to be
over the past 40 years, and achieving continuous accredited, which is conducted through survey by
improvement has been one of the driving goals. peer surveyors
ACHS accreditation programs are based on onduct of the survey, a process that includes
c
partnerships and consultations with key stakeholders preparatory activities by the healthcare organisation,
and participants in the healthcare industry, so that the such as collation of evidence of improvement,
standards and accreditation services reflect the needs of followed by an assessment by surveyors of the
ACHS member organisations and encourage member organisation’s compliance with the standards
ownership of the programs. ward of accreditation, and reporting of the
a
ACHS does not only seek to provide accreditation results of survey to relevant bodies and the public
programs and services in Australia and overseas, it aims as appropriate.
to improve the level of industry understanding attached Accreditation agencies themselves should be surveyed
to current health practices and protocols by improving and accredited, to ensure that they maintain the
the level of clinical data available to members. necessary credibility and legitimacy.3 ACHS and its
The ACHS Clinical Indicator Program has been EQuIP standards are accredited by the International
operating within ACHS since 1993, following an initial Society for Quality in Health Care (ISQua).
agreement with the Australian medical colleges in 1989.
It was developed in partnership with the colleges and
associations as a means of actively recording and
identifying what has been improved over time, and
areas that need further improvement. The ACHS Clinical
Indicator Program is one of only a few of this kind of
recording tool anywhere in the world, and as such, is a
leader in its field.
1 Nicklin, W. The value and impact of health care accreditation: A literature review. Ottawa CA;
The ACHS mission is ‘‘to strengthen safe, quality Accreditation Canada. Accessed from http://accreditation.ca/sites/default/files/value-and-
health care by continuously advancing standards and impact-en.pdf on 29 February 2016.
education nationally and internationally’’. 2 Montagu, D. Accreditation and other external quality assessment systems for healthcare:
Review of experience and lessons learned. London UK; Health Systems Resource Centre.
Accessed from https://www.wbginvestmentclimate.org/toolkits/public-policy-toolkit/upload/
Accreditation-Review-Montagu-2003.pdf on 29 February 2016.
3 Shaw, C. D. and the International Society for Quality in Health Care (ISQua) Toolkit Working
Group. Toolkit for accreditation programs. Melbourne VIC; ISQua. Accessed from https://
www.acep.org/uploadedFiles/ACEP/About_Us/Leadership/Committees/categorization_tf/
ISQuaAccreditationToolkit.pdf on 29 February 2016.
March 2016 7
SECTION 1 ACHS and Accreditation
1.3 The EQuIP principles Striving for best practice - the organisation compares
its performance with, or learns from, others and
The ACHS Evaluation and Quality Improvement Program
applies best-practice principles. Organisations might
(EQuIP) is based upon principles which support best
demonstrate their efforts through:
practice and which are designed to facilitate a culture
of continuous improvement. These principles can be iscovering new techniques and technologies, and
d
applied to all aspects of service within a healthcare using them to achieve world-class performance
organisation. learning from others to increase the efficiency and
A consumer focus in care provision is demonstrated by: effectiveness of processes
nderstanding the needs and expectations of present
u improving consumer / patient satisfaction
and potential consumers / patients and outcomes.
ensuring consumers / patients are the priority
1.4 What is EQuIP?
valuating the service from the consumer /
e
patient perspective. Introduced in 1996, ACHS’ Evaluation and Quality
Improvement Program (EQuIP) is a four-year quality
Effective leadership demonstrates responsibility and assessment and improvement program for healthcare
commitment to excellence in care provision, quality organisation that supports excellence in consumer /
improvement and performance by: patient care and services. It is designed to provide a
providing direction for the organisation / health service framework which will assist and support healthcare
organisations to ensure the provision of safe, high quality
ursuing the ongoing development of strategies,
p care and services, and to achieve continuous quality
systems and methods for achieving excellence improvement. If this is achieved, accreditation will follow.
inspiring and motivating the workforce and encouraging The key components of EQuIP are:
staff to contribute, develop and learn
the standards that organisations work to achieve
considering proposals that are innovative and creative.
yearly self-assessment to evaluate performance
a
Continuous improvement - management and staff against the standards
demonstrate how they continually strive to improve the
quality of care. Continuous improvement assists the CHS assistance and guidance around the
A
organisation / health service through: organisation’s self-assessment
looking for ways to improve as an essential part of iennial onsite surveys by an external, experienced
b
everyday practice team of accreditation surveyors to provide an
independent assessment of the organisation’s
onsistently achieving and maintaining quality care
c performance against the standards
that meets consumer / patient needs
the improvement process undertaken by
onitoring outcomes in consumer / patient care and
m organisations to address the recommendations
seeking opportunities to improve both the care and from the onsite surveys.
its results.
The EQuIP Standards comprise a series of criteria
Evidence of outcomes - organisations depend on the and elements, arranged under graded ratings that
measurement and analysis of performance. Indicators of reflect increasing maturity of an organisation’s quality
good care processes or, wherever possible, outcomes of improvement activities.
care demonstrate a commitment to maintaining quality
and striving for ongoing improvement by:
roviding critical data and information about key
p
processes, outputs and results
reflecting those factors that lead to improved health
and/or quality of life for consumers / patients or to
better operational performance.
1.5 The review of EQuIP
Approximately every four years, ACHS undertakes
a review of its core EQuIP accreditation program, to
ensure that its standards remain up-to-date, evidence-
based, and relevant to member organisations.
During the review process, ACHS consults widely
with its stakeholders through online surveys, Working
Groups, field review and pilot surveys, to ensure that
its members have the opportunity to voice their opinion
of the current standards and to highlight areas for
improvement. The final EQuIP standards therefore reflect
what ACHS’ members consider vital in the areas of
accreditation and quality improvement.
March 2016 9
SECTION 2 Overview of EQuIP
2.1 The EQuIP framework Each element identifies what should be in place to at least
fulfil the requirements of the criterion at a certain rating
EQuIP6 focuses on the issues considered to be of the
level. (Refer to Section 2.5 Expectations for ratings.)
greatest importance in providing safe, high quality health
care. The standards have been developed in consultation Guidelines:
with the healthcare industry and address the Clinical, The guidelines give definitions and provide more
Support and Corporate Functions of the organisation. information and guidance on demonstrating
achievement against the standards at the criterion level.
The EQuIP6 Standards and criteria express goals that
are common to different types of services. This means EQuIP6 has 3 functions, 13 standards, and 47 criteria.
that although the evidence presented by different The arrangement of the standards and criteria into
healthcare organisations for a criterion may vary, the three functions of Clinical, Support and Corporate
consideration of evidence can be made in the context of identifies the fundamental responsibilities of the key
organisational structure, geography, consumer / patient provider groups within a health service.
type and services.
he Clinical Function sets out the standards that
T
EQuIP6 is structured in a hierarchy, as follows: are predominantly associated with clinical care.
functions Achievement of these standards is largely the
responsibility of health professionals.
standards
he Support Function contains standards and
T
criteria
criteria in which quality improvement requires
elements clinical and corporate staff to work together,
sometimes with assistance from internal ‘support
guidelines.
staff’ or external consultants.
Function:
he Corporate Function identifies those standards
T
A function is a group of standards.
and criteria for which the governing body of the
Standard: organisation is predominately responsible.
The standard describes the overall goal; for example
The arrangement of the EQuIP6 functions provides a
Standard 1.1, Consumers / patients are provided with safe,
basic model for understanding corporate and clinical
high quality care throughout the care delivery process.
governance, and the difference between the two. The
Criteria: ACHS Board defines Corporate governance as how
The criteria describe key components of the goal, which an organisation is managed, its structures, culture,
are necessary for meeting the goal; for example Criterion policies and strategies, and how it interacts with its
1.1.1, Assessment ensures current and ongoing needs stakeholders. It defines Clinical governance as the
of the consumer / patient are identified. systematic approach to maintaining and improving
the quality of care within a clinical care setting, health
Elements:
program or health system. It involves an understanding
For each criterion, there is a series of elements which:
and acceptance that the governing body of a healthcare
explains the criterion organisation has a responsibility for the quality of care
escribes some important practices for each level
d delivered by a service and that this accountability is
of achievement shared equally with the health professionals providing
this care.
s hould not limit practices; organisations are
encouraged to undertake and present additional
activities that respond to the criterion statement
s hould be regarded as a framework for total quality
rather than a checklist of compliance
rovides direction for improvement activities and for
p
achieving better practice.
The Clinical and Support Functions (see Table 1)
reflect clinical governance; the Support and Corporate
Functions reflect corporate governance.
Function 1 - Clinical has six standards:
1.1 Continuity of care
1.2 Access
1.3 Appropriateness
1.4 Effectiveness
1.5 Safety
1.6 Consumer focus
Function 2 - Support has five standards:
2.1 Quality improvement and risk management
2.2 Human resources management
2.3 Information management
2.4 Population health
2.5 Research
Function 3 - Corporate has two standards:
3.1 Leadership and management
3.2 Safe practice and environment
Table 1 identifies at a glance the three functions, the 13
standards (colour highlighted) and each of the 47 criteria.
March 2016 11
Table 1. EQuIP6 Standards

1. CLINICAL
and Criteria
1.1 Consumers / patients are provided with safe, high quality care throughout the care
delivery process.
Key: EQuIP6
1.1.1 Assessment ensures current and ongoing needs of the consumer / patient are identified.
13 Standards
1.1.2 Care is planned and delivered in collaboration with the consumer / patient and, when relevant,
47 Criteria the carer to achieve the best possible outcomes.
16 Mandatory Criteria 1.1.3 Consumers / patients are informed of the consent process, and they understand and provide
consent for their health care.
1.1.4 The organisation implements effective systems for the management of medical emergencies,
including the identification and care of deteriorating consumers / patients.
1.1.5 Processes for clinical handover, transfer of care and discharge address the needs of the
consumer / patient for ongoing care.
1.1.6 Systems for ongoing care of the consumer / patient are coordinated and effective.
1.1.7 Processes for preparing for end-of-life, and for delivering consumer / patient end-of-life care,
are managed with dignity and comfort, and family and carers are supported.
1.1.8 The health record ensures comprehensive and accurate information is collaboratively
gathered, recorded and used in care delivery.
1.2 Consumers / patients and communities have access to health services and care
appropriate to their needs.
1.2.1 The community has information on health services appropriate to its needs.
1.2.2 Access and admission / entry to the system of care are prioritised according to healthcare needs.
1.3 Appropriate care and services are provided to consumers / patients.
1.3.1 Appropriate health care and services are delivered in the most appropriate setting.
1.4 The organisation provides care and services that achieve effective outcomes.
1.4.1 Outcomes of clinical care, including individual care episodes and the overall effectiveness of
care, are evaluated by healthcare providers.
1.5 The organisation provides safe care and services.
1.5.1 Medication management systems support the safe and effective use of medicines.
1.5.2 The infection control system supports safe practice and ensures a safe environment for
consumers / patients and healthcare workers.
1.5.3 The incidence and impact of breaks in skin integrity, pressure ulcers and other wounds are
minimised through wound prevention and management programs.
1.5.4 The incidence of falls and fall injuries is minimised through a falls management program.
1.5.5 The system to manage blood, blood components / products, sample collection and consumer /
patient blood administration ensures safe and appropriate practice.
1.5.6 The organisation ensures that the correct consumer / patient receives the correct procedure
on the correct site.
1.5.7 The organisation ensures that the nutritional needs of consumers / patients are met.
1.6 The governing body is committed to consumer / patient participation.
1.6.1 Consumers / patients, carers and the community participate in the planning, delivery and
evaluation of the health service.
1.6.2 Consumers / patients are informed of their rights and responsibilities.
1.6.3 The organisation meets the needs of consumers / patients and carers with diverse needs and
from diverse backgrounds.
2. SUPPORT 3. CORPORATE
2.1 The governing body leads the organisation in its commitment to 3.1 The governing body leads the
improving performance and ensures the effective management of organisation’s strategic direction to
corporate and clinical risks. ensure the provision of quality, safe
2.1.1 The organisation’s continuous quality improvement system demonstrates services.
its commitment to improving the outcomes of care and service delivery. 3.1.1 Governance is assisted by formal
2.1.2 The integrated organisation-wide risk management framework ensures structures and delegation arrangements
that corporate and clinical risks are identified, minimised and managed. within the organisation.
2.1.3 Healthcare incidents are managed to ensure improvements to the 3.1.2 Strategic and operational planning and
systems of care. development support the organisation’s
delivery of safe, high quality care
2.1.4 Healthcare feedback, including complaints, is managed to ensure and services.
improvements to the systems of care.
3.1.3 Processes for credentialing and defining
2.2 Human resources management supports quality health care, a the scope of clinical practice support safe,
competent workforce and a satisfying working environment for staff. high quality health care.
2.2.1 Workforce planning supports the organisation’s current and future ability 3.1.4 External service providers are managed
to deliver safe, high quality care and services. to maximise safe, high quality care
2.2.2 The recruitment, selection and appointment system ensures that the skill and services.
mix and competence of staff, and mix of volunteers, meets the needs of 3.1.5 Documented corporate and clinical policies
the organisation. and procedures assist the organisation
2.2.3 The performance management system ensures the competence of staff to provide safe, high quality care
and volunteers. and services.
2.2.4 The learning and development system ensures the skill and competence 3.2 The organisation maintains a safe
of staff and volunteers. environment for employees, consumers
2.2.5 Support systems promote staff wellbeing and a positive work environment. / patients and visitors.
2.3 Information management systems enable the organisation’s goals 3.2.1 Safety management systems ensure
to be met. the safety and wellbeing of consumers /
patients, staff, visitors and contractors.
2.3.1 Health records management systems support the collection of
information and meet the consumer / patient and organisational needs. 3.2.2 Assets, goods and general services are
managed safely and used efficiently
2.3.2 Corporate records management systems support the collection of
and effectively.
information and meet organisational needs.
3.2.3 Waste and environmental management
2.3.3 Data and information are collected, stored and used for strategic,
supports safe practice and a safe and
operational and service improvement purposes.
sustainable environment.
2.3.4 The organisation has an integrated approach to the planning, use and
3.2.4 Emergency and disaster management
management of information and communication technology (I&CT).
supports safe practice and a
2.4 The organisation promotes the health of the population. safe environment.
2.4.1 The organisation conducts health promotion and consumers / patients, 3.2.5 Security management supports safe
carers, staff and the community are educated about better health practice and a safe environment.
and wellbeing.
2.5 The organisation encourages and adequately governs the conduct
of research to improve the safety and quality of health care
within organisations.
2.5.1 The organisation’s research program develops the body of knowledge,
protects staff and consumers / patients and has processes to
appropriately manage the organisational risk associated with research.
March 2016 13
2.2 The EQuIP criterion ratings 2.3 Mandatory criteria

The EQuIP criteria have been developed around a A mandatory criterion is one where it is considered
five-level rating scale designed to measure and support that without evaluation, the quality of care or the safety
continuous improvement in key areas of a healthcare of people within the organisation could be at risk.
organisation’s operation. Mandatory criteria are those where a rating of Marked
Achievement (MA) or higher is required to gain or
Each of the 47 EQuIP6 criteria has five possible
maintain ACHS accreditation.
levels of achievement: Little Achievement (LA), Some
Achievement (SA), Marked Achievement (MA), Extensive The ACHS Board determined that the following question
Achievement (EA) and Outstanding Achievement (OA). be used to decide mandatory status for EQuIP6
criteria: Is this ACHS criterion so important that
Organisations and surveyors will use the elements in
failure to achieve an MA rating should result in
each of the criteria to rate the level of the organisation’s
non-accreditation?
achievement. The elements are not meant to be an audit
checklist; they describe the practices that contribute The rules for selection were that the criterion
to the achievement of each level. While the manner in is fundamental:
which the elements are implemented and the evidence
to consumer rights, and/or
presented may differ between healthcare organisations,
each organisation should be able to demonstrate that as a core component of safe, high quality care, and/or
their practices address the intent of the elements, and
to staff, visitor and consumer safety
that their evidence responds to their aims or purposes.
... and the criterion could not be adequately covered by
an overarching mandatory criterion such as care delivery,
quality improvement, and/or risk management.
There are 16 mandatory criteria in EQuIP6. Table 1
highlights the mandatory criteria in each of the three
functions. The mandatory criteria are identified throughout
EQuIP6 by italicised text.
LA SA MA EA OA
Little Some Marked Extensive Outstanding

Achievement Achievement Achievement Achievement Achievement
LA elements plus LA, SA elements plus LA, SA, MA elements All elements in LA, SA,
LA elements
the SA elements the MA elements plus the EA element MA, EA and OA
Awareness Implementation Evaluation Distinction Leadership

The organisation The organisation The organisation The organisation The organisation is a
understands basic develops and collects data, achieves superior peer leader in systems
requirements and implements systems. evaluation of performance and and outcomes.
demonstrates policy systems occurs, outcomes through
and legislative and improvements advanced systems
compliance. are made to ensure and processes.
better practice.
Table 2 ‘The criterion rating format’ will assist organisations to better understand how the elements can support rating
achievement. Surveyors will use this model when assigning ratings for organisations.
2.4 Not Applicable (NA) criteria 2.5 Expectations for ratings
There are a few criteria and elements in EQuIP6 that Achieving MA
may not be applicable to some organisations. Criteria
The Marked Achievement (MA) rating in each of the 47
may be described as not applicable when the topic of
criteria requires that organisations evaluate their systems.
the criterion would never occur or would never have the
The goal is to determine whether the systems that the
potential to occur in the organisation.
organisation has implemented work effectively and
An organisation will need to formally discuss and agree whether there is potential to improve, and perhaps to give
with its Customer Services Manager any criteria that insight into how this might be achieved. This applies not
are not applicable to the organisation prior to an onsite only to the evaluation of clinical systems but also to the
survey being undertaken. All EQuIP criteria will be evaluation of organisation-wide policy and programs.
considered applicable to all organisations, except where
Evaluation is judging the value of something by gathering
it has been formally agreed that they are not applicable.
valid information about it in a systematic way and by
It is accepted that in some organisations there may be
making a comparison; its purpose is to help to decide what
some criteria which are only partially relevant, but in
to do, to justify earlier actions or to contribute to scientific
these cases the criteria will still be applicable for ACHS
knowledge. Evaluation of a process or system involves
onsite survey purposes. If elements of a criterion are
a review of performance measures and other qualitative
not applicable, the rationale should be provided in the
data, including the opinions of those directly involved in, or
Electronic Assessment Tool (EAT).
affected by, a process. It may include comparisons against
earlier times, other departments / organisations or classes
Criterion Examples where the of consumers / patients or personnel.
criterion may be considered
not applicable There are many different methods of evaluation that
can be used in health services. The ACHS EQuIP6
1.1.4 Medical Advisory services
Risk Management and Quality Improvement Handbook
Emergencies
provides further information on assessing performance
1.1.6 Ongoing Care Advisory services and evaluation, and is available on the ACHS website.
1.1.7 End of Life Advisory services The organisation should assess whether a process or
1.5.1 Medications Advisory services / services that system is meeting its own needs and/or those of its
never prescribe or administer consumers / patients, and whether there is scope for
medications, or store medications on improvement. Areas identified for improvement may
the premises require further investigation before a decision is made to
1.5.3 Skin Integrity Advisory services progress. Evidence of data collection, its evaluation, and
1.5.5 Blood Services that never administer blood action taken, or reasons for inaction, would be expected
Management or blood products or take pre- for an MA rating. There is more to evaluation and quality
transfusion blood samples improvement than measuring a process or system.
1.5.6 Consumer / Advisory Services are not required Significant quality improvement projects with
Patient to meet elements that relate to documented evidence of baseline measurement,
Identification instrument accountability, i.e. LA b), considered options for improvement, and demonstrated
SA a) (iii), (iv), (v), MA c) positive outcomes from the changes implemented,
would be a good foundation for advancing to
1.5.7 Nutrition Advisory Services, unless the service
achievement of an EA rating.
has a requirement to assess the
nutritional status of a consumer /
patient, in which case, evidence must
be provided of that assessment
2.5.1 Research Organisations that never undertake or
participate in research
Table 3 may assist organisations to apply for

not-applicable criteria.
March 2016 15
Achieving EA CALCULATE: the magnitude of the benefit - increased

efficiency, reduced costs, fewer complications in
In EQuIP6, the expectation for achievement of an EA
consumers / patients, decreased mortality rates in
rating has changed. Whereas previously an organisation
consumers / patients, etc.
could earn an EA rating by meeting the requirements of
MA and one or more of the EA elements (‘and/or’), the CONTINUE: the new practice must be sustainable.
organisation must now:
Benchmarking is the continuous measurement of a
eet the requirements of all the LA, SA and
m process, product, or service compared to that of the
MA elements, strongest competitor, to those considered industry
leaders, or to similar activities within the organisation,
ot have any recommendations for the relevant
n
in order to find and implement ways to improve
criterion, and
that process, product or service. This is one of the
e able to show distinction in its systems and
b foundations of both total quality management and
practices for the relevant criterion. continuous quality improvement.
In order to facilitate this change, the EA elements across To achieve an EA rating, it is not sufficient for the
EQuIP6 have been streamlined, and there is now only organisation merely to carry out benchmarking. Rather,
one element under the EA rating for each criterion. the organisation should be able to demonstrate
that it has used benchmarking data as the basis of
The different ways in which an organisation might
improvement activities.
demonstrate distinction in the relevant criterion are many
and varied, however the existing markers of innovation, If organisations do not have access to comparative
benchmarking and high level quality improvement are data, they should seek alternative ways to gauge the
still relevant. efficiency and effectiveness of their systems / processes.
Departments / wards may be able to compare
For an organisation to achieve an EA rating, the entire
processes with other departments / wards in the same
survey team will discuss the evidence and decide by
organisation (i.e. internal benchmarking), considering the
joint agreement as to the merits of the award.
similarities and differences between their sites. Similar
Innovation is the application of new or better ideas, functions and processes, such as scheduling or the
in order to improve a system, process or service. collection of customer feedback, could be compared
To achieve an EA rating, organisations will need against other industries. The objective of benchmarking
to demonstrate that they have found new ways of is to consider and test alternative systems and
solving problems and improving services, perhaps by processes, and adopt those that will best meet the
applying existing techniques to new areas of operation, organisation’s needs. Evidence of benchmarking
conducting different or broader consultation in order provided towards an EA rating should include details of
to ‘brainstorm’ fresh solutions, introducing alternative the improvements made as a result of the findings from
technologies or techniques, or by testing several benchmarking, as well as the improved outcomes.
potential approaches until the most successful one
High-level quality improvement projects that have a
is identified. Organisations may also demonstrate
robust structure, and are about a redesign of systems,
improved consumer / patient outcomes through
processes and performance, rather than just a review,
innovation in the way that care is delivered - for example,
can be provided as evidence to achieve an EA rating.
by involving different people in the process, changing
Organisations can submit this evidence by highlighting
where care is delivered, or refining the interaction of
these types of projects, preferably in a quality
health professionals with the consumer / patient and/or
improvement report that is to a ‘publishable’ standard.
their carer.
The British Medical Journal (BMJ) group journal, Quality
In order for an organisation to self-rate EA for innovation, it
and Safety in Health Care, provides an outline of the
must show evidence of a planned approach, for example:
structure of a ‘publishable quality improvement report’
CREATE: a new / improved process or procedure that is a - see http://qshc.bmj.com/site/about/guidelines.xhtml,
better utilisation of resources, adopts new methods, etc. and scroll down to ‘Quality improvement Reports’.
COMPARE: with existing practice, with other institutions,
with the literature
Briefly, the content of a quality improvement report level of performance and evidence that the organisation
should include: is considered to be a leader. Surveyors will then
evaluate the submission and the evidence provided, and
background of the project
determine whether an OA can be awarded.
assessment of problems
Surveyors may also award an OA rating without a
results of assessment / measurement submission from the organisation. If surveyors consider
an organisation is performing at an OA level, they will
strategies for quality improvement / change
assist the organisation to develop a one-page summary
outcomes, lessons and messages. describing its leadership status, which will then be
Organisations that wish to present their quality included in the survey report.
improvement report to surveyors to evidence a self-
rated EA should understand that surveyors have an
expectation of a project conducted and presented at
a ‘publishable’ standard. This does not mean that the
work has or must be published (though it may be), but
that the project has been conducted, and is presented
as evidence, to the appropriate standard.
Achieving OA
To achieve an OA rating, an organisation must meet all
requirements of the LA, SA, MA and EA elements, as
well as demonstrating leadership.
Leadership does not necessarily mean that the
organisation is the best, but rather that it can
demonstrate it is outstanding amongst its peers.
An OA rating requires that an organisation has been
recognised as outstanding by bodies external to the
organisation. For example, other organisations may
seek the organisation’s recognised expertise, adopt
systems / processes developed by the organisation,
or invite representatives of the organisation to present
their achievements or conduct education / training in a
particular field. This advanced achievement may lead
to the writing of a textbook, or an invitation to deliver
a key-note address or similar at a conference. (Please
note that merely presenting at a conference does not
necessarily mean that the work is of OA rating standard.)
The difference between an EA and OA rating is this
requirement for external recognition / adoption of
the organisation’s achievements. While an EA rating
rewards an organisation which has excellent systems
and processes internally, an OA rating is reserved for
those organisations whose achievements have been
recognised externally to the organisation itself.
While organisations cannot self-rate at an OA level, if
an organisation believes that it is a leader in a criterion,
surveyors should be provided with a brief (one-page)
submission summarising the steps taken to achieve this
March 2016 17
2.6 The EQuIP accreditation cycle

Accreditation against the EQuIP standards requires
organisations to participate in a four-year cycle of
events, with one activity to be completed during each
year of the cycle.
Phase 1 Phase 2
Self assessment Organisation-Wide Survey
ew members provide a self
N (OWS)
assessment against all criteria. weeks prior to OWS, members
6
xisting members provide progress
E provide ACHS with a self assessment
on action taken towards addressing against all criteria and progress on
the recommendations from the action taken towards addressing the
previous survey. recommendations from the previous
survey. The Quality Improvement Plan
embers submit their register of key
M is uploaded to EAT.
organisational risks (risk register).
he full risk register is provided to the
T
embers submit their Quality
M surveyors at survey.
Improvement Plan.
ll criteria are surveyed and progress
A
on recommendations from the
previous survey is reviewed.
1 2
ACHS ACCREDITATION
4 3
Phase 4 Phase 3
Periodic Review (PR) Self assessment
weeks prior to PR, members
6 embers provide progress on
M
provide ACHS with a self assessment action taken towards addressing the
against all mandatory criteria and recommendations from the previous
progress on action taken towards survey.
addressing the recommendations
embers submit their register of key
M
from the previous survey. The Quality
organisational risks (risk register).
Improvement Plan is uploaded to EAT.
embers submit their Quality
M
he full risk register is provided to the
T
Improvement Plan.
surveyors at survey.
andatory criteria are surveyed and
M
progress on recommendations from
the previous survey is reviewed.
SECTION 3 The EQuIP6 Guide
3.1 Terminology and definitions ealth professional: any professionally qualified

H
individual involved in the provision of health care. The
In moving from EQuIP5 to EQuIP6, an attempt has been
term encompasses medical practitioners, nurses, all
made to ensure that the standards, criteria, elements
allied health professionals and others active in clinical
and guidelines have been written in the most inclusive
practice, whether registered or unregistered.
language, so that they may apply to and be understood
in organisations across the healthcare spectrum, and olicy: a documented statement of expected actions
P
internationally as well as in Australia. and responsibilities. A policy may be developed by a
healthcare organisation or by a higher authority, such
For this reason, a number of terms and expressions
as a Health Department, but is always interpreted and
found in EQuIP5, which referred specifically to the
implemented in the context of the organisation.
Australian context, have been removed from EQuIP6.
This does not mean that the requirement of the ractical / Practicable: ’when practical’ is at the
P
standard / criterion / element has changed. In interpreting convenience of the organisation, ‘when practicable’ is
the requirement, healthcare organisations should apply as soon as it is possible.
the standard / criterion / element to their own particular
elevant: logically connected. For example, the
R
context, and to the needs of their community.
EQuIP standards, criteria and elements make use of
Certain terms used in The EQuIP6 Guide have a broad terms such as ‘policy’ or ‘legislation’. When
particular meaning within the standards, criteria, interpreting these standards / criteria / elements,
elements and guidelines of EQuIP. These terms may not organisations will only apply what is relevant to their
be those commonly used within member organisations. operation, not all policies or all legislation.
For the benefit of users of The EQuIP6 Guide, the Required: when needed or necessary.
following definitions are provided:
orkplace health and safety: an area concerned
W
ppropriate: consistent with current best practice
A with the safety, health and welfare of people engaged
and the requirements of the consumer / patient. in work or employment. In the healthcare setting, this
includes consumers / patients, staff and visitors. Other
t-risk: characterised by an increased danger of, or
A
terms that may be used include ‘Occupational Health
susceptibility to, a medical condition or other adverse
and Safety’ and ‘Work Health and Safety’.
circumstances. The term ‘at-risk’ may apply to
particular populations or to individuals. ulnerable consumers / patients and groups:
V
vulnerable consumers / patients and groups are
are plan: a written statement of a consumer /
C
those that are either indigenous, or a significant part
patient’s needs, prepared following assessment to
of the population, i.e. some immigrants, individuals or
guide subsequent medical treatment, arrangements
groups of a certain socioeconomic standing, and that
for ongoing care, and referrals as necessary. Other
have distinctive, identified health issues.
terms for ‘care plan’ include ‘management plan’ and
‘care management plan’.
ommunity: the people to whom a healthcare
C
organisation provides services. An organisation’s
‘community’ is always defined in terms of the
organisation itself, and may be geographical,
socioeconomic or medical.
onsumer / patient: a person accessing the
C
services provided by a healthcare organisation or
an individual health professional. Other terms for
‘consumer / patient’ include ‘patient’, ‘client’,
and ‘customer’.
March 2016 19
SECTION 4 Further Information
4.1 Healthcare regulators Because the items included within a named policy may
vary between jurisdictions, it would be wise to note
While each healthcare organisation will be governed
details (such as page numbers, chapters or clauses) and
by its own Board, Chief Executive Officer or owner(s),
provide this information to surveyors, so that evidence
it will also be subject to oversight and governance by a
can quickly be validated if required.
healthcare regulator, usually a branch of government.
These regulators may go by various titles, for example, Procedures are the specific methods employed to
the Ministry of Health, the Department of Health, the implement and carry out policies in day-to-day activities
Commission or Council on Health, or the Health Authority. of the organisation.
Many healthcare organisations will be obligated to fulfil Together, policies and procedures ensure that a point
certain requirements put in place by their healthcare of view held by the governing body of an organisation
regulator, for example, implementing policy, instituting is translated into actions which result in an outcome
public health programs, or submitting healthcare data compatible with that view.
to the regulator. These obligations will take precedence A guideline is any document that aims to streamline
over alternative policy / program / data requirements particular processes according to a set routine. By
instituted by the organisation’s governing body. definition, following a guideline is never mandatory -
a better term for a mandatory guideline would be
4.2 Policies, procedures, protocols, a protocol.
guidelines and codes of practice
Guidelines are an essential part of the larger process
The purpose of a policy is to provide a clear, documented of governance. However, it is important to differentiate
statement of the expectations of tasks and concepts that clinical guidelines, which outline decisions and criteria
is consistent with organisational objectives. regarding diagnosis, management, and treatment in
specific areas of health care. Clinical guidelines are
In the context of EQuIP6, the term ‘policy’ refers to a
usually based on a review of evidence by experts
written statement(s) which acts as a guide and reflects
who reach a consensus on practical approaches to
the position and values of the organisation on a given
diagnosis, management or treatment. Their aim is to
subject. A policy is a set of coherent decisions with
standardise medical care, to raise the quality of care and
a common long-term purpose(s). All procedures and
to reduce several kinds of risk.
protocols should be linked to a policy statement.
Guidelines may be issued by and used by any
The source of a given policy may vary. Where the
organisation (government, public or private) to make the
relevant healthcare regulator develops policy to address
actions of its staff or departments more predictable, and
management of a particular area of operation, for
presumably of higher quality.
example infection control, the organisation is required
to implement that policy in a manner that fulfils its A code of practice is a set of guidelines issued by an
obligations and is appropriate to its context. In these official body or a professional association, for example
circumstances, the organisation may develop its own a Medical Association, to its members, to help them
guidelines, procedures or other such document, to comply with its ethical standards.
explain and guide the implementation of the policy.
Where there is no overarching policy developed by a 4.3 Vulnerable / At-risk populations
healthcare regulator, the organisation should develop and individuals
and implement its own policy, drawing upon current Some criteria and elements in EQuIP6 require the
best-practice standards and guidelines, or other relevant organisation to provide appropriate care and services for
material. It should be evident which standards and/or populations or individuals considered at increased risk of
guidelines the organisation referred to in developing poor health outcomes.
its policy.
The term ‘at-risk’ covers a wide range of factors that
Organisations should be aware that they are not may have an impact upon care and care outcomes. An
expected to have a separate policy for every element individual may be assessed at being at increased risk of
that mentions a policy. A range of issues may be falls because they are elderly and/or frail; at increased
addressed under a single policy, and when this is the risk of a specific disease because of their genetic
case, organisations should inform the surveyors of this.
background; or at increased risk of mental health issues
because of their socioeconomic circumstances. The
organisation must address such increased risk factors
in its assessment of the individual, and ensure that
appropriate care and services are provided, either during
the subsequent care episode, or via appropriate referrals.
A particular sector of society may also be collectively
at higher risk, according to specific conditions that will
vary from country to country, area to area, or between
urban and rural territories. For example, in Australia the
indigenous Aboriginal and Torres Strait Islander peoples
are recognised as having a lower life expectancy than
the general population, and as not always receiving
equivalent care to that provided for people of other
racial backgrounds in similar circumstances.1 The Close
The Gap program was instituted by the Australian
government to address these issues; it requires
Australian healthcare organisations to implement
systems for recognising and addressing the specific
healthcare needs of indigenous Australians.
A country’s indigenous people may not necessarily be at
increased risk of poor health outcomes. However, at the
same time, certain other sectors of the population may
be identified as being at-risk - for example, particular
ethnic or immigrant groups, people of a particular
gender, or people living in circumstances that increase
the likelihood of physical or mental illness.
In some countries / territories, there may be government
programs aimed at better providing for the healthcare
needs of those at increased risk. Where such programs
are instituted, the organisation will be expected to fulfil
their requirements. Where no such programs exist, the
organisation should seek to identify those at risk in its
own community, and to ensure that its care, assessment
processes and referral systems are appropriate for
their needs.
Various EQuIP6 criteria and elements require
organisations to define their ‘community’. The term
‘community’ does not, or does not necessarily, refer
to the geographical area in which the organisation
is situated. Rather, it is a reflection of the cohort of
consumers / patients to whom the organisation provides
services, which may be based upon location, a referral
system, or the specific medical services being delivered.
1 Australian Indigenous HealthInfoNet. Overview of Australian Indigenous health status 2013.

Australian Indigenous HealthInfoNet, Edith Cowan University; Mt Lawley WA. Accessed from
http://www.healthinfonet.ecu.edu.au/health-facts/overviews on 22 February 2016.
March 2016 21
SECTION 5 Standards, criteria,
elements and guidelines
1.1 Continuity of Care Standard There are eight criteria in this standard. They are:
The standard is: Assessment ensures current and ongoing
1.1.1
Consumers / patients are provided with safe, high needs of the consumer / patient are identified.
quality care throughout the care delivery process. Care is planned and delivered in collaboration
1.1.2
The intent of the Continuity of Care standard is to ensure with the consumer / patient and, when relevant,
that organisations provide high quality care and a caring the carer to achieve the best possible outcomes.
environment to the consumer / patient at all times. They 1.1.3
Consumers / patients are informed of the
should do this: consent process, and they understand and
from the time that the consumer / patient enters the provide consent for their health care.
healthcare organisation or service 1.1.4
The organisation implements effective systems
through to when the consumer / patient is discharged for the management of medical emergencies,
or transferred to another organisation / service; and including the identification and care of
deteriorating consumers / patients.
during any ongoing care they provide after discharge.
Processes for clinical handover, transfer of
1.1.5
The specific needs of vulnerable consumers / patients
care and discharge address the needs of the
and population groups should be considered throughout
consumer / patient for ongoing care.
the criteria of Standard 1.1
1.1.6 Systems for ongoing care of the consumer /
patient are coordinated and effective.
1.1.7 Processes for preparing for end-of-life, and for
delivering consumer / patient end-of-life care,
are managed with dignity and comfort, and family
and carers are supported.
The health record ensures comprehensive and
1.1.8
accurate information is collaboratively gathered,
recorded and used in care delivery.
March 2016 23
SECTION 5 Standards, criteria, elements and guidelines
Standard 1.1: Consumers / patients are provided with safe, high quality
care throughout the care delivery process.
Implementation
Criterion LA Awareness SA LA plus the following
Criterion 1.1.1 a) Guidelines to direct the assessment a) Assessments are conducted

of the physical, spiritual, cultural, and documented as soon as
Assessment ensures current and
psychological and social needs of practicable.
ongoing needs of the consumer /
consumers / patients are readily
patient are identified. b) Consumers / patients are involved
available to staff.
in the assessment process.
This is a mandatory criterion
b) Guidelines are available on the
c) A support person / carer is
specific needs of vulnerable
involved in assessment whenever
consumers / patients and
practicable.
population groups.
d) Planning for transfer of care
c) There are processes to identify,
/ discharge commences at
assess and manage vulnerable
assessment, is multidisciplinary
when necessary, and coordinated.
population groups.
d) There are processes for
the assessment of a
consumer / patient’s need for
health education.
e) Referral systems to other relevant
health service providers are in place.
Overview Relationships of 1.1.1 with other criteria

This criterion determines the importance of the The organisation’s delivery of safe, high quality care
assessment as a first step in ensuring that care is (Standard 1.1) begins for each consumer / patient
planned and delivered in a holistic, coordinated, efficient with the process of assessment. This will determine
manner. It recognises that the assessment phase should access to the system and/or admission according to
promote a consultative, collaborative approach that the inclusion / exclusion criteria where appropriate, and
actively involves the consumer / patient and carer so consumer / patient need (Criterion 1.2.2), and will impact
that it meets their needs and they may understand what upon the planning and delivery of care (Criterion 1.1.2).
is occurring. The notes taken during assessment will form part of a
comprehensive and accurate health record (Criterion
1.1.8) and will facilitate handover of care (Criterion 1.1.5).
Effective assessment requires the active involvement
of the consumer / patient and, when appropriate, his
or her carer(s) (Criterion 1.6.1). It will also ensure that
consumers / patients with diverse needs and from
diverse backgrounds (Criterion 1.6.3) are provided with
the appropriate support and services.
Evaluation Distinction Leadership
MA SA plus the following EA MA plus the following OA EA plus the following
a) T
he assessment process is a) The organisation shows distinction a) The organisation demonstrates it is
evaluated, and improvements are in consumer / patient assessment a leader in systems for consumer
made as required. and planning for transfer of / patient assessment and planning
care / discharge. for transfer of care / discharge.
b) Processes for identifying, assessing
and managing vulnerable
consumers / patients and groups
are evaluated, and improvements
are made as required.
c) Planning for transfer of care /
discharge is evaluated to ensure
that it:
(i) routinely occurs
(ii) is multidisciplinary when required
(iii) includes referral to specialty
services when required
(iv) meets consumer / patient and
carer needs.
d) R
eferral systems are evaluated,
and improvements are made
as required.
This criterion requires healthcare ave referral systems to other relevant service
H
organisations to: providers in place.
onduct assessments and document them as soon
C
as practicable, with the involvement of the consumer /
Consumer / patient assessment
patient and support person / carer if one is available. An episode of care begins with assessment and requires
contact between clinical staff and the consumer /
se evidence-based guidelines that will assist
U
patient. An assessment can initiate additional services
staff to assess physical, spiritual, cultural / ethnic,
and assistance. An ineffective or incomplete assessment
psychological and social needs of consumers /
could increase the risk of errors that may affect health
patients, as well as the need for health education.
outcomes, and/or consumer / patient satisfaction with
ave systems to identify vulnerable consumers /
H the service.
consumer groups which may be at increased risk and
Assessments should:
guidelines on how those consumers / patients and
groups may be managed. rovide a comprehensive overview of a consumer /
p
patient’s health and wellbeing and allow for diagnoses
outinely plan for transfer of care / discharge
R
and the identification of risks
at assessment and ensure these plans are
multidisciplinary, include referral to specialty services
when required, and meet consumer / patient and
carer needs.
March 2016 25
Criterion 1.1.1 Reassessment should occur at regular intervals, and

Assessment ensures current and ongoing following any change in the health status of the consumer /
patient. Failure to undertake a risk assessment in a timely
needs of the consumer / patient are identified. manner, particularly where other staff assume it has been
(continued) done, can have serious safety implications.
be multidisciplinary, with more than a single
professional background contributing to the review of the Prompt points
consumer / patient. This may be as simple as a medical
practitioner and a nurse, or may involve consultation with ow is the timeliness of assessments
H
medical specialists, allied health professionals, and even monitored by the organisation or its
non-medical expertise from areas such as education, departments? What improvements have been
community services or security made to ensure timeliness?
reference assessment guidelines that reflect ow are assessments made available to
H
consumer / patient needs, and the needs of the other staff? What is done to prevent a lag
organisation, or even department. These may vary between assessments and the completion of
significantly between organisations health records?
reference guidelines developed specifically for hat assessment information is recorded in the
W
the needs of a professional group, such as the health record? How does staff know what is
guidelines developed by medical colleges, if expected to be recorded?
relevant. For example, the Hong Kong College of re there completed assessments in consumer /
A
Anaesthesiologists has guidelines for safe sedation patient health records? Do they follow a
for diagnostic and therapeutic procedures. Senior consistent structure / format?
staff who have adopted a specific set of standards,
guidelines and processes are expected to understand ow does the consumer / patient health record
H
why the chosen system or process is used by their demonstrate a multidisciplinary approach to
department / organisation. Possible reasons assessment / diagnosis? In a multidisciplinary
include organisational policy, clinical preferences, environment, what measures avoid repeating
and types of consumers / patients admitted the same questioning / paperwork?
e timely; policy should direct what is considered

b hat measures are used to evaluate the
W
satisfactory timing, which should aim to ensure that effectiveness of the assessment process?
information is available when needed If audits of health records are used, how do
health record audits demonstrate compliance
include members of the consumer / patient’s family with assessment processes? Following
in discussions during an episode of care and during evaluation, what actions have been taken to
recovery and/or ongoing care. As early as possible in improve compliance?
the assessment process, and ideally with agreement
from the consumer / patient, at least one carer / family hat formal information is provided to
W
member should be involved in care planning with consumers / patients as part of the assessment
healthcare providers. In some cases this will be essential, process? An example might be a ‘preparing for
for example for consumers / patients who are severely surgery’ brochure.
injured or distressed, intellectually impaired, very young ow is information about the outcome of
H
or who have limited capabilities in speaking the language an assessment relayed to consumers /
of the healthcare provider patients? How is their understanding of this
e conducted and documented soon as practicable,
b communication checked? Are carers / other care
with the involvement of the consumer / patient and providers included in these discussions? How
support person / carer if one is available. does the organisation identify a relevant carer?
Guidelines direct the holistic assessment of
consumers / patients Prompt points
Holistic assessment should identify the physical, ho undertakes the assessment? Who
W
spiritual, cultural, psychological and social needs of the records information in the assessment
consumer / patient. These issues can affect the way report? Are any other partners, such as
care and treatment are delivered, as well as way the anaesthetists, dietitians, community services, a
consumer / patient may respond to care and treatment. GP or carers involved in the assessment?
Examples of relevant guidelines include: ow does the organisation’s staff learn about
H
cultural boundaries? How is orientation used?
easurement of mental health and social and
m
emotional wellbeing
guidelines on conditions specifically related to stress Vulnerable consumers / patients and
ugmentative and alternative communication
a consumer groups
clinical guidelines Identifying which consumers / consumer groups may be
linical guidelines for the physical care of mental
c at increased risk and how those consumers / patients
health consumers and groups may be managed is an integral part of
assessment. There are health inequalities among many
uidelines for adults on how to communicate with
g population groups, and while it is clear there are these
adolescents about mental health problems and other differences, the reason for them sometimes remains
sensitive topics unclear. Health inequalities are variations in health status
information on culture and ethnicity for that are driven by inequalities in society.
health assessments Although all consumers / patients may experience some
national guides to a preventive health assessment. form of vulnerability when hospitalised, in the context
of this criterion, vulnerable consumers / patients and
Where relevant, assessment notes should include: consumer groups can be described as:
lanning for discharge: the return to home poses
p s ocially vulnerable - a person’s basic statistical data in
particular challenges for consumers / patients who relation to their potential for illness
live alone, or who support children, or family members sychologically vulnerable - the actual or potential
p
with a disability, mental illness or terminal condition harm to the identity of self and/or other emotional
ccess to care: consumers / patients isolated through
a effects such as anxiety or stress caused by the
a rural location or transport issues may struggle to ailment or treatment
meet some appointment schedules hysically vulnerable - the actual physiological state
p
urrent health status including comorbidities,
c where an individual is susceptible to further morbidity
functional capacity, mental health, oral health, general or mortality.
literacy / health literacy, support networks, etc.
religious and cultural / ethnic beliefs: may impact
decision making in areas such as blood transfusion
and pain management
fertility preferences: important for planning before
initiating many chemotoxic therapies
dietary restrictions and preferences.
March 2016 27
Criterion 1.1.1 Planning for transfer of care / discharge

Assessment ensures current and ongoing The organisation should routinely plan for transfer of
needs of the consumer / patient are identified. care / discharge at assessment and ensure these plans
(continued) are multidisciplinary, include referral to specialty services
when required, and meet consumer / patient and
Vulnerable consumers / patients and consumer carer needs.
groups who may be at increased risk include, but are Planning for transfer of care / discharge should include:
not limited to:
onsideration of the consumer / patient’s
c
the aged, frail or disabled social situation, health status and living arrangements
the socioeconomically disadvantaged s trong relationships with a variety of referral partners,
indigenous populations in some countries, and preferably reflected in clear, agreed referral protocols
non-indigenous in others representatives of potential ongoing care providers.
residents in rural and remote areas Wherever appropriate, a carer or support person
should be involved in care planning
prison inmates
follow-up with the referring health professional to
defence force veterans
ensure potential risks and challenges that were
disadvantaged ethnic minority residents. identified by a thorough assessment process are met,
particularly where the organisation may have only a
limited role in ongoing care provision.
Prompt points For further information on transfer of care / discharge,
hat features of this organisation and
W refer to criterion 1.1.5.
consumer / patient pool determine or
influence how vulnerable consumers / patients
are defined? Prompt points
ow are vulnerable consumers / patients
H hat processes facilitate communication
W
identified? What changes are made to better during the transfer of care to ensure that
manage the identified risks? information gained at assessment is followed-up?
ow are records of expanded assessments,
H ow and when has the transfer of care /
H
such as falls risk or anaesthesia risk discharge system been evaluated? What were
assessments, integrated with the health record? the findings? As a result of investigations, have
any changes to the assessment process been
hat guidelines / other resources are available
W
made or planned?
to the organisation’s staff to assist them to
identify at-risk consumer / patient groups?
ow are at-risk consumer / patient records
H
identified? How is the identification of at-risk
consumers / patients used for clinical treatment?
ow do staff understand and meet the
H
specific needs of any identified at-risk
consumers / patients or groups who may
require services?
Referral systems • clear and universally applied eligibility criteria
From the time a consumer / patient enters the • prioritisation according to clinical need, preferably
healthcare organisation, his or her health record will according to priority of access policy and
document information that may be relevant to providers agreed criteria
of ongoing care. Organisations should ensure that • timely response to referral, or application of
relevant information about consumers / patients, their demand management measures such as referring
home, their care and other healthcare providers is on if necessary
accessible to the referring physician so that it can be
communicated to all partners in ongoing care. • advising referrer of referral outcome, preferably
within an agreed timeframe.
In an unscheduled setting, such as an emergency
department, the ‘referral to a relevant service provider’
may involve admission to the organisation and an Prompt points
internal handover to a ward setting. This is discussed in
more detail within criterion 1.1.5. Is there a system of referral through the
department / organisation - if so, does it
A referral system requires: contribute to consistency, legibility, detail and/or
s trong relationships with a variety of referral partners, timeliness of information transfer?
preferably reflected in clear, agreed referral protocols oes it include a centrally updated listing of
D
ccess to up-to-date service directories of referral
a relevant service providers and their contact
options that meet a range of consumer / patient needs details that will facilitate appropriately directed
(including accessibility, opening hours, cost, etc.) referral communications?
lear policy and procedures for associated functions,
c ow effective is the process? How satisfied
H
which include: are health professionals with the process? Has
there been any feedback from organisations
• holistic identification of consumer / patient need(s) receiving referrals from this facility?
• assessment of risks faced by the consumer / patient
and/or staff
• documentation, or integration with consumer /
patient management system software applications
• selection of suitable referral option(s) in partnership
with the consumer / patient and/or carer
• checking suitability of referral option(s), for example,
area of expertise, services offered, accessibility,
eligibility criteria, priority for service and waiting times
• sharing of relevant health information with explicit,
informed consumer / patient consent
• documenting the consumer / patient consent to
share identified health information with a specified
referral option
• minimising duplication of effort or actions
that require the consumer / patient to re-tell
his / her ‘story’
• sending / transmitting information according to
privacy requirements
• timely acknowledgement of receipt of referral,
preferably within an agreed timeframe
March 2016 29
Criterion 1.1.1
Assessment ensures current and ongoing Audit of records, for example the health record
or referral documentation, or tracking of clinical
needs of the consumer / patient are identified.
indicators to measure performance
(continued)
Feedback from consumers / patients and/or
referral physicians and organisations sought, for
The following evidence may help to example by satisfaction survey
address criterion 1.1.1
dmission process / procedure (health professional
A Suggested reading
and/or consumer / patient satisfaction)
Standards for Medical Assessment and Planning Units in
re-admission assessment records for
P Public and Private Hospitals. Sydney NSW: Internal Medicine
elective procedures Society of Australia and New Zealand (IMSANZ). Available
from: http://www.imsanz.org.au/documents/item/413 Viewed
Care and assessment plans 12 February 2016.
Health record - consumer / patient details Kessler Psychological Distress Scale. Available from: http://
/ history, referral documents, clinical notes www.blackdoginstitute.org.au/docs/5.K10withinstructions.pdf
(potentially demonstrating multidisciplinary input) Viewed 12 February 2016.
- audits of completeness WHO guidelines on conditions specifically related
Discharge policy / discharge planning procedure to stress. Available from: http://apps.who.int/iris/
bitstream/10665/85119/1/9789241505406_eng.pdf Viewed
ards’ discharge board(s) / discharge planning
W 12 February 2016.
teams / referral systems
Clinical guideline: Augmentative and alternative
Transition care programs communication. Speech Pathology Australia, 2012.
Available from: http://www.speechpathologyaustralia.org.
Triage systems / guidelines / performance tracking au/library/Clinical_Guidelines/24072012%20FINAL%20
otes from multidisciplinary meetings (case
N Augmentative%20and%20Alternative%20Communication%20
Cl.pdf Viewed 2 February 2016.
conferences) to discuss management for
consumers / patients with complex care needs Clinical guidelines for the physical care of mental health
consumers. Available from: https://www.clinicalguidelines.gov.
Medication reconciliation processes au/portal/2053/clinical-guidelines-physical-care-mental-health-
dditional forms for recording expanded
A consumers Viewed 12 February 2016.
assessments Communicating with adolescents. Guidelines for adults on
how to communicate with adolescents about mental health
Information brochures for consumers / patients,
problems and other sensitive topics. Available from: https://
for example regarding admission or preparation mhfa.com.au/sites/default/files/MHFA_communicate_
for surgery adolescents_-guidelines.pdf Viewed 12 February 2016.
uidelines that specifically cover identified
G Information on culture and ethnicity for health assessments,
at-risk groups in the context of the organisation’s available at the Centre for Culture, Ethnicity and Health.
clinical interests and consumer / patient pool, Available from: http://www.ceh.org.au/resources Viewed 12
for example Aboriginal and Torres Strait Islander February 2016.
issues, defence force mental health issues, etc. National guide to a preventive health assessment for Aboriginal
onsistent reporting systems, such as
C and Torres Strait Islander people; National Aboriginal
Community Controlled Health Organisation. Available from:
SBAR (Situation, Background, Assessment,
http://www.naccho.org.au/promote-health/national-guide-to-
Recommendation) a-preventive-health-assessment / Viewed 12 February 2016.
agging of consumers / patients or their health
T
records to highlight risk, such as for allergies or
high risk of falls
Australian Institute of Health and Welfare (AIHW). Improving
identification of Aboriginal and Torres Strait Islander peoples
in health data. Melbourne VIC; AIHW; 2009. Available from:
https://www.lowitja.org.au/sites/default/files/docs/Identification_
report_Kelaher2010.pdf Viewed 12 February 2016.
The Hong Kong College of Anaesthesiologists. Guidelines for
safe sedation for diagnostic & therapeutic procedures. April
2012. Available from: http://www.hkca.edu.hk/ANS/standard_
publications/guidep02.pdf Viewed 18 March 2016.
March 2016 31
Implementation
Criterion 1.1.2 a) Guidelines for care planning and a) Care planning and delivery are
delivery are based on current based on the assessment of
Care is planned and delivered in
professional standards and consumer / patient needs, in
collaboration with the consumer /
evidence-based practice, and are partnership with the consumer /
patient and, when relevant, the
readily available to staff. patient and their carer.
carer to achieve the best
possible outcomes. b) C
are planning addresses the b) Care is coordinated, planned and
diverse physical, spiritual, cultural, delivered by skilled and trained
medical, psychological and social health professionals within a
needs of consumers / patients. multidisciplinary team with an
identified team leader.
c) Care planning addresses the
specific needs of vulnerable c) Care planning, decisions, actions
consumers / patients and and changes are documented
population groups. in the consumer / patient
health record, and are
d) C
onsumers / patients are informed
regularly reassessed.
of factors impacting on their health
and a plan for promoting their d) The consumer / patient is regularly
individual wellbeing is discussed. informed about their health status,
and provided with information that
e) Care is provided in response to
allows them to understand their
consumer / patient needs in a
care, care delivery options, and
timely manner and in accordance
changes to their care plan.
with relevant policy / guidelines.
f) C
are planning and delivery reflect
the requirements of the consumer /
patient’s advance care directive
where applicable.

This criterion outlines the importance of care planning Care planning and care delivery are an integral part of
and delivery in response to consumer / patient needs the consumer / patient journey (Standard 1.1). Care
as identified in the assessment process, and of a planning should consider the processes of access and
consultative, collaborative approach to the provision admission (Criterion 1.2.2), how the most effective care
of health care that will actively involve the consumer / can be delivered and the outcomes of the care evaluated
patient and their carer. (Criterion 1.4.1), the various aspects of ongoing care
(Criterion 1.1.6), and how the most appropriate care can
be delivered in the most appropriate setting (Criterion
1.3.1). All decisions made should be recorded in the
health record (Criterion 1.1.8).
Consumers / patients should participate in their own
care planning (Criterion 1.6.1), which is one of their
healthcare rights (Criterion 1.6.2). Planning should
encompass the diverse needs and diverse backgrounds
of consumers / patients (Criterion 1.6.3), and how these
a) C
ompliance with guidelines a) The organisation shows distinction a) The organisation demonstrates
and practices for care planning in care planning and delivery. it is a leader in care planning and
and delivery is monitored and delivery practices.
evaluated, and improvements are
made as required.
b) T
he care planning and delivery
process is evaluated, and
improvements are made
as required.
c) Multidisciplinary team processes
for care delivery are evaluated,
as required.
d) The regular reassessment of the
consumer / patient is evaluated,
as required.
may impact upon the delivery of care. Effective care ddress the needs of vulnerable consumers / patients
A
planning and delivery are facets of the organisation’s and consumer / patient groups.
integrated risk management framework (Criterion 2.1.2),
and failures in this area may lead to incidents (Criterion Inform consumers / patients of their health status
2.1.3) and complaints (Criterion 2.1.4). including when there are changes made to care
planning, and promote their individual wellbeing.
This criterion requires healthcare onsider the implications of consumer / patient
C
organisations to: decisions that are documented in advance
care directives.
nsure care planning and delivery of care are based on
E
the assessment of consumer / patient needs and are
coordinated and delivered by multidisciplinary teams.
se evidence-based guidelines that will assist staff to
U
assess physical, spiritual, cultural, psychological and
social needs of consumers / patients.
March 2016 33
Criterion 1.1.2 Effective planning, delivery and coordination of care may

Care is planned and delivered in collaboration draw upon:
with the consumer / patient and, when uidelines developed by professional colleges
g
relevant, the carer to achieve the best and/or associations
possible outcomes. (continued) clinical pathways / care plans
legislative requirements, medico-legal requirements,
Care planning and delivery based on the standards, codes of practice, ethics and frameworks
assessment of consumer / patient needs
the organisation’s policies and procedures
The planning, delivery and coordination of care is the
core business of all healthcare organisations. The key uidelines for consumers / patients identified as being
g
considerations in care planning are that: at high risk, such as standard protocols for cardiac
arrest or acute psychotic episodes
are is planned and documented according to the
c
assessment of consumer / patient needs rganisational strategies to deal with high-risk
o
activities, which will vary within the health sector and
there is input from the consumer / patient and relevant be influenced by the consumer / patient. Examples
care providers of known high-risk activities include management of
there is consideration that a second opinion may blood transfusions and medication management
be sought identified strategies to promptly identify / detect
are planning and delivery are based on the best
c and deal with poor nutritional status, delirium, acute
available evidence psychotic episodes, falls, depression, deterioration in
consumer / patient health condition and cardiac arrest
are is delivered by competent individuals and
c
multidisciplinary teams uidance to identify and manage changes in
g
consumer / patient health status including appropriate
are is coordinated between all members of the team
c referral within the organisation or to community
(including carers) services following discharge. Examples include the
the needs of vulnerable consumers / patients are management of pressure areas, incontinence, post-
identified and managed appropriately surgical complications, deterioration in clinical status,
development of iatrogenic complications, transfer to
the environment within which care is provided is an Intensive Care Unit (ICU) and postnatal care
comfortable, caring and appropriate to consumer /
patient needs. evidence-based research and guidelines.
The care plan or clinical pathway may include:

oals to be achieved, which should reflect the clinical
g
condition of the consumer / patient
tests and investigations to be conducted
procedures and interventions to be provided
multidisciplinary team referrals
onsumer / patient education strategies to
c
be implemented
timeframes to be met
delineation of responsibilities
planning for transfer of care / discharge
transfer of care.
Organisations should consider vulnerable populations
Prompt points within their own countries, and should also consider
the implications of consumers / patients being born in
re clinical guidelines / pathways used
A another country. Some people from other countries are
in care planning referenced to evidence- hospitalised at significantly higher rates for a number of
based source(s)? How frequently are these health conditions. These conditions, and the countries of
reviewed and updated? birth with higher rates, include:
re medico-legal requirements considered and
A tuberculosis - India, Vietnam, Philippines, China
met by the care planning processes? How is
this recorded? lung cancer - United Kingdom and Ireland
Is there evidence of revised care plans? How diabetes - Greece, India, Italy, Vietnam, middle east
are revisions to care plans managed? heart attack - India
Is there evidence of multidisciplinary care in the heart failure - Italy, Greece, Poland
health record? How is prime responsibility (the
team leader) for consumer / patient care assigned ialysis - Greece, Italy, Vietnam, Philippines,
d
and demonstrated within the health record? Croatia, India.
hen are case conferences used to coordinate

W
care? How are they managed? Prompt points
re the members of multidisciplinary teams
A o organisational policies / programs
D
chosen by the team leader or is this determined for care planning recognise and reflect
by organisational policy / procedures? healthcare priorities for identified vulnerable
populations? Is this stated in the documents or
referenced?
Vulnerable consumers / patients and
consumer / patient groups ave processes / policies been developed for
H
classes of consumers / patients or disease
Some population groups experience marked health states for vulnerable populations?
inequalities compared with others.
For example:
Informing consumers / patients of their
eople living in rural and remote areas tend to have
p health status
higher levels of disease risk factors and illness than
those in major cities Consumers / patients and, where appropriate, carers
should understand that there are multiple choices
eople from the lowest socioeconomic status groups
p navigated by their health professional on their behalf
are likely to have poorer health when planning their care.
eople with disability experience significantly poorer
p xplanation should be provided for consumers /
E
health than those without disability patients and carers so that they understand the
indigenous Australians are generally less healthy diagnosis, prognosis, treatment options and illness
than other Australians and are more likely to die at prevention strategies.
younger ages. elivery of the information should be timely, and
D
provided in a suitable way for the individual consumer /
patient to understand his or her treatment options in
collaboration with their carer(s).
here appropriate, carers should be made aware of,
W
and referred to, services and support for carers.
March 2016 35
Criterion 1.1.2 Consumers / patients may require education to

Care is planned and delivered in collaboration understand their personal responsibility for their long
term wellbeing.
with the consumer / patient and, when
relevant, the carer to achieve the best
possible outcomes. (continued) Prompt points
hat standard information is provided
W
A framework for shared decision making was outlined
to consumers / patients to help them
in a paper by Towle et al., to evaluate whether care
understand the care delivery process?
planning was undertaken as a partnership between
consumer / patient and health professional. ow is communication about care
H
processes documented in the consumer /
The framework includes:
patient health record?
stablishing or reviewing the consumer / patient’s
e
hat records are used to document
W
preferences for information (such as amount or format)
discussions with consumers / patients about
stablishing the consumer / patient’s preferences for
e promoting better health?
their role in decision making
re offers of education / support programs to
A
xplaining any uncertainty about the ‘best’ course of
e promote better chronic disease management
action to take recorded in the health record? How are
scertaining and responding to the consumer /
a recommendations to receptive consumers /
patient’s ideas, concerns and expectations patients followed up?
identifying options available, evidence of their efficacy

and their relevance for the consumer / patient’s Documented advance care directives
existing situation
There should be a system for developing and
elping the consumer / patient to reflect on and
h implementing advance care directives for consumers /
assess the impact of alternative decisions with regard patients. Advance care directives are designed to assist
to his or her lifestyle and values consumers / patients to plan for future medical care
advising of any variation in clinical care by providing a platform where they can document their
wishes in the event that they are unable to vocalise
negotiating a decision in partnership them. Ensuring the consumer / patient understands
greeing on an action plan and making next
a their health status and treatment options will assist in
step arrangements. developing the advance care directive.
Advance care directives:
Where decisions are complex or will involve family
members, consumers / patients may be provided with a ome into effect when a consumer / patient has lost
c
‘take home’ summary to assist them to recall their options their capacity to communicate a treatment decision
and consider them with others. Any discussions / s hould be reviewed on a regular basis to ensure
outcomes should be documented in the consumer / consumer / patient choices have not changed
patient health record.
nsure that the consumer / patient’s wishes are
e
onditions requiring a commitment by consumers /
C followed over the carer / family wishes
patients to managing their condition include:
s hould be recorded in the consumer / patient
vercoming the temptations of withdrawal from drug
o health record.
addiction, including smoking cessation
Organisations should ensure there is a system that
lood pressure and cholesterol management to
b alerts health professionals about the existence of an
reduce the risk of heart attack and stroke advance care directive, and health professionals should
dietary management for coeliac consumers / patients. ensure that the advance care directive is referred to
when appropriate.
Suggested reading
Prompt points National Health and Medical Research Council. Australian
hat processes are there in place to
W Clinical Practice Guidelines Portal. Available from: https://www.
clinicalguidelines.gov.au / Viewed 16 February 2016.
assist consumers / patients to document
an advance care directive? The 14th biennial health report of the Australian Institute of
Health and Welfare. Available from: http://www.aihw.gov.au/
hat alert system is used to ensure health
W australias-health-publications / Viewed 12 February 2016.
professionals are aware that an advance care
directive is in place? National Pain Strategy. Pain management for all Australians.
Developed by the National Pain Summit initiative. Led by:
ow does the organisation implement the
H Australian and New Zealand College of Anaesthetists. Faculty
advance care directive? of Pain Medicine. Australian Pain Society. Chronic Pain
Australia. Available from: http://www.chronicpainaustralia.org.
au/files/PainStrategy2010Final.pdf Viewed 12 February 2016.
Various publications and guidelines: The Lowitja Institute;
The following evidence may help to Australia’s national institute for Aboriginal and Torres Strait
address criterion 1.1.2 Islander health research. Available from: http://www.lowitja.org.
au / Viewed 12 February 2016.
linical pathways / care plans (with references or
C
Flores G. Devising, implementing, and evaluating interventions
original source)
to eliminate health care disparities in minority children.
olicies or guidelines that are used in care
P Pediatrics 2009; 124(Suppl3): S214-S223. Available from:
planning - easily accessible format https://www.researchgate.net/publication/38040682_
Devising_Implementing_and_Evaluating_Interventions_to_
olicies / procedures on record keeping to
P Eliminate_Health_Care_Disparities_in_Minority_Children
facilitate care planning Viewed 12 February 2016.
ealth records demonstrating
H Agency for Healthcare Research and Quality (AHRQ). Tools
multidisciplinary input with a responsible and information on shared decision making. The SHARE
health professional identified consistently Approach. A five-step process for shared decision making
that includes exploring and comparing the benefits, harms,
Case conference notes and risks of each option through meaningful dialogue about
what matters most to the patient. Available from: http://
valuation of communication delivery or of its
E www.ahrq.gov/professionals/education/curriculum-tools/
comprehension by consumers / patients shareddecisionmaking/index.html Viewed 12 February 2016.
valuation of consumer / patient satisfaction
E Towle A, Godolphin W, Grams G and Lamarre A. Putting
including satisfaction with the environment in informed and shared decision making into practice. Health
which care was received Expectations 2006; 9(4): 321-323. Extract on shared
decision making Available from: http://www.longwoods.com/
olicy / guidelines specifically on management
P content/20947 Healthcare Quarterly, 12(Sp) August 2009:
and implementation of advance care directives e186-e190.doi:10.12927/hcq.2009.20947. Viewed 15
February 2016.
March 2016 37
Implementation
Criterion 1.1.3 a) Policy / guidelines addressing a) Consent is obtained for

consent are consistent with investigations, treatments or
Consumers / patients are informed
relevant legislation, standards, procedures and any associated
of the consent process, and they
guidelines and/or codes of costs, and for the communication
understand and provide consent for
practice, and are readily available of consumer / patient information,
their health care.
to staff. in accordance with the
This is a mandatory criterion organisation’s policy / guidelines.
b) Health professionals are educated
about the consent policy / b) There is a process to manage:
guidelines and how to obtain
(i) w
hen consent cannot be given
informed consent.
at the appropriate time
c) Consumers / patients and carers
(ii) w
hen the consumer / patient
are provided with information on
does not have the capacity to
recommended investigations,
provide consent
treatment or procedures, the
risks involved and the costs, in (iii) p
rovision of consent by
appropriate formats / languages. someone other than the
consumer / patient
(iv) the limits of consent.
c) D
etails of the information provided
to the consumer / patient in the
process of obtaining informed
consent is documented in the
health record.
Overview onsent for collection of health information, and to

C
any use of that information and/or disclosure by the
This criterion defines the requirements for
organisation to third parties, is usually required under
obtaining consent and ensuring the process is
privacy laws.
managed appropriately.
he consumer / patient and/or carer must be
T
In this document, the term ‘consent’ covers a number of
provided with adequate information to allow informed
different legal requirements:
financial consent.
he consumer / patient and/or carer should be
T
informed in broad terms of the nature of any invasive
procedure which is to be performed. This consent
protects the consumer / patient and also operates as
a defence to legal action.
he consumer / patient and/or carer should be
T
informed of material risks inherent in the procedure
or treatment. This is part of the duty of care owed
to the consumer / patient by the appointed health
professional who provides treatment.
a) T
he consent process is evaluated, a) The organisation shows a) The organisation demonstrates it
and improvements are made distinction in its management of is a leader in consent systems.
as required. the consent process.
b) C
ompliance with the consent
process is monitored and
evaluated, and strategies for
improvement are identified and
implemented as required.
Relationships of 1.1.3 with other criteria This criterion requires healthcare

The need for the organisation to obtain informed organisations to:
consent to treatment from the consumer / patient is a Comply with relevant legislation about consent.
vital aspect of the planning and delivery of care (Criterion
1.1.2). Consent is also necessary in advanced planning btain informed consent for investigations, treatments
O
for end-of-life care (Criterion 1.1.7), including decisions or procedures and any associated costs, and
about organ donation. The consumer / patient has a document the consent.
right to understand his or her treatment options, and to Obtain consent to communicate personal information.
give or withhold informed consent (Criterion 1.6.2), and
to have access to support services such as interpreters anage instances when the consumer / patient
M
when required (Criterion 1.6.3). The consent process cannot provide their own consent.
is an aspect of the organisation’s integrated risk
management framework (Criterion 2.1.2), and failure
to manage consent processes correctly may lead to
complaints (Criterion 2.1.4).
March 2016 39
Criterion 1.1.3 s ituations where procedures, care and treatment

Consumers / patients are informed of the normally requiring consent may be given without consent
consent process, and they understand in private hospitals, the requirement for at least an
and provide consent for their health care. acknowledgment of consent and what the obligations
(continued) of visiting medical staff are to provide consent
documentation as covered in the facility’s by-laws.
Relevant legislation on consent There are procedures that have proven controversial in
Consent is the first of the World Health Organization’s some situations, for which written consent may be a
Best Practice Protocols: Clinical Procedures Safety, wise precaution. These include:
which were first published in 2004 and reformatted in
blood and blood derivative transfusions
2012; worldwide, consent for invasive investigations,
treatment or procedures on consumers / patients is a other tissue transplants and tissue-derived infusions
fundamental expectation of healthcare providers.
testing for blood-borne disease where a service
Consent is a significant aspect of the assessment of provider may have been exposed to risk
consumer / patient needs both from a clinical and
testing for a condition that is notifiable, may be
non-clinical perspective. Most countries have laws
untreatable or has associated stigma
addressing consent to treatment and organisations
should have information on relevant legislative treatments that may impact future
requirements and guidelines. Policies addressing reproductive capacity
consent should be in accordance with the legislation and rovisional consent for other procedures additional
p
relevant guidelines and organisation-wide practices must to those on the consent documentation that are
comply. Consent can include financial, procedural, ethics considered necessary in the judgement of the surgeon
and/or research consent. during an operation
The requirements for gaining consent should be defined s ituations where an alternative health professional is to
in the organisation’s policy; this will influence how the undertake the procedure
procedural details are addressed.
isposal / testing / research donation of tissues
d
The consent policy should reflect jurisdictional legislation removed during surgery
and address the following:
imaging that carries independent risks when
the organisation’s responsibilities in regard to undertaken during a procedure requiring sedation
gaining consent
ecisions to refuse treatment against medical
d
the procedure, care, treatment and investigation recommendations
options and costs that require written, verbal or
implied consent voidance of cardiopulmonary resuscitation in
a
terminal consumers / patients (consent given in the an
the process used to obtain consent, including ways advance care directive, and frequently abbreviated
that information may be provided to the consumer / as NFR).
patient (verbally, brochures, using interpreters)
Orientation programs for new staff should include the
ow consent is to be documented in the consumer /
h consent process. An understanding of the consent
patient’s health record policy by healthcare providers cannot be assumed.
hen a surrogate decision maker, rather than the
w
consumer / patient, may give consent
the use of interpreters / interpreter services when the
consumer / patient is not proficient in the primary
language of the organisation’s representatives
hotography and use of mobile phones, including
p
Prompt points recording or filming of care or treatment
oes the organisation have copies of
D the presence of visitors, such as medical students, in
relevant legislation / codes of practice etc. the operating theatre
on consent? Does the consent policy comply ny invasive procedures that occur after admission,
a
with, and reference this legislation / code for example catheterisation or invasive radiology.
of practice?
oes the policy state the procedures /
D In obtaining consent, organisations should:
circumstances to which it applies? How does onsider the implications in organ and tissue
c
the organisational policy address potentially donation, where consent issues can be particularly
controversial situations? challenging; hospitals undertaking organ transplants
Is consent covered in orientation or other must have policy in place
training for clinical staff? How is the nsure consent forms that are presented to
e
organisation’s consent policy made readily consumers / patients avoid the use of acronyms
accessible to staff? wherever possible and, where technical language is
re audits undertaken to check that consent
A included, ensure a verbal explanation of the document
is being obtained in accordance with the is provided before it is signed
organisation’s policy? onsider the literacy capacity, as well as health literacy
c
re consent levels considered satisfactory?
A capacity, of consumers / patients and make every
What actions have been taken to maintain effort to ensure understanding
or improve consent levels or to reduce risks include a system for accommodating private sector
associated with consent? requirements, where there are cascading levels
of consent; for example, the treating practitioner
will usually obtain consent for recommended
Informed consent is obtained investigations, treatments or procedures and their
Organisations should obtain informed consent for costs within their own rooms prior to providing that
investigations, treatments or procedures and any health care
associated costs and document the consent in the nsure there is either a copy of the signed consent
e
consumer / patient health record. obtained by the treating health professional or a
A completed consent process should include a signed ‘acknowledgement of the consent’, in the
discussion of the following issues: consumer / patient health record
the nature of the proposed care, treatment, nsure the environment where consent is
e
services, medications, interventions, investigations explained to the consumer / patient is private and
or procedures free from distractions.
possible benefits, risks, complications and side effects
the probability of achieving care and treatment goals
reasonable alternatives to the proposed care and
treatment and the relevant risks, complications and
side effects of alternative treatments including the
possible results of receiving no treatment or care
ny limitations on the confidentiality of information
a
learned from or about the consumer / patient
stimated costs of hospitalisation, prior to or
e
upon admission
March 2016 41
Criterion 1.1.3 here information may affect employment

w
Consumers / patients are informed of the opportunities or financial transactions due to changing
consent process, and they understand perceptions of risk (e.g. attempted suicide, survived
cancer following treatment, family history of disease)
and provide consent for their health care.
(continued) ase history in referrals to other healthcare providers
c
or briefing notes to imaging or pathology professionals
isease, vaccination or transplant registries (in some
d
Prompt points cases includes names)
hat processes are used to manage
W relevant Notifiable Diseases Surveillance Systems
consent where the consumer / patient's
proficiency in the main language of the country / ase history described in teaching or published
c
organisation is uncertain? papers, where images or tissues are used in teaching
(even when de-identified), or when consumers /
hat processes are used to manage requests
W patients are visited by a tutorial group
for organ donation (where this may apply)?
here application forms are completed and submitted
w
here a procedure is explained to consumers /
W by the organisation on behalf of consumers / patients,
patients at the organisation, what information is for instance, when applying for access to some
provided to assist them to understand the risks medical devices or for an organ transplant.
and benefits of the procedure?
There are also specific circumstances where reporting
hat procedure is used to provide accurate
W is legally mandated and in cases of suspected violence,
financial estimates to consumers / patients? it may be wiser not to forewarn the consumer / patient.
oes the organisation take action to ensure
D Health professionals should be familiar with the
that consumers / patients understand the legislation operating in their jurisdiction.
cost implications?
ow is compliance with the consent
H Prompt points
process evaluated?
nder what circumstances does the
U
organisation seek a signed consent for the
Consent to communicate transfer of information?
personal information ow is any risk associated with information
H
provision broached with consumers / patients?
Personal information should only be collected for the
legitimate activities of a healthcare organisation and
used only for purposes related to the reason for which
Managing instances when the consumer /
the data were originally collected. Many countries have
legislation to address this. patient cannot provide their own consent
This requires that consent be sought, except in some Organisations should have specific policies and/or
specifically stated circumstances, before information is procedures to address circumstances where:
transferred to other organisations or people, such as: consent cannot be given at the appropriate time
ommunications with medical funding bodies such as
c the consumer / patient does not have the capacity to
Medicare and the Health Insurance Commissions provide consent
s amples identified by name when sent to diagnostic there is provision of consent by someone other than
laboratories for testing that may be associated with the consumer / patient
social stigma (e.g. sexually transmitted diseases,
heritable diseases) and any subsequent contact tracing there needs to be limits to the consent.
Circumstances where consent may not be able to be
given at the time of service may include: The following evidence may help to
in an emergency, where the consumer / patient is address criterion 1.1.3
unable to give consent and the treatment is required ccess to relevant legislation / codes
A
immediately to save the person’s life; or to prevent of conduct / codes of practice / guidelines
serious injury to a person’s health; or to prevent the and standards
consumer / patient from suffering or continuing to
suffer significant pain or distress rganisational consent policy that complies
O
with legislation
hen the consumer / patient is affected by a
w
mental illness ealth records containing consent forms or
H
notes on discussions about consent
when the consumer / patient is a minor.
raining and information resources for health
T
Managing circumstances where the consumer / patient professionals on consent
does not have the capacity to provide consent Estimates of procedure costs with signed consent
may include:
omplaints management in situations related
C
seeking a substitute decision maker to consent
n assessment of competence, which should involve
a ealth records audit to assess levels of consent
H
three aspects: and quality of process
1. Does the person understand? eview of consent forms and communication
R
2. Does the person believe what they are being told? documents for ease of understanding
3. Can the person make a judgment based on

this information?
reference to advance care directives
treatments authorised by statute or court order.
Prompt points
Is there policy / guidelines for managing
situations where consent may not have
been obtained from a consumer / patient?
What relevant legislation / codes of practice etc.
have been referenced in the policy / guidelines?
nder what circumstances are consumers /
U
patients deemed incompetent in the
organisation? How is this managed?
ow are health professionals and other relevant
H
staff educated about these circumstances?
March 2016 43
Criterion 1.1.3
Consumers / patients are informed of the
consent process, and they understand
and provide consent for their health care.
(continued)
Suggested reading
World Health Organization. Best practice protocols: Clinical
procedures safety. Available from: http://www.who.int/surgery/
publications/BestPracticeProtocolsCPSafety07.pdf Viewed 12
February 2016.
National Health & Medical Research Council (NHMRC).
General Guidelines for Medical Practitioners on Providing
Information to Patients. Available from: https://www.nhmrc.
gov.au/guidelines-publications/e57 Viewed 12 February 2016.
Information about the Australian Privacy Principles. Available
from: https://www.oaic.gov.au/privacy-law/privacy-act/
australian-privacy-principles Viewed 12 February 2016.
Truog RD. Consent for organ donation — balancing conflicting
ethical obligations. N Engl J Med 2008; 358(12): 1209-
1212. Available from: http://www.nejm.org/doi/full/10.1056/
NEJMp0708194. Viewed 12 February 2016.
Mental Illness Fellowship of Australia. Fact Sheets: Mental health
legal frameworks. Available from: http://www.mifellowship.org/
content/fact-sheets Viewed 12 February 2016.
Australian Institute of Family Studies. Mandatory reporting
of child abuse. National child protection clearing house
resource sheets 2014. Available from: https://aifs.gov.au/cfca/
publications/mandatory-reporting-child-abuse-and-neglect
Viewed 12 February 2016.
Australian Government. Australian Law Reform Commission.
Informed consent to medical treatment. Available from:
https://www.alrc.gov.au/publications/10-review-state-and-
territory-legislation/informed-consent-medical-treatment
Agency for Healthcare Research and Quality (AHRQ).
Improving Patient Safety Systems for Patients With Limited
English Proficiency; A Guide for Hospitals. Available from:
http://www.ahrq.gov/sites/default/files/publications/files/
lepguide.pdf Viewed12 February 2016.
Appelbaum PS. Assessment of patients’ competence to
consent to treatment. N Engl J Med 2007; 357(18): 1834-
1840. Available from: http://www.nejm.org/doi/full/10.1056/
NEJMcp074045 Viewed 12 February 2016.
Australian Government. Australian Law Reform Commission.
Decision Making by and for Individuals Under the Age of 18.
Available from: http://www.alrc.gov.au/publications/68.%20
Decision%20Making%20by%20and%20for%20Individuals%20
Under%20the%20Age%20of%2018/capacity-and-health-info
March 2016 45
Implementation
Criterion 1.1.4 a) Policy / guidelines addressing a) There is governance / committee

the management of medical oversight of medical
The organisation implements
emergencies are consistent with emergency responses.
effective systems for the
relevant standards, guidelines
management of medical b) Medical emergency management
and/or codes of practice, and are
emergencies, including the plans are developed, reviewed
readily available staff.
identification and care of and tested in consultation with
deteriorating consumers / patients. b) Regular observations are recorded relevant staff.
for each consumer / patient on
This is a mandatory criterion c) Equipment and resuscitation
standardised observation charts.
trolleys are standardised
c) There is a system to identify and throughout the organisation.
manage clinical deterioration in
d) Rostering ensures that medical
consumers / patients.
emergency respondents
d) There are processes to are available to meet
escalate the care of a organisational needs.
deteriorating consumer / patient
e) Relevant health professionals
when necessary.
are trained in appropriate first
e) Medical emergency response response techniques.
plans and instructions are
f) Relevant health professionals
prominently displayed throughout
are trained in advanced clinical
the organisation.
life support.
f) H
ealth professionals are educated
and trained at orientation and
annually in the correct response to
medical emergencies.
g) Health professionals and other
relevant staff are trained in basic
life support and records of the
training are maintained.

This criterion is new to EQuIP, and is included to Systems and processes for identification and management
support organisations to have systems, policies and of the deteriorating consumer / patient are a major aspect
procedures, and training programs in place that identify of the organisation’s emergency management (Criterion
and manage potential situations that may arise, in terms 3.2.4) and risk management (Criterion 2.1.2). Assessment
of consequence, probability and preventive actions for (Criterion 1.1.1) should identify consumers / patients at risk
medical emergencies, including clinical deterioration of of deterioration, and this should be addressed in the care
consumers / patients. Organisations should demonstrate plan (Criterion 1.1.2) and documented in the health record
development and implementation of appropriate medical (Criterion 1.1.8). Should deterioration result in death,
emergency response systems and the capacity to appropriate end-of-life care is required (Criterion 1.1.7).
respond to clinical deterioration of consumers / patients. All instances of consumer / patient deterioration should
be reviewed, and outcomes in this area of management
evaluated (Criterion 1.3.1). Failure to effectively manage
a) T
he organisation-wide medical a) The organisation shows a) The organisation demonstrates
emergency management system is distinction in its management of it is a leader in medical
evaluated, and improvements are medical emergencies. emergency preparedness and
made as required. management systems.
b) T
he system to identify and
manage deteriorating consumers /
patients is evaluated, and
as required.
c) Records of emergency calls are
maintained and responses are
made as required.
d) There are demonstrated links
between identification of
deteriorating consumers / patients
and escalation of care.
e) Staff training and competence in
managing medical emergencies
f) Outcomes of the evaluation of
the organisation’s responses to
medical emergencies are reported
to the governing body.
the deteriorating consumer / patient may be regarded as Record consumer / patient

an incident (Criterion 2.1.3), and may lead to complaints observations on an evidence-based
(Criterion 2.1.4).
general observation chart
This criterion requires healthcare The design of an observation chart can have a
organisations to: substantial impact on the decision accuracy and
response times of health professionals in recognising
ecord consumer / patient observations on an
R abnormal observations.
evidence-based general observation chart.
Organisations should ensure regular observations are
Identify and manage clinical deterioration. recorded, and that the observation charts:
Have a medical emergency response plan. are designed according to human factors principles
nsure staff are trained in first aid, basic life support
E
and advanced life support, as appropriate to their role.
March 2016 47
Criterion 1.1.4 Identify and manage clinical deterioration

The organisation implements effective systems All healthcare organisations should develop policy
for the management of medical emergencies, and a system for identifying, reporting and managing
including the identification and care of deteriorating consumers / patients. In the past,
deteriorating consumers / patients. (continued) organisations have focused on having effective
mechanisms in place for resuscitating a consumer /
include the capacity to record information about patient after the onset of cardiac or respiratory arrest.
heart rate, respiratory rate and adequacy of A substantial amount of effort and resource utilisation
oxygenation, blood pressure, temperature and level of is still expended on this serious adverse event, which is
consciousness (alert, responding to voice, responding associated with an in-hospital mortality of approximately
to pain, unresponsive) graphically over time 80%. Evidence suggests that better outcomes will be
achieved if signs of deterioration are recognised at
include thresholds for each physiological parameter or an earlier stage and the consumer / patient is treated
combination of parameters that indicate abnormality accordingly. For example, research has shown that
s pecify the physiological abnormalities and other very few consumers / patients who suffer a cardiac or
factors that would trigger the escalation of care respiratory arrest do so suddenly and without warning.
The vast majority of consumers / patients show signs of
include actions required when care is escalated. deterioration for up to eight hours prior to an arrest.
The frequency of observations should be determined by Trigger thresholds should be set and relevant staff must
organisational policy; however, consideration should be know what those thresholds are. Ideally, the thresholds
made for: should be shown on the observation charts to ensure
early detection of consumer / patient deterioration.
the specific consumer / patient condition as identified
during the assessment Escalation protocols should:
the care delivery setting (post-surgical, ICU, general llow for a graded response dependent on the
a
ward, etc.) level of abnormal physiological measurements,
changes in physiological measurements or other
ny changes in the consumer / patient
a identified deterioration. The graded response should
health status. incorporate options such as increasing the frequency
of observations or appropriate interventions from the
nursing and medical staff on the ward
Prompt points
e tailored to the characteristics of the healthcare
b
hat observation charts are used
W facility, including consideration of issues such as the
within the organisation? How do these size and role of the organisation, the location of the
differ from department to department? Has organisation, available resources, equipment, remote
consideration been given to standardising the telemedicine systems, external resources such as
design of observation charts? ambulances, the potential need for transfer of the
ow often are observations performed? Are
H consumer / patient to another facility
they recorded each time? The system used by an organisation to facilitate
ow can deterioration be identified on the
H identification and management of a deteriorating
observation charts? How will staff know when consumer / patient may include:
and how to escalate care? s pecialist response teams (such as Rapid Response
Teams or Medical Emergency Teams) or a nominated
department, person or service
review of observation charts and their use
echanisms to encourage carers, other staff and
m
visitors to recognise signs of deterioration and to alert
health professionals
uidelines on appropriate responses based on
g The medical emergency response system should:
clinical signs efine seriously ill consumers / patients, at-risk
d
rotocols that are accessible, supported by training,
p consumers / patients and consumers / patients
and effective across all shifts whose condition is deteriorating using abnormal
observations and vital signs (calling criteria)
ommunication strategies to ensure relevant
c
information is provided to the right health rovide rapid response to seriously ill consumers /
p
professionals at the right time. patients and those whose condition is deteriorating
operate across the whole organisation
Three fundamental aspects contribute to clinical
deterioration in a hospital: be designed around consumer / patient needs
failure to plan, for example, failing to perform a e-emphasise the usual hierarchies and
d
comprehensive consumer / patient assessment, inter-professional barriers
planning treatments and setting goals provide rapid consultation by experts in critical illness.
reakdown of communication between consumers /
b
patients and staff or between staff and other staff The medical emergency response system
should include:
failure to recognise the early signs of deterioration in a
consumer / patient’s condition. olicy about how often emergency equipment and
p
trolleys are checked, for example a ‘seal’ can be
placed on checked trolleys so that relevant people
Prompt points know that the trolley has not been used since the last
check, or a signature could be recorded each time the
ow is a consumer / patient’s health
H trolley is checked
status assessed and monitored during
care delivery? the frequency of checks; some organisations
will check emergency trolleys three times a day,
oes the presentation of information in the
D depending on the demands normally placed on this
consumer / patient health record make it easy resource and on the type of organisation and the
to detect a deteriorating consumer / patient? location of the emergency equipment / trolley
If there are long waiting periods for a service, onitoring compliance with its policy in regard to
m
such as in emergency departments, are how often the emergency equipment / trolleys are to
consumers / patients monitored for a change be checked
in health status, for example, the triage
category reclassified? testing of pagers, which should occur daily, regular
maintenance of other equipment (according to
manufacturer’s instructions), and testing according to
A medical emergency response system organisational policy, which would be commensurate
and plan with the organisation's requirements, based on the
frequency of use, amount of equipment, etc.
A medical emergency response plan sets out the
procedure for reacting to clinical deterioration in a
consumer / patient who is located outside of a critical
care unit. The medical emergency response plan should
be prominently displayed throughout the organisation,
and education and training should be provided to all
staff, appropriate to their role within the organisation.
March 2016 49
Criterion 1.1.4 Staff training in first aid, basic life support

The organisation implements effective systems and advanced life support
for the management of medical emergencies, Basic life support and advanced life support training
including the identification and care of is required for health professionals and other staff,
deteriorating consumers / patients. (continued) depending upon their roles and responsibilities within
the organisation. Survival after cardiac arrest is related
Strategies for maximising the impact of a hospital rapid to time taken for resuscitation and defibrillation to
response system include: commence. At many hospitals, the healthcare worker
most likely to be present when a consumer / patient
engaging the support of all health professionals
suffers a cardiac arrest is a nurse.
nsuring that there is leadership and support from
e
First aid supplies and trained personnel should be
senior hospital executives
available to all facilities in the organisation, including non-
implementing strategies that promote hospital-wide clinical areas. Availability and positioning of the kits is of
awareness of the system particular importance in areas distant from consumer /
patient care areas and where there is a risk of physical
nsuring an urgent response to any staff concern,
e
injury, such as:
whether life-threatening or not
kitchens
nsuring a 24/7 response by staff with appropriate
e
skills, knowledge and experience sterilising departments
uilding outcome indicators into the system and
b maintenance workshops
ensuring targeted feedback of data
gardening sheds
onducting regular multidisciplinary meetings to
c
laundries.
discuss individual cases and outcome indicators.
Organisations should ensure:
Prompt points there are sufficient numbers of trained first aid officers
with access to appropriate first aid kits
re medical emergency response plans
A
and instructions prominently displayed that trained staff can monitor the stock in first aid
in the organisation? How was the medical kits, so that kits reflect the type and level of risk in
emergency response plan developed? that workplace
ow are health professionals educated
H the names and contact details of trained individuals
and trained in the correct response to with first aid responsibilities are posted in all areas
medical emergencies? there are processes to manage a serious injury
hat education is provided to staff about
W to a staff member in a non-clinical area, where an
the system to manage deteriorating ambulance may need to be summoned, rather than the
consumers / patients? individual making their own way to treatment areas
ow often is the medical emergency response
H ircumstances where the medical emergency
c
plan evaluated? What changes have been made response team may need to be called, rather than a
to the plan following evaluation? first aid officer, are clear to all staff.
Suggested reading
Prompt points Australian Commission on Safety and Quality in Health Care
here are first aid kits situated within
W (2010). National Consensus Statement: Essential Elements
for Recognising and Responding to Clinical Deterioration.
the organisation?
Available from: http://www.safetyandquality.gov.au/wp-
Who is responsible for checking them? content/uploads/2012/01/national_consensus_statement.pdf
ccording to policy, what percentage of staff
A
are required to receive basic life support Kenneth M Hillman, Jack Chen and Daryl Jones. Rapid
Response Systems. Med J Aust 2014; 201 (9): 519-521.
training? What percentage of staff have received
Available from: https://www.mja.com.au/journal/2014/201/9/
basic life support training? rapid-response-systems Viewed 12 February 2016.
ow does the organisation decide what staff
H Australasian College of Emergency Medicine. Quality
require advanced life support training? What Standards for Emergency Departments and other Hospital-
percentage of required staff have received based Emergency Care Services (1st Edition 2015).
advanced life support training? Available from: https://www.acem.org.au/Resources/ED-
Resources/Quality-Standards.aspx Viewed 12 February 2016.
Rapid Response and Medical Emergency Teams:
Resuscitation Central. Available from:http://www.
The following evidence may help to resuscitationcentral.com/documentation/rapid-response-
address criterion 1.1.4 medical-emergency-team / Viewed 12 February 2016.
olicy / guidelines on management of

P Recognising and Responding to Clinical Deterioration: Use of
deteriorating consumers / patients, including Observation Charts to Identify Clinical Deterioration. Available
from: http://www.safetyandquality.gov.au/wp-content/
escalation procedures
uploads/2012/02/UsingObservationCharts-20091.pdf Viewed
vidence of clinical or governance arrangements
E 12 February 2016.
to identify the individual or committee with Clinical Excellence Commission. Partnering with Patients. The
oversight of recognition and response systems REACH Model. Available from: http://www.cec.health.nsw.
gov.au/programs/partnering-with-patients/pwp-reach
Records of reviews of clinical emergency calls
ecords of reviews of deaths and
R
cardiopulmonary arrests
vidence of discussions about rapid
E
response systems and any actions taken to
improve response
ecords of workforce attendance at
R
training on recognising and responding to
clinical deterioration
se of general observation charts to trigger rapid
U
response mechanisms
vidence of readily available information detailing
E
how to call for assistance
March 2016 51
Implementation
Criterion 1.1.5 a) Policy / guidelines addressing a) There is an effective, organisation-

clinical handover, transfer of care wide system for clinical handover
Processes for clinical handover,
and discharge are readily available within the organisation, which
transfer of care and discharge
to staff. ensures that all necessary
address the needs of the consumer /
information about the consumer /
patient for ongoing care. b) Results of investigations follow the
patient is communicated.
consumer / patient through the
referral system. b) Processes for transfer of care and
discharge ensure continuity of
c) Arrangements with other health
care and timely notification
service providers and the carer
between referrers and health
are made with consumer / patient
service providers.
consent and input, and
confirmed prior to transfer of c) There is evidence to demonstrate
care or discharge. that external health service
providers receive timely notification
d) Discharge information is recorded
about consumers / patients
in the consumer / patient
discharged to their care.
health record.
d) Discharge information is discussed
with the consumer / patient
and the carer, and a discharge
summary is provided.
e) Formalised follow-up occurs for
at-risk consumers / patients.

This criterion outlines the importance of ensuring Effective processes for handover, transfer of care and
that clinical handover is effective and that healthcare discharge are a vital component of the journey of care
organisations have and follow established processes (Standard 1.1). Planning for discharge should begin when
to ensure consumers / patients a smooth and safe a consumer / patient is admitted (Criterion 1.2.2) and be
transition when an episode of care is completed, or considered during assessment (Criterion 1.1.1) and care
when there is a change in clinical personnel. planning (Criterion 1.1.2). Clinical handover / transfer of
care is key to effective ongoing care within an organisation
(Criterion 1.1.6) as well as following discharge. Discharge
information should feed into a system of ongoing care that
will promote smooth recovery or satisfactory management
of a chronic condition.
Good discharge planning should ensure that ongoing
care and services are appropriate for consumer /
patient needs and capabilities, and delivered in the most
appropriate setting (Criterion 1.3.1).
Good communication at clinical handover and
appropriately detailed discharge information aims to
promote consumer / patient safety (Standard 1.5).
a) T
he processes for clinical a) The organisation shows distinction a) The organisation demonstrates it
handover, transfer of care and in its management of clinical is a leader in processes for clinical
discharge are evaluated, and handover, transfer of care handover, transfer of care
improvements are made and discharge. and discharge.
as required.
b) T
he system for providing
discharge and referral information
to consumers / patients and
external health service providers is
made as required.
c) The system for follow-up of at-risk
consumers / patients is evaluated,
as required.
In particular, there are key relationships with safe This criterion requires healthcare
and effective medication practices (Criterion 1.5.1), organisations to:
maintenance of skin integrity (Criterion 1.5.3), reducing
the likelihood of falls (Criterion 1.5.4) and ensuring that ave systems to ensure that consumer / patient
H
consumers / patients, particularly the frail aged or those clinical handover, transfer of care and discharge
who are incapacitated, receive appropriate hydration processes provide all necessary information to
and nutrition to facilitate their recovery (Criterion 1.5.7). ongoing health professionals.
Involving consumers / patients in discharge planning nsure discharge information is recorded and
E
can present challenges, but will help to avoid provided to the consumer / patient, the carer and the
misunderstandings that might lead to readmission, health professional providing ongoing care.
as well as ensuring that organisations meet their nsure that clinical handover, transfer of care,
E
responsibilities to those with diverse needs and from discharge and arrangements made with other health
diverse backgrounds (Criterion 1.6.3). service providers are discussed with consumers /
patients, and information is provided.
nsure that follow-up occurs for consumers / patients
E
identified as being at-risk.
March 2016 53
Criterion 1.1.5
Processes for clinical handover, transfer of Prompt points
care and discharge address the needs of hat policies / processes / guidelines
W
the consumer / patient for ongoing care. does the organisation use to manage
(continued) discharge? Internal transfer of care, e.g.
between departments / healthcare facilities?
Consumer / patient clinical handover, Handovers at shift changes?
transfer of care and discharge re the same processes used organisation-
A
wide? If not, where, why and how have specific
Good handover and communication with ongoing adaptations to the processes been made?
providers and carers is at the heart of an effective
healthcare system and stands alongside consumer / hat standardised processes are used to
W
patient clinical documentation, letters of referral and ensure continuity of care at clinical handover?
transfer and discharge documentation. Together, these Are these processes followed throughout
make up the links in the chain of continuity of consumer / the organisation? How effective have these
patient care. processes proven to be?
Organisations should ensure there is:
olicy / guidelines that address the requirements for
p Clinical handover and transfer of care
clinical handover, transfer of care and discharge
Clinical handover refers to the transfer of professional
a system for implementing the policy or guidelines responsibility and accountability for some or all aspects
of care for a consumer / patient, or group of consumer /
method for evaluating whether these processes
a
patients, to another person or professional group on
are effective.
a temporary or permanent basis. Effective clinical
Policies / guidelines should include: handover results in the safe transfer of care of
consumer / patients.
the handover situations to which they apply
Handover occurs:
ersons who should be involved in the
p
communication, and appropriate responses where from one provider or team of providers to another
face-to-face briefings are not possible t points of consumer / patient transition
a
care information including: across settings
• diagnoses and current condition of the between services or levels of care

consumer / patient ue to the need to organise clinical work into
d
• recent changes in condition or treatment manageable shifts
• anticipated changes in condition or treatment ... and includes handover of consumer / patient
information and material risks.
• suggestions on what to watch for in the next interval
of care The approach to handover should provide opportunities
for receivers of information to ask and respond to
rint or electronic information that should be available
p questions, ideally in person. For the specific department
to the incoming carer / health professional. or ward, the process should be standardised, yet
Processes aimed at improving one aspect of consumer / flexible, so that sufficient consumer / patient-specific
patient care, such as shorter shifts to reduce fatigue information is always communicated to facilitate
among health professionals, mean that a greater number continuity of care and consumer / patient safety.
of handovers will be required, each carrying its own risk Whatever the details of the handover process, there
of miscommunication. Similarly, growing use of ‘agency’ should be a defined minimum set of data about each
staff who operate under different systems as they move consumer / patient that must be communicated.
between wards and organisations, may add further
inconsistencies if guidelines are not followed.
ll necessary information about past, present and
a
Prompt points future care is communicated clearly to the consumer /
patient and/or to ongoing care providers
re there any situations where face-to-
A
face clinical handover cannot occur? If the consumer / patient and carer understand what is
so, what happens under these circumstances? to happen and why.
What documentation, forms or records support
or replace a face-to-face transfer of care?
Prompt points
as the incident monitoring system or
H
complaints process identified any problems hat processes are in place for transfer /
W
resulting from communication failures at clinical discharge of consumers / patients? Is there a
handover? If so, what efforts have been made system of review of discharge summaries sent
to reduce the problems? to GPs (and specialists) for quality and content?
Are clinical staff trained in the use of the
software where discharge summaries are
Discharge done electronically?
Discharge refers to the release of a consumer / patient Is there a system that provides opportunities to
from care or the movement of a consumer / patient from identify impending transfers / discharges for the
one setting of care to another. same or following day?
Types of discharge are affected by circumstances, oes the transfer / discharge process enable
D
and include: enough time for discussion of ongoing care with
the carer?
routine discharge
re discharge summaries ready at the time of
A
self-discharge / discharge at own risk
transfer / discharge of the consumer / patient?
one organisation to another
Is there a system in place to identify when
death. e-discharge summaries do not reach
the destination?
Specific elements to be included in the discharge
instructions could include:
instructions on post-hospital care to be used by the
Discharge summaries
consumer / patient or the caregiver / support person There is an expectation that a discharge summary will
in the consumer / patient's home be provided to:
rescriptions and over the counter medications that
p the consumer / patient
are required after discharge (including a reconciliation
the healthcare provider to whom the consumer /
of such medications)
patient is discharged
arning signs and symptoms that may indicate a
w
the referring healthcare provider
need to seek immediate medical attention
the health record.
ritten instructions regarding the consumer / patient's
w
follow-up care.
The key issues to be considered in the transfer of care

or discharge of a consumer / patient are that:
it has been appropriately planned with the
consumer / patient and/or their carer and the
multidisciplinary team
it is actioned in a smooth and timely fashion
March 2016 55
Criterion 1.1.5 Consumer / patient test results

Processes for clinical handover, transfer of As consumers / patients move through a
care and discharge address the needs of multidisciplinary care process, it is important that their
the consumer / patient for ongoing care. diagnostic test results are available. Repeating the same
(continued) tests within a short time interval has long been identified
as a potentially wasteful practice.
Important items of information to be included in the Electronic access to test results allows:
discharge summary are:
etter clinical decision making through access to
b
treatment whilst in hospital timely and complete information at the point of care
a list of diagnoses fficiency of practices and reduced workloads as tests
e
follow-up treatment do not have to be repeated, improving consumer /
patient satisfaction
management and outcomes
nhanced consumer / patient safety and a higher
e
list of medications at discharge standard of consumer / patient care
dates of admission and discharge.
cost savings.
The discharge summary should:
In addition, this access will:
rovide the consumer / patient, referring healthcare
p
nsure the use of standardised test names and
e
provider and any other relevant healthcare providers
result formats
with information about ongoing plans and their
responsibilities in ongoing management of the llow collation of appropriate data into meaningful
a
consumer / patient cumulative reports
e available to relevant healthcare providers so
b rovide consumers / patients with their reports in an
p
that any ongoing treatment is informed by the appropriate manner with appropriate interpretation.
discharge summary
ontain contact details of an informed healthcare
c
provider in the event that further information is Prompt points
required for consumers / patients transferred hat processes ensure that pathology
W
between organisations. and imaging results are available to all
health professionals who may need them for
decision making? What are the systems for
Prompt points archiving and retrieval of images?
hat information is provided by
W ow does the health record system link
H
organisations / healthcare providers consumers / patients, their care plans and
to which / whom consumers / patients are ongoing monitoring data with test and image
transferred? What feedback has been received results? Can the information be accessed from
regarding the usefulness of this information / the bedside / within the ward / other locations?
timeliness of its arrival? How are test / imaging results transferred
as the organisation checked with the relevant
H when the consumer / patient moves to
healthcare providers to whom it most frequently another part of the hospital or visits another
refers consumers / patients to determine that health professional?
their needs for timely information about referred
consumers / patients are met?
Is there evidence in the consumer / patient
satisfaction process that appropriate discharge
information is provided to GPs?
Arrangements made with other ommunication in relation to medication management,
c
healthcare providers particularly for products such as warfarin, which
requires that consumers / patients understand the
Inpatient care is increasingly being supported by need for ongoing monitoring and adjustment
outpatient transition care or community care that may
be delivered in a hospital complex or at an independent arning signs and symptoms that may indicate a
w
location. Ensuring a smooth transition from inpatient or need to seek immediate medical attention, such as
emergency / casualty services to other service providers abnormal bleeding
is a growing challenge. These transitions have been hich health professionals will be responsible for the
w
identified as key junctions in care, where communication consumer / patient's care following discharge.
breakdowns and delays in information transmission may
threaten consumer / patient safety or at best, lead to An example of proactive discharge planning with
negative comments and poor public relations. consumer / patient involvement might include
assigning a specific discharge person to work with
Well-informed consumers / patients who understand consumers / patients prior to their discharge to
the planning of their care are more capable of managing arrange follow-up appointments, confirm medication
their condition proactively and potentially avoiding reconciliation, conduct consumer / patient education
re-hospitalisation. with an individualised instruction booklet, conduct
Consumers / patients who have been specifically post-discharge follow-up to ensure there have been no
identified as offering distinct challenges in the provision problems in relation to discharge planning and to provide
of information include: education materials to the primary care provider.
those with poor literacy and poor health literacy
(sometimes, but not always related) Prompt points
onsumers / patients with weak proficiency in the
c oes the organisation check that
D
main language of the country / organisation consumers / patients and carers have
those with sensory (particularly vision and hearing received appropriate information relating to
impaired) or memory deficits. their condition and transfer / discharge? Is the
consumer / patient’s understanding of that
Organisations should: information ever reviewed?
nsure discussions are supported by printed advice,
e ave discharge education leaflets for
H
ideally a brochure or leaflet consumers / patients been evaluated
with regard to their content and/or
avoid complex language and too much jargon
communication effectiveness?
avoid busy layouts and small print
as the quality of information entered on clinical
H
rovide sources for further information particularly in
p handover documentation been audited?
relation to specific diseases
include helpline numbers and website addresses as
pointers to further information
rovide comparative information and information
p
about lifestyle issues to aid consumer / patient
decision making.
Specific elements to be discussed with the consumer /

patient in the discharge instructions could include:
instructions on post-hospital care to be used by
the consumer / patient or the caregiver / support
person in the consumer / patient’s home
March 2016 57
Criterion 1.1.5
Processes for clinical handover, transfer of The following evidence may help to
care and discharge address the needs of address criterion 1.1.5
the consumer / patient for ongoing care. Completed discharge plans
(continued) olicies / guidelines / processes on clinical
P
handover, transfer of care and discharge
Follow-up for consumers / patients
ecords system that facilitates health
R
identified at being at-risk professional access to consumer / patient
The categories of consumers / patients considered at-risk imaging and pathology test results
will vary between health services. Organisations should eview of quality and content of discharge
R
form a clear view of how they identify at-risk consumers / summaries by senior staff
patients. Examples include consumers / patients:
ome care, aged care or community services
H
judged to be at risk of suicide liaison systems and information
ith chronic diseases, particularly those with complex
w taff training in systems / processes for clinical
S
monitoring or medication needs, as occurs in asthma, handover, transfer of care and discharge
diabetes mellitus, rheumatoid arthritis and acute including the use of software / templates
coronary syndrome
ecords of inquiries, complaints, other feedback
R
who are frail, aged, debilitated, intoxicated or children post-discharge, ideally monitored and evaluated
who experienced an adverse event while admitted. over time
eviews of process adherence, communication
R
Formalised follow-up of at-risk consumers /
efficacy, consumer / patient satisfaction
patients should:
associated with discharge, transfer of care,
involve a planned process for after the consumer / and/or clinical handover
patient has been discharged or transferred from the
eedback from GPs as to the usefulness of
F
treating health facility / health professional
discharge summaries
include establishment of the timing of follow-up
include establishment of mode of follow-up, for
example a post-discharge phone call, email or SMS.
Whichever form the follow-up takes, it should be
documented in the health record and the consumer /
patient should receive a copy of the follow-up plan.
Prompt points
hich consumers / patients are
W
followed-up post-discharge? What is the
method of follow-up? What is the timing of this
contact and why has this timing been chosen?
hat factors does the organisation use to
W
determine whether consumers / patients might
be at-risk of difficulties after discharge?
re risk assessments conducted prior to
A
discharge and does a copy of this go to
the referrer?
Suggested reading
The Australian Medical Association. Safe handover: Safe patients.
Guidance on clinical handover for health professionals and
managers. Available from: https://ama.com.au/sites/default/files/
documents/Clinical_Handover_0.pdf Viewed 12 February 2016.
American Medical Association. Resources for Improving
Patient Handoffs. Available from: http://www.ama-assn.org/
ama/pub/about-ama/our-people/member-groups-sections/
resident-fellow-section/rfs-resources/patient-handoffs.page
Australian and New Zealand College of Anaesthetists (ANZCA).
Statement on the Handover Responsibilities of the Anaesthetist.
Background paper. Available from: http://www.anzca.edu.
au/resources/professional-documents/pdfs/ps53bp-2013-
statement-on-the-handover-responsibilities-of-the-anaesthetist-
background-paper.pdf Viewed 15 February 2016.
The Australian Commission on Safety and Quality in Health
Care. Resources to assist health professional-leaders and
managers to implement solutions and tools for improving
clinical handover practices. Available from: http://www.
safetyandquality.gov.au/search/clinical+handover Viewed 12
February 2016.
Resources include:
• Implementation Toolkit for Clinical Handover
• Ossie Guide to Clinical Handover
• National Clinical Handover Initiative Pilot Program
• Safety and Quality Evaluation of Electronic Discharge
Summary Systems.
Clinical Excellence Commission. In Safe Hands.
ISBAR Resources. Available from: http://www.cec.health.nsw.
gov.au/programs/insafehands/clinical-handover Viewed 15
February 2016.
Health Education and Training Institute (HETI) Clinical Handover
(ISBAR Tool) elearning. Available from: http://www.heti.nsw.
gov.au/Courses/-Clinical-Handover-ISBAR-tool / Viewed 15
February 2016.
March 2016 59
Implementation
Criterion 1.1.6 a) There are formal processes for a) Care coordination and/or case
timely coordination of ongoing management is available for
Systems for ongoing care of the
care by multiple health service appropriate consumers / patients
consumer / patient are coordinated
providers. and their carers.
and effective.
b) There are systems for screening, b) Strategies are developed to
prioritisation and readmission of reduce acute presentations
at-risk consumers / patients, and and avoidable admissions of
those with chronic conditions. consumers / patients with
chronic conditions.
c) Information on relevant external
health service providers is available c) Processes are in place to
to staff. ensure effective management
of consumers / patients
d) Written and verbal information is
with chronic conditions who
provided to consumers / patients
develop an unrelated health
about their chronic condition.
issue and/or deteriorate.
d) Education is available for
consumers / patients with chronic
conditions and their carers on how
to manage the condition.

This criterion refers to the active and supportive Systems for coordinated ongoing care are a major
management of care for people with chronic or complex aspect of the management of the consumer / patient’s
conditions as well as the process that follows an care journey (Standard 1.1), and should be integrated
admission to a healthcare organisation. All healthcare with the organisation’s procedures for access and
organisations involved in the ongoing care of consumers / admission (Criterion 1.2.2), assessment (Criterion 1.1.1),
patients should actively contribute to a seamless collaborative care planning (Criterion 1.1.2), clinical
continuum of care for the consumer / patient and fulfill handover, transfer of care and discharge (Criterion 1.1.5)
their responsibilities for their part in the process of and care of the dying (Criterion 1.1.7).
ongoing care.
The coordination of ongoing care is facilitated by the
timely and accurate entry of data into the health record
(Criterion 1.1.8) and the management of the health
record system (Criterion 2.3.1).
Coordination of ongoing care helps to ensure that the
care is both appropriate (Criterion 1.3.1) and effective
(1.4.1).
Health promotion activities by the organisation assist
consumers / patients to understand their health, address
risk factors and better manage chronic conditions
(Criterion 2.4.1).
a) T
he ongoing care process is a) The organisation shows a) The organisation demonstrates
evaluated with consumer / patient distinction in the management it is a leader in systems for
involvement, and improvements of ongoing care. ongoing care.
b) T
he strategies developed to
reduce acute presentations
and avoidable admissions are
made as required.
c) The screening, prioritisation and
readmission of at-risk consumers /
patients are evaluated, and
as required.
d) The information and education
provided for consumers / patients
requiring ongoing care and
their carers are evaluated, and
as required.
This criterion requires healthcare Care coordination and/or case

organisations to: management
nsure care coordination and/or case management
E To achieve good health outcomes, many consumers /
is available for appropriate consumers / patients and patients need care from more than one healthcare
their carers, and that information on relevant external provider. Consumers / patients with chronic or complex
health service providers is available to staff. conditions in particular require ongoing care, whilst
others need some ongoing care and follow-up after an
ave systems for screening, prioritisation and
H
inpatient admission. The goal of care coordination is
readmission of at-risk consumers / patients and those
continuing care that appears seamless and achieves
with chronic conditions, and strategies to reduce
better health outcomes.
acute presentations and avoidable admissions of
consumers / patients with chronic conditions. Effective processes for ongoing care may include:
rovide information and education for consumers /
P learly defined points of entry to inpatient, ambulatory
c
patients with chronic conditions and their carers on and primary care and community services
how to manage the condition.
ccess routes, assessment procedures and pathways
a
Implement effective management of consumers / through the service / system that are as seamless as
patients with chronic conditions who develop an possible for the consumer / patient
unrelated health issue and/or deteriorate.
lear arrangements for liaison and referral between
c
services and organisations
roles and responsibilities that reflect a multidisciplinary,
integrated care approach
March 2016 61
Criterion 1.1.6 Screening, prioritisation and readmission of

Systems for ongoing care of the consumer / at-risk consumers / patients
patient are coordinated and effective. Regardless of whether it is their primary reason for
(continued) presentation at the healthcare facility, consumers /
patients with chronic diseases require ongoing care.
efined levels of responsibility for ongoing care,
d For example, although surgical facilities may not be
which will vary between organisations and, in larger responsible for management of the chronic condition,
organisations, between departments / wards documentation of needs and selection of services must
ollaborative arrangements to be able to meet the
c take the chronic condition and its management
ongoing care needs of consumers / patients into consideration.
involvement of health professionals, the consumer / Chronic diseases that may impact ongoing care
patient and, where appropriate, his or her carer in following surgery or an acute injury include:
ongoing care planning autoimmune diseases
ctive support to enable the consumer / patient to
a diabetes
understand and manage his or her condition
arthritis
support services for carers
cardiovascular disease
aintenance of ambulatory care wherever
m
obesity
possible, but with appropriate access to acute
care when required asthma.
integration of record systems to facilitate secure and
Other chronic conditions requiring ongoing care include:
reliable information exchange
chronic obstructive pulmonary disease (COPD)
n understanding of consumer / patient rights that
a
facilitates access of consumers / patients to their renal disease
health records.
communicable diseases including HIV / AIDS
neurological conditions such as epilepsy
Prompt points Alzheimer’s disease and other dementias
hich, if any, consumers / patients
W
multiple sclerosis
receive care coordination / case
management support at this organisation? cerebral palsy
hen was the ongoing care process last
W Parkinson’s disease.
reviewed? What were the findings? Assuming
When coordinating ongoing care, organisations:
there were some changes following the review,
how effective have they been? s hould consider psychiatric disorders when
planning ongoing care for consumers / patients
ow are relationships developed with other
H
service providers? What types of facilities / with schizophrenia, depression and other long-term
health professionals does the organisation conditions, although they are rarely identified as
most commonly liaise with when planning and ‘chronic disease’
delivering ongoing care? ay need to work with a carer to make decisions that
m
hat formal arrangements or protocols for
W are appropriate and manageable for the consumer /
ongoing care provision tie the organisation to patient following surgery or other illness
these ‘partners’ in care provision? s hould work to develop processes for effective
ow are health professionals informed about
H identification and screening of new and returning
and updated regarding referral options for consumers / patients with chronic conditions
ongoing care?
ight establish ‘fast track’ admission and readmission
m A range of strategies can be used to significantly reduce
processes that provide access to direct assessment by repeated hospitalisation and avoidable admissions,
health professionals for some classes of consumer / particularly among consumers / patients recently
patients with chronic conditions at times when they discharged. The organisation should consider focusing
are vulnerable to acute deterioration on chronic conditions with the greatest burden of
disease within its population group, or those with greater
rovide education and training initiatives to support
p numbers of avoidable admissions. Approaches will differ
consumers / patients to manage their disease so according to the specific disease or target population,
as to reduce the risk of acute crises that might however strategies may focus on:
require readmission.
preventing health deterioration in the community
identifying alternative management for those
Prompt points that deteriorate
here demand for services exceeds
W roviding different approaches for at-risk
p
supply, how does the organisation screen consumers / patients who present to the organisation
and prioritise consumers / patients requiring
ongoing care? roviding more targeted support for at-risk
p
consumers / patients discharged home.
re there processes in place to manage
A
consumers / patients who regularly
return and require readmission due to Prompt points
an ongoing condition?
ow does the organisation screen and
H
prioritise the needs of consumers / patients
Reducing acute presentations and with chronic or complex conditions?
avoidable admissions hat chronic conditions common in the
W
Consumers / patients with chronic conditions and organisation’s community result in significant
poor continuity of care have more visits to emergency numbers of acute presentations or
departments and more medical non-elective hospital avoidable admissions?
admissions than consumers / patients with regular hat strategies are in place to reduce acute
W
contact with a health professional. Better continuity of presentations or avoidable admissions to
care reduces unplanned admissions and emergency hospital (for example, self-management, better
department presentations, as well as meeting consumer / coordination of care or choice of different
patient requirements. clinical interventions)?
There is potential to reduce the impact of the most ow is the effectiveness of these strategies
H
common chronic conditions on the inpatient hospital measured and what improvements have
system, through prevention, early detection, maintenance been made?
of control using proven treatments and management in
settings other than bed-based hospital care.
Ongoing care may include:
regular monitoring of the condition by a single
practitioner or a multidisciplinary team
se of pathology tests that can alert deteriorating
u
control or the onset of problems
ducating the consumer / patient to manage his or her
e
condition and recognise signs of deterioration in control
facilitating supportive networking by consumers /
patients and/or carers managing similar conditions.
March 2016 63
Criterion 1.1.6
Systems for ongoing care of the consumer / Prompt points
patient are coordinated and effective. hat chronic disease self-management
W
(continued) support programs or strategies are
provided by the organisation? Which health
Information and education for professionals are educated and supported
consumers / patients in the delivery of such interventions? How
is this service publicised and what referral
All organisations have a responsibility to provide mechanisms are in place?
education or facilitate its availability for consumers /
patients who need it to progress from inpatient to or whom do the organisation’s chronic disease
F
outpatient care. The overarching goal of chronic disease management support programs or strategies
care is self-management; education and coaching cater? How is the education delivered?
are key to achieving effective daily management by In cases where consumers / patients attend
consumers / patients. education provided by another supplier, how
Education and information for consumers / patients can: are referrals made and outcomes followed-up?
How are the appropriateness and suitability of
e provided in diverse settings and using different
b referrals measured?
media, such as written information, a consultation or
mentoring session, a small group training session or hat specific consumer / patient education
W
pre-recorded video segments programs are in place? How does the
organisation measure the consumer / patient
nsure effective management during recovery from
e outcomes and impact of these programs?
surgery or a serious illness by facilitating recovery,
developing strength and promoting independence here there are no formal education programs
W
offered by the facility, what action would
e delivered by a health professional, an educator
b be taken for a consumer / patient whose
or, as occurs for many of the priority conditions, a understanding of his or her chronic condition
multidisciplinary team and approach to self-management could
ake use of web-based technology or multi-hospital
m be improved?
links, for example in rural and isolated areas that have
previously required prohibitive travel
Consumers / patients with chronic
mpower consumers / patients to proactively
e conditions who develop an unrelated health
self-manage their conditions, supported by the
health service
issue and/or deteriorate.
Consumers / patients receiving care for a chronic
nable carers to understand the condition and to
e
condition may not necessarily receive care for another,
support the consumer / patient who must manage
unrelated condition; individuals with chronic conditions
it, if they also participate in the same education or a
may not receive important routine outpatient medical
program catering specifically for them.
treatments for conditions unrelated to their chronic
condition. Accurate assessment should reduce the
likelihood of people with chronic conditions having an
unrelated condition overlooked.
Where consumers / patients have more than one chronic
condition, care coordination is important to ensure
the care and treatment provided considers all of the
conditions. Managing co-morbidities is challenging. Even
though one condition may contribute or be connected to
another, the treatments may conflict with each other.
Consumers / patients with chronic conditions who Suggested reading
develop an unrelated health issue and/or deteriorate.
Screening tools such as the Flinders Program™ of Chronic
ill need treatment for the primary condition to be
w Condition Self-Management, Partners in Health Scale. Flinders
considered together with any other treatments and University, School of Medicine. Available from: https://www.
health concerns flinders.edu.au/medicine/sites/fhbhru/self-management.cfm
s hould be monitored because of the co-morbid
Australian Government. Department of Health. National
conditions; what appeared to be the right treatment for Strategic Framework for Chronic Conditions. Available from:
one condition may generate a new health problem. http://www.health.gov.au/internet/main/publishing.nsf/content/
nsfcc Viewed 12 February 2016.
Department of Human Services. HARP Chronic Disease
Prompt points Management Guidelines. Available from: http://docplayer.
ow do assessment processes ensure
H net/6003521-Harp-chronic-disease-management-guidelines.
that unrelated conditions are not overlooked html Viewed 12 February 2016.
in consumers / patients with chronic conditions? Cochrane reviews of educational and self-management
interventions to guide nursing practice. A review. Available
ow is care coordinated when a consumer /
H
from: https://www.researchgate.net/profile/Ian_Norman/
patient with a chronic condition develops an publication/23477169_Cochrane_reviews_of_educational_
unrelated condition and/or deteriorates? and_self-management_interventions_to_guide_nursing_
Is there evidence of multidisciplinary care in practice_A_review/links/0046352c5a3983dd6e000000.pdf
the health record? How is prime responsibility Viewed 12 February 2016.
(the team leader) for consumer / patient Holly C. Felix, Beverly Seaberg, Zoran Bursac, Jeff
care assigned and demonstrated within the Thostenson, M. Kathryn Stewart. Soc Work Health Care.
health record? 2015; 54(1): 1–15. Why do patients keep coming back?
Results of a Readmitted Patient Survey. Available from: http://
www.ncbi.nlm.nih.gov/ pmc/articles/PMC4731880/ Viewed
15 February 2016.
The following evidence may help to
Case management system and evaluation
rrangements with other providers such as aged
A
care services, disease education services, allied
health providers
Surveys of consumer / patient perceptions
ealth professionals’ feedback regarding
H
arrangements for ongoing care
ealth professionals’ feedback regarding their
H
ability to access data from earlier admissions
eadmission rates and other chronic
R
disease indicators
March 2016 65
Implementation
Criterion 1.1.7 a) Policy / guidelines addressing the a) Processes ensure that advance
management of consumer / patient care directives are followed
Processes for preparing for end-of-
end-of-life care are consistent with where appropriate.
life, and for delivering consumer /
relevant legislation, standards,
patient end-of-life care, are managed b) When clinically indicated,
guidelines and/or codes of practice,
with dignity and comfort, and family consumers / patients are
and advance care directives, and
and carers are supported. referred to palliative care, pain
are readily available to staff.
management services and/or
b) Processes for the management of other support services.
death and related issues address
c) Processes are in place for the
diverse spiritual, cultural, and
management of a sudden or
social beliefs.
unexpected death.
c) P
olicy / guidelines direct the
d) There is a support system to
recognition and recording of
assist family, carers, patients and
advance care directives.
staff affected by a death and
d) The organisation has access to related issues.
palliative care, pain management
e) There are processes to support
and/or other support services.
staff, consumers / patients and
e) R
elevant health professionals carers involved in organ and
are educated in end-of-life care tissue donation.
processes, including related
f) Relevant health professionals
ethical considerations.
are trained in organ and tissue
f) The organisation has processes to donation processes.
identify the primary caregiver for
a consumer / patient in an end-of-
life situation.
g) Where appropriate, the organisation
has policy / guidelines addressing
organ and tissue donation.
Overview Note:
This criterion will apply to healthcare organisations
This criterion is intended to ensure that healthcare
in varying degrees; however it is applicable to all
organisations place a high priority on the care and
organisations. While a death in facilities such as a
management of consumers / patients at the end of life, and
day hospital or community health service may occur
provide appropriate support services for families / carers.
unexpectedly and be considered a sentinel event,
occasionally a consumer / patient will die in such
facilities and policy and procedures covering this rare
and tragic event are needed. All organisations should
also be aware of local end-of-life care options and
be able to refer inquiries regarding eventually fatal
conditions and end-of-life care to appropriate sources.
a) C
ompliance with policy, a) The organisation shows a) The organisation demonstrates it
procedures and guidelines distinction in its management is a leader in systems for end-of-
addressing end-of-life-care, of end-of-life care. life care.
including cultural sensitivity and
staff education, is monitored and
evaluated, and improvements
made as required.
b) C
ompliance with advance care
directives is evaluated, and
as required.
c) Clinical review committees,
including morbidity / mortality
and case review, evaluate the
appropriateness of referrals to
palliative care, pain management
services, and/or other support
services, and improvements are
made as required.
d) Processes surrounding dying
and death are evaluated, and
as required.
Relationships of 1.1.7 with other criteria Deterioration of the consumer / patient during an
episode of care (Criterion 1.1.4) may result in death.
This criterion covers a distinct phase of the consumer /
patient care journey (Standard 1.1). In some cases, Because death and dying occur within the context of
a transition occurs from striving to combat a disease cultural beliefs and traditions, and spiritual and religious
course according to an original care plan (Criterion 1.1.2) values, organisations must provide for consumers /
to managing the passage to death with end-of-life or patients with diverse needs and from diverse
palliative care, although in many cases the two care backgrounds (Criterion 1.6.3).
pathways are delivered in alignment. Such a transition
may occur along with a transfer of care (Criterion 1.1.5),
such as to home, a hostel or other palliative care facility,
where there will also be a transfer of responsibility.
March 2016 67
Criterion 1.1.7 ow decisions are to be made regarding the

h
Processes for preparing for end-of-life, and for management of dying consumers / patients. This
delivering consumer / patient end-of-life care, includes whether and how ‘Not For Resuscitation’
(NFR) orders are used, and the development and use
are managed with dignity and comfort, and of advance care plans or directives
family and carers are supported. (continued)
the process for identifying and meeting cultural,
spiritual and religious values and belief requirements
This criterion requires healthcare
organisations to: the early identification of the carer
Manage the end of life of consumers / patients. the early identification of the legal decision maker
nsure advance care directives are recorded
E the role of the family of a dying person
and followed. ow disagreements within the healthcare team and/or
h
Provide access to relevant support services. with or within a family can best be resolved
Have systems that allow for organ and tissue donation. hen to involve a clinical ethics committee or similar
w
body regarding difficult issues relating to life support
nsure relevant staff are educated in end-of-life
E
processes, as appropriate. ow to best facilitate organ and tissue donation
h
should this be an appropriate action to offer
Managing the end of life of (see below).
consumers / patients Sudden or unexpected death can occur in any location
without warning, and policy and procedures to manage
Supporting and managing the inevitable processes
such an event should be in place in all organisations.
of dying and death is commonplace in health care.
The frequency and nature of this varies widely, both
according to the organisation type and the stage of the
Prompt points
dying process at which the consumer / patient comes
into contact with the organisation. hat end-of-life policy and procedures
W
are in place?
Needs-based end-of-life care is a quality management
approach that evaluates the individual holistic needs hat are the relevant legislation or common law
W
of the consumer / patient and his or her family / carer, obligations and does policy reflect this?
and coordinates appropriate care. It recognises the ow does the organisation’s philosophy, values,
H
interdependent physical, social, emotional, cultural and culture, structure and environment contribute to
spiritual aspects of care and includes the combination the provision of competent and compassionate
of broad health and community services that care for a end-of-life care?
person at the end of his or her life. The goal of end-of-
life care is to maximise quality of life through appropriate ow does the organisation measure
H
needs-based care for each person, with a focus on implementation across the organisation?
symptom control and comfort rather than cure. Use hat evaluation processes are in place
W
of a term such as ‘comfort care’ to describe end-of- and how do they contribute to continuous
life care is recommended, as comfort is a familiar and improvement of end-of-life care?
unambiguous concept in everyday experience.
Healthcare organisations that care for dying and
deceased individuals should ensure that the following
are included in their policy and procedures:
ow information relating to the prognosis and
h
healthcare requirements of consumers / patients is
communicated, and by whom
Advance care directives / advance
care plans Prompt points
Advance care planning is the process of preparing ow is advance care planning and
H
for likely scenarios near the end of life. It includes an decision making undertaken? How are
assessment of, and dialogue about, a consumer / such decisions documented?
patient’s understanding of his or her medical history and ow has the organisation identified legislation
H
condition, values, preferences and personal and family / around advance care directives? How are these
familial resources. Advance care planning supports requirements reflected in policy and procedure?
consumers / patients in communicating their wishes
about their end of life. Where possible, organisations ow does the organisation facilitate access to
H
should encourage the use of advance care plans. spiritual or pastoral care?
Advance care planning involves a consumer / patient:
ppointing a person, known as a substitute decision
a Access and appropriate referral to relevant
maker, who can make healthcare decisions for them if support services
they are too unwell to do this for themselves
The end-of-life needs of many are provided along
ocumenting their desires in an advance care
d a continuum of care. Quality care at the end of life
directive, sometimes known as a ‘living will’. is provided by a range of carers, professional and
An advance care directive is a document which contains otherwise - from community or family members, to
instructions that consent to, or refuse, specified primary or generalist care providers, to specialist
medical treatments and that articulate care and lifestyle palliative care providers, based on the individual’s needs
preferences in anticipating future events or scenarios. It and choices.
becomes effective in situations where the consumer / Consumers / patients with eventually fatal conditions
patient is no longer able to make decisions. For this may live a significant period of time with these
reason, advance care directives are sometimes referred conditions. In addition to malignancies, more people
to as living wills. Organisations should consider, however, than ever now eventually die of chronic and complex
if there are additional requirements under legislation, conditions, with longer periods between diagnosis and
particularly for refusal of life-sustaining treatment. death. For much of this time, consumer / patient care
Ethical clinical practices in implementing advance care may be well managed by primary care and specialist
directives include: providers, but consumers / patients may also benefit
from episodes of care / support from other specialty
rovision of necessary pain relief based on the
p areas such as:
consumer / patient’s individual clinical need
ain management services, either within the
p
ithholding or withdrawing life-sustaining treatments
w organisation or in the broader service system
that are no longer effective or that do not benefit
the consumer / patient, including any treatment the grief counselling / psychosocial support
consumer / patient has refused s pecialist palliative care providers, particularly as the
omplying with a consumer / patient's refusal
c condition deteriorates
of treatment. carer support and home care services.
March 2016 69
Criterion 1.1.7 • in the case of death of a child, the use of memento
Processes for preparing for end-of-life, and for books, photos, clothing, blankets, etc., and
facilitating preferred contact with the deceased
delivering consumer / patient end-of-life care,
are managed with dignity and comfort, and • bereavement follow-up program including
family and carers are supported. (continued) memorial services.
Staff in all roles can be affected by death and
should be encouraged to access bereavement
Prompt points support as necessary.
hat pain management, palliative care,
W
grief support and other services does the
organisation provide, or have effective referral Prompt points
relationships with? hat bereavement support system is
W
hat protocols are in place to guide
W in place?
health professionals regarding assessment and ow are consumers / patients and their families
H
referral for such services? encouraged to access bereavement support?
ow does the organisation measure and
H ow is death and dying normalised within the
H
evaluate the appropriateness and timing culture of the organisation?
of referrals to specialist palliative care, pain
management, chaplaincy, psychological and ow are staff and volunteers encouraged to
H
other support services? access bereavement support?
How is the system evaluated and improved?
Bereavement support
In addition to referrals to specialist services, consumers / Organ and tissue donation
patients and carers may need some sort of additional In circumstances where a consumer / patient wishes
support. All people, regardless of religious, faith or to donate his or her whole body or specific organs for
cultural background, may have pastoral and spiritual transplantation, scientific research or teaching purposes,
care needs. Most organisations’ consumer / patient arrangements should be made with relevant organ and
cohort is multicultural and multifaith, therefore the tissue donation agencies or body bequest programs,
organisation should provide access to sensitive, according to what exists in the jurisdiction. In respect
respectful responses from a range of skilled chaplaincy, of living donor transplantation, national protocols
spiritual or pastoral care practitioners, particularly for developed by the relevant authority, such as a Human
consumers / patients, families, carers and staff involved Organ Transplant Board, should be consulted.
in end-of-life care. Spiritual or pastoral care acts to
relieve suffering by providing a moral frame of reference Organisational policy should cover areas such as:
and/or meaning in the face of suffering. It is a significant roles, authority, appointment processes and ongoing
component of integrated end-of-life care, can facilitate education of a designated officer or a donor /
the rebuilding of relationships, and provide support with transplant coordinator and other staff
grieving around losing a life.
staff education and support
Bereavement support requires:
the process of recognising the possibility of organ
assessment of religious and/or spiritual needs and/or tissue donation
identification of formal and informal support systems identification of potential donors
bereavement support strategies, such as: recognition of prior expressions by potential donor on
• access to social work, spiritual or pastoral donor registries or otherwise
care support iscussing the option of organ and/or tissue donation
d
• bereavement information packs with the family
liaison with donor / transplant coordinators Staff education
confidentiality Many staff participate in the care of dying or deceased
consumers / patients, including health professionals,
etermination and certification of brain death
d
technicians, chaplains, ward assistants, porters,
according to relevant jurisdictional legislation
mortuary attendants and other relevant staff. Volunteers
donation after cardiac death can also play a role. The organisation should provide
education and support to ensure that staff and
medical management of the potential donor
volunteers are appropriately qualified for the level
retrieval surgery of service offered, and also demonstrate ongoing
donor family support participation in continuing professional development.
ethical and professional standards Recognition that health professionals often find it
difficult to initiate or discuss end-of-life care issues
staff support and decision making with consumers / patients and
donor / recipient correspondence their carers can be addressed through the provision of
relevant education within an openly supportive culture.
donor family follow-up. Many health professionals have been educated within a
Organisations should also have systems in place to system that focuses on cure, rather than the inevitable
support access to organ and tissue donor / transplant process of ageing and dying, and some may view
coordinators. Donor coordinators play a pivotal role in death as medical ‘failure’. As death reviews are one of
coordinating the organ and tissue donation process. the ways a doctor’s performance is audited, actual or
perceived pressures to continue active management
rather than withdrawing or withholding it should also
Prompt points be addressed.
hat policy is in place regarding organ

W Education should therefore be tailored to the specific
and/or tissue donation? groups, and cover areas such as:
hat processes does the organisation use to

W the philosophy, values, culture, structure and
identify potential donors? environment for the provision of competent and
compassionate end-of-life care
ow are organ and/or tissue donor
H
activities evaluated? relevant policies and procedures, including for
organ donation
oes the organisation perform an audit of
D
all deaths to see if potential donors had communication skills
been identified? What are the results? symptom control and effective pain management
What improvement processes have
been implemented? use of technology in end-of-life care
s kills to competently begin and guide discussions
around end of life and facilitate consumers / patients’
decision making
advance care planning
avigating ethical issues such as ongoing use of
n
technology to sustain life and tissue or organ donation
organ and tissue retrieval following death
mortality management
addressing spiritual care needs.
March 2016 71
Criterion 1.1.7
Processes for preparing for end-of-life, and for The following evidence may help to
delivering consumer / patient end-of-life care, address criterion 1.1.7
are managed with dignity and comfort, and Documented policies, including
family and carers are supported. (continued) • staff education policies and evidence of
education in relevant areas, e.g. end-of-
life care, pain management, advance care
Prompt points planning, mortality management, organ and
hat orientation and education is in
W tissue donation, etc.
place for various staff and volunteer groups • when and how end-of-life issues and decision
regarding end-of-life care? making is raised with consumers / patients,
ow does the organisation ensure that
H their carers and staff
all relevant staff receive appropriate • decision making and documentation guidelines
education and participate in ongoing
professional development? • cultural, religious and pastoral / spiritual
care guidelines
ow are relevant volunteers educated regarding
H
their role in end-of-life care? • organ donation, including profile, triggers,
processes and outcomes
ow are health professionals encouraged and
H
supported to initiate, discuss and document vidence of mechanisms to deal with family /
E
end-of-life care issues and decision making with familial issues
consumers / patients? vidence of compliance with legislative
E
hat organ and tissue donation education
W requirements
program is in place? ealth record review for advance care plans,
H
documented decisions and their outcomes
vidence of care provision by, or referral to,
E
specialist palliative care, pain management
and other services, including evidence of staff
education in end-of-life management
vidence of access to and uptake of
E
bereavement support systems
vidence of organ and tissue donations
E
undertaken according to national guidelines
Suggested reading
Palliative Care Australia resources, including Advanced
Care Directives, the Clinical Trigger Tool and GIVE Protocol.
Available from: http://palliativecare.org.au / Viewed 12
February 2016.
Palliative Care Australia. Standards for Providing Quality
Palliative Care for all Australians. Available from: http://www.
palliativecare.org.au / Viewed 12 February 2016.
Australian Government. Organ and Tissue Authority. Information
on organ and tissue donation, including the DonateLife™
Network and the Australian Paired Kidney exchange (AKX)
program. Available from: http://www.donatelife.gov.au/health-
professionals Viewed 12 February 2016.
The Transplantation Society of Australia and New Zealand
(TSANZ). Information and access to guidelines. Available from:
http://www.tsanz.com.au / Viewed 12 February 2016.
Spiritual Care Australia; an association of practitioners in
chaplaincy, pastoral care and spiritual services. It exists within,
and is a part of, contemporary multi-faith, multi-cultural Australia.
Available from: http://www.spiritualcareaustralia.org.au Viewed
12 February 2016.
Royal Australian College of Surgeons. Audits of Surgical
Mortality. Available from: http://www.surgeons.org/Content/
NavigationMenu/Research/Audit/default.htm Viewed 12
February 2016.
March 2016 73
Implementation
Criterion 1.1.8 a) Policy / guidelines addressing a) There is a system to monitor

health record documentation are compliance with health
The health record ensures
consistent with relevant legislation, record creation and
comprehensive and accurate
standards, guidelines and/or documentation policies.
information is collaboratively
codes of practice, and are readily
gathered, recorded and used in b) Health professionals use the
available to staff.
care delivery. health record to document and
b) Every consumer / patient has a communicate all aspects of care
health record with a recognised delivery in accordance with the
unique identifier. organisation’s policy / guidelines.
c) Health professionals are provided c) Health records are monitored
with orientation and ongoing for completeness and
education in the organisation’s legibility, including:
processes for health record
(i) the readability of written and
creation and documentation.
printed material
d) Authorised internal and external
(ii) the use of black or blue ink
health professionals have access to
information about the consumer / (iii) for clarity of scans /
patient in accordance with relevant photocopies
privacy legislation.
(iv) the use of approved
e) Consumers / patients are provided abbreviations only
with information on how to access
(v) that no blank areas are left.
their health records.
d) R
esults of reviews and clinical
consultations are made available
to health professionals at the point
of consumer / patient care.

This criterion focuses on the collaborative gathering This criterion addresses the gathering and entry
and recording of information that provides the content of information into the health record, and how that
of individual health records, and how a consumer / information is used in the delivery of care. This process
patient’s record facilitates the delivery of care. Complete, will be facilitated by records management systems that
accurate health records are fundamental to the provision meet the needs of both the consumer / patient and
of safe, high quality care. the organisation (Criterion 2.3.1), and which in turn are
supported by the organisation’s processes for data
The intent of this criterion is to ensure that consumer /
collection and storage (Criterion 2.3.3) via its integrated
patient health records are comprehensive and efficiently
approach to information and communication technology
maintained, and that consumer / patient confidentiality
(Criterion 2.3.4).
is protected.
The health record should accurately reflect the
consumer / patient’s journey through the care delivery
process (Standard 1.1), and ensure the provision of
safe care and services (Standard 1.5). The entry of
data into the health record is a vital aspect of effective
a) H
ealth records are evaluated to a) The organisation shows distinction a) The organisation demonstrates it
ensure that they meet medico- in its management and use of is a leader in systems to collect,
legal requirements, professional health record content. record and use consumer / patient
documentation standards, health information.
guidelines and/or codes of
practice, and improvements are
made as required.
b) H
ealth records are evaluated to
ensure that the clinical content
supports safe, high quality care,
as required.
c) Evaluation of the completeness
and legibility of the health record
is addressed through the use of
audits, and improvements are
made as required.
d) Timeliness of inclusion of reports
and information from reviews, tests
and other clinical investigations
into the health record is evaluated,
as required.
and coordinated ongoing care (Criterion 1.1.6) and of This criterion requires healthcare
the process(es) of clinical handover (Criterion 1.1.5), organisations to:
including the exchange of information between referrers
and providers by which continuity of care is maintained ave a comprehensive health record with a
H
(Criterion 1.2.2). Correctly managed health records recognised unique identifier for each
should allow meaningful evaluation of the outcomes of consumer / patient.
clinical care (Criterion 1.4.1). Ensure that health records are legible and complete.
The information in the health record should assist the rovide relevant access to health records at the point
P
organisation in meeting its responsibility towards those of care.
with diverse needs and from diverse backgrounds
(Criterion 1.6.3). The consumer / patient has a right to Ensure that health record monitoring occurs.
access his or her own health record, and to expect that
privacy and confidentiality will be maintained (Criterion
1.6.2). Failure of the organisation to respect these rights
may lead to complaints (Criterion 2.1.4).
March 2016 75
Criterion 1.1.8 Good policies and systems are important, but it is

The health record ensures comprehensive even more important that all contributors to those
systems work to maintain their integrity. During an
and accurate information is collaboratively episode of care, there are likely to be many contributors
gathered, recorded and used in care delivery. to a consumer / patient health record. Each health
(continued) professional must understand and take responsibility
for the integrity of his or her entries. All professional
The comprehensive health record interactions with the consumer / patient and all
treatments, however insignificant and predictable,
Having a single health record for each consumer /
should be recorded.
patient is vital for continuity of care. The health record
should outline all identified needs of consumers / Health professionals must recognise the health record
patients, and the care / management received. as a communication tool, rather than a document for
personal notes.
Regardless of whether a record is electronic or
paper-based: A consumer / patient attending a healthcare facility for
the first time will require a health record to be created.
ccess and use should always be managed according
a
Various management strategies may be used to ensure
to legislation, policy and the organisation’s processes
consistency and completeness of records and
it is primarily a medico-legal and communication should include:
document, which records those events and decisions
training of staff who open / create new records
required by health professionals to manage consumer /
patient care both contemporaneously and in time computer prompts or reminder cards
sequence. It may provide evidence in lawsuits, limiting access to ensure only designated staff will
hearings or inquests. The health record can protect open / create new records.
the legal interests of the organisation and the health
professional, or it can become a legal risk
the location and if possible the appearance of Prompt points
inserts / data attachments should be consistent and re the health record content policies
A
predictable within each record and procedures used by the organisation
t the end of an episode of care, the record should be
a referenced to legislation, standards and/or
retained in accordance with legislative requirements professional codes / guidelines? How frequently
and to guide ongoing and future care are they reviewed and updated? When was the
last review of health records policy undertaken?
the health record may be used by coders and
statisticians to produce data for calculating the ow do clinical and administrative staff
H
incidence of diseases, adoption of different treatment members with health record responsibilities
protocols, and for quality control and planning access policies or other guidance documents?
the information in the record may be utilised by health ow does the design of the health record
H
professionals, administrators and researchers facilitate the recording and communicating of
key aspects of care received within a ward or
it is the backbone of evidence for almost every
department? For what structured documents
medical professional liability action: it will be used to
are standardised templates available and used
reconstruct the episode of care and may also be used
(e.g. discharge summaries, pathology reporting,
as evidence in other types of legal proceedings, royal
radiology reporting, specialist referrals)?
commissions and formal inquiries.
re health professionals completing the records
A
to ensure that events and decisions required to
manage care are appropriately documented?
Unique identifiers
Health records belonging to a single consumer / patient Prompt points
or single episode of care should be linked by a unique ow are individuals identified within the
H
identifier. Each consumer / patient should be assigned records system? When an individual first
an identifier that will be constant for his or her presents, what checks ensure that he or she
health records. does not have a pre-existing health record?
The unique consumer / patient identifier should ensure: oes every consumer / patient have their own
D
orrect identification of the consumer / patient health
c health record? Are duplicate records ever
record on each subsequent visit to the organisation found in the system? What processes are used
to detect and correct duplications within the
that all information about the care and treatment record system?
provided to the consumer / patient is stored in the
correct health record oes the organisation assign individual
D
consumers / patients or episodes of care with
ll reports and/or results of investigations from other
a the unique key in its health records system?
organisations or departments are integrated into the How is the allocation of these unique key
correct consumer / patient’s record. numbers coordinated across the organisation?
Policy and procedure to address the unique identifier hat system-based precautions prevent
W
should include: different sites / departments issuing a second
identifier for the same person?
ersonal details that should be collected to
p
adequately allocate the consumer / patient ow are multiple identifiers checked? What
H
unique identifier, as well as the organisation’s process is followed when multiple identifiers
approved identifiers are discovered?
s ystems to support the allocation and maintenance of

the unique identifier Legible and complete health records
cross-referencing of unavoidable multiple records Despite the availability of many guidelines on the
the need for phonetic searches of names that sound importance of health record documentation, poor
alike but are spelled differently documentation continues to be a major factor in medical
indemnity claims and adverse events. All entries and
the need for alias searches to identify people who use associated documents should be legible, whether they
more than one name are paper-based or electronic. Illegible handwriting
rocesses to differentiate between people with the
p impacts on the standard of treatment provided and can
same name lead to errors.
rocesses for tracking provision of care where

p Organisations should ensure that:
consumers / patients access services anonymously. data are organised in a logical sequence
An electronic consumer / patient master index or central only approved abbreviations are used
index, used to store the unique identifiers, can range
from a simple database to complex systems, depending ntries to paper health records are made in blue or
e
on organisational size, corporate / regional infrastructure black indelible ink only
and available resources. ntries are dated and initialed, and always include
e
time of action
there is no erasure: where changes are needed,
a strikethrough should be used and the
changes initialed
andwriting is legible, not only to the author, but to
h
other users of the record
March 2016 77
Criterion 1.1.8 ated, timed and signed, with the enterer’s name and
d
The health record ensures comprehensive professional designation printed in block letters after
and accurate information is collaboratively the entry; a pager number or other contact is desirable
gathered, recorded and used in care delivery. ...and that:
(continued) only approved abbreviations are used
ny alterations to handwritten notes are attributed to

a any student entries are countersigned.
a health professional: alterations to handwritten notes
without attribution are illegal and can be confusing,
and in the event of an adverse outcome may also be a Prompt points
cause for suspicion and accusations of ‘cover-up’ hat types of audits of health record
W
aterials printed from electronic systems use fonts
m entries and their legibility are undertaken?
and type sizes that are legible and commonly used. Is the review managed by a person with
knowledge of clinical care, its conventions and
Organisations should also consider that: risks? When problems have been identified,
how is the information communicated to
legibility can also be problematic with some relevant staff and what actions are undertaken
communications technologies, and page formatting of to reduce the associated risks?
printouts from databases may also impact the legibility
of the information displayed If scanning is used in the organisation, does
the review include checks on the legibility of
dministrators check incoming faxes and proactively
a print documents scanned into electronic
request that poor quality or incomplete faxed materials record systems?
be resent
s canned items are checked for legibility prior to
assignment to a consumer / patient health record and Monitoring health record quality
that the resolution is adequate. Audits or other monitoring should be undertaken to ensure:
Policy / guidelines and procedures should address compliance with policy
the organisation’s requirements for standard forms to
be incorporated into the health record as needed, for timeliness of investigations and responses to referrals
example, a standard observation chart or a form that that where a consumer / patient’s condition has changed
identifies the organisation’s vulnerable populations. or deteriorated, documentation of the subsequent
Whatever standard forms are used within an management, including assessment and changes to the
organisation, it is important that all users of the health care plan, are evident in the health record.
record know what is to be used, where the forms can be
obtained and the information that should be recorded. Audits can aid in the understanding of, and where
necessary improve, turnaround time of investigation results,
To assess whether information in a health record is as well as indicating whether clinical staff access the results
capable of communicating the intended message, of investigations to ensure that significant results are not
record system audits should be managed and, ideally, overlooked. Contemporaneous documentation can be
undertaken by staff with clinical training or experience, in audited to determine whether the record was updated
the form of a multidisciplinary review panel. close to the time that the care was delivered.
A health record audit of the standard of documentation Audits can also be conducted on:
can commence with a basic chart audit to determine
whether the entries are: the various charts contained in the health record,
including medication charts, fluid balance charts, and
legible observation charts
in black or blue pen
corrected as per organisation policy
are plans and risk assessments, such as falls risk,
c lthough there is no legal obligation to transfer
a
nutrition and skin integrity assessments, including to consumer / patient records, health professionals
determine whether they were updated and signed on involved in ongoing care should be provided with at
a daily basis least a discharge summary suitable for inclusion in
their record
images and pathology results, to ensure they are
included in, or linked to, the record, and that results transfer of clinical information will usually be
of these assessments were considered during coordinated between health professionals
care planning
release of information for ongoing care is often
ischarge summaries, to ensure they were completed
d specified as part of the consent for a procedure,
and that records of their despatch are present for all however in some circumstances organisations may
consumers / patients. request signed consent from the consumer / patient
before transferring the record.
Where any deficiencies in health record quality or
accuracy are identified by audit, an action plan should Privacy and other laws also specifically regulate the
be developed, and all improvements documented. sharing of health information, with directions that may
apply only under specific circumstances. In the context
of an organisation and the jurisdiction in which it
Prompt points operates, it is worth considering the relevance of:
hat systems are used in this
W privacy legislation
organisation to monitor health
health services legislation
record quality?
Freedom of Information (FOI) legislation
ow frequently are formal audits undertaken?
H
How are the results disseminated to the public health notifications required under law
relevant staff?
child protection legislation
hat checks of the relevance and
W
HIV / AIDS legislation
completeness of the record are included in any
review process? mental health legislation
power of attorney and guardianship legislation.
Access to records and information by
health professionals Prompt points
Wherever possible, there should be capability for health ow does the organisation facilitate
H
professionals to access all components of a health access for health professionals to all
record, where they believe there is a clinical need, components of the record in a timely manner?
both during and outside office hours. It is important How is record access ensured after hours?
that the health record is available at the time the health
professional is providing care and treatment to the ow are health professionals who are new
H
consumer / patient. Similarly, in priority situations, to a ward or organisation oriented to ensure
health professionals at other sites should be able to that they can access all aspects of an existing
consult someone who can source information about a consumer / patient’s health record?
discharged or transferred consumer / patient. ow does the organisation and/or its different
H
Policy and procedure about accessing consumer / departments manage the competing demands
patient health records should consider that: for access to records and personal
privacy / confidentiality?
the health record is the property of the health service
providing care, and not of individual practitioners
ealth professionals may request a summary of an
h
episode of care or specific inclusions from the record
where relevant
March 2016 79
Criterion 1.1.8
The health record ensures comprehensive Prompt points
and accurate information is collaboratively here is the organisation’s information
W
gathered, recorded and used in care delivery. on consumer / patient access to their
(continued) health record available? How are consumers /
patients advised about access to their health
Consumer / patient access to personal record? How are consumers / patients assisted
to understand the content of their health record
health records when access is given?
Health information is deemed a personal record, and hat advice is given to consumers / patients
W
while the consumer / patient does not have ownership about transferring information to another
of the record, he or she does have the right to access it. health professional?
Healthcare organisations should have processes in place ow are staff made aware of the procedures for
H
by which the consumer / patient can gain access to his consumer / patient health record access? How
or her own health record, and this information should is compliance with procedures and timeliness
be proactively provided to the individual prior to or upon of response to consumer / patient requests for
admission. This aspect of consumer / patient rights is health record access monitored?
discussed in more detail within criterion 1.6.2.
Consumers / patients may request changes to
correct any errors in their record and organisational
policy should reflect this, in accordance with relevant The following evidence may help to
legislation. Organisations should provide information on: address criterion 1.1.8
how this should be done ontent of health records - cross-references to
C
the fees charged (if any) for providing access, which other records or evidence of flags or hyperlinks
should not be excessive. to indicate another record in another format
may help to demonstrate techniques to facilitate
The content of the health record must be protected professional access
because it contains information about individuals
that may be personally or financially damaging if esults of health record audits; any
R
accessed inappropriately. communications to staff or training materials
developed to respond to audit findings
echniques / systems used to ensure a unique
T
identifier on each record and avoid duplication
when it is assigned
olicies and procedures, including techniques or
P
additional materials used to respond to specific
organisational or department requirements
Standardised forms and templates
Instructional materials, such as lists of approved
abbreviations or ‘how to’ guidance for staff
rientation, training or review programs that
O
ensure new or contract staff adopt correct and
consistent systems and processes in unfamiliar
clinical settings
eviews to eliminate any duplication of records
R
for individual consumers / patients
Standards
AS 2828.1-2012 Health records Part 1: Paper-based
health records.
AS 2828.2-2012 Health Records Part 2: Digitized (scanned)
health record system requirements.
Suggested reading
Australian Medical Association. AMA Code of Ethics.
Canberra: AMA. Available from: https://ama.com.au/media/
ama-code-ethics-foundation-doctor-patient-relationship
Australian Medical Association. Ethical Guidelines for Doctors
on Disclosing Medical Records to Third Parties - 2010.
Revised 2015. Available from: https://ama.com.au/position-
statement/guidelines-doctors-disclosing-medical-records-
third-parties-2010 Viewed 12 February 2016.
Australian Medical Council. Good Medical Practice: A Code of
Conduct for Doctors in Australia. Available from: http://www.
medicalboard.gov.au/Codes-Guidelines-Policies/Code-of-
conduct.aspx Viewed 12 February 2016.
Institute for Safe Medication Practices (ISMP). ISMP’s list of
error-prone abbreviations. Available from: https://www.ismp.
org/tools/errorproneabbreviations.pdf Viewed 12 February 2016
Australian Commission on Safety and Quality in Health
Care. Recommendations for Terminology, Abbreviations
and Symbols used in the Prescribing and Administration of
Medicines. Available from: http://www.safetyandquality.gov.
au/wp-content/uploads/2012/01/32060v2.pdf Viewed 12
February 2016.
Australian Commission on Safety and Quality in Health Care.
Recognising and Responding to Clinical Deterioration: Use
of Observational Charts to Identify Clinical Deterioration.
Available from: http://www.safetyandquality.gov.au/wp-
content/uploads/2012/02/UsingObservationCharts-20091.pdf
Government of South Australia and South Australia Health.
A Guide to Maintaining Confidentiality in the Public Health
System. Available from: http://dlb.sa.edu.au/tsftfmoodle/
pluginfile.php/995/mod_resource/content/0/COMMUNICATE_
AND_WORK_EFFECTIVELY_IN_HEALTH/element_1/
confidentiality_in_health_system_pamphlet.pdf Viewed 12
February 2016.
March 2016 81
1.2 Access Standard

The standard is:
Consumers / patients and communities have
access to health services and care appropriate to
their needs.
The intent of the Access standard and criteria is to ensure
that communities and consumers / patients have access
to necessary health care and services. Organisations
should ensure that the community has information on
available health services and that access is determined by
the clinical needs of consumers / patients.
There are two criteria in this standard. They are:
he community has information on health
1.2.1 T
services appropriate to its needs.
1.2.2 A
ccess and admission / entry to the system
of care are prioritised according to
healthcare needs.
Access is a fundamental dimension of quality in health
care. There will be different issues about access
depending on the service (acute or community) and
the sector (public or private). Each organisation should
interpret the criteria in a manner relevant to their sector
and service.
March 2016 83
Standard 1.2: Consumers / patients and communities have access to
health services and care appropriate to their needs.
Implementation
Criterion 1.2.1 a) The organisation has defined the a) Services are designed to meet the
community that it serves. needs of the identified community.
The community has information
on health services appropriate to b The organisation develops or b) Consumers / patients are provided
its needs. sources information about the with information about the specific
specific services it provides and service(s) they are using.
supplies this information to
c) An internal service directory listing
the community.
operational and contact details of
c) Health professionals within the external health service providers is
organisation have information on maintained and made available to
relevant external services. relevant staff.
d) Relevant external health service d) There is collaboration between the
providers are supplied with organisation, consumers /
information on the health service patients, carers and external
and are informed of referral and health service providers to develop
entry processes. information about referral and
entry processes.

This criterion outlines the requirement for an organisation Healthcare organisations should provide relevant
to identify the community it serves, in order to ensure information for consumers / patients, their carers and
that it provides the necessary information about its members of the general public about the organisation
services, and about external services, appropriate to the and its services, including clear information for
needs of its community. consumers / patients about the treatment and care
they may receive. Information should also be provided
to health professionals who are involved in ongoing
care (Criterion 1.1.6) or transfer of care (Criterion 1.1.5),
or who may refer consumers / patients to the service
(Criterion 1.2.2).
Information content should be provided with
consideration for consumers / patients with diverse
needs and from diverse backgrounds (Criterion 1.6.3),
and in addition to services provided, should address
issues such as access to health care and admission
processes (Criterion 1.2.2), consent processes (Criterion
1.1.3) and consumer / patient rights and responsibilities
(Criterion 1.6.2).
a) T
he organisation evaluates a) The organisation shows distinction a) The organisation demonstrates it
the information supplied to the in the provision of health service is a leader in providing information
community about the services it information to its community. on health services appropriate to
provides, and improvements are the community’s needs.
made as required.
b) T
he organisation evaluates
processes for dissemination of
information on its services,
as required.
c) Maintenance of the external health
service providers’ directory is
made as required.
d) The organisation evaluates its
collaboration with consumers /
patients, carers and external
health service providers, and
as required.
This criterion requires healthcare order to access those services. It will then be able to
organisations to: address any special needs of consumers / patients, for
example, making kosher and halal meals available, or
Define the community that they serve. providing a designated play area for children.
ave information available about their healthcare
H The community that the organisation serves may be
services for consumers / patients and defined in two ways:
health professionals.
ublic healthcare organisations have a responsibility
p
nsure information about relevant external health
E for providing health services to a general community,
service providers is available for health professionals usually defined geographically
and consumers / patients.
private healthcare organisation’s community,
a
Defining community needs however, is those consumers / patients who are
referred to the health service, by whatever means,
It is important that an organisation defines its
for care. Most private health services do not have a
community and/or the typical users of its services, in
responsibility for satisfying the needs of a geographic
order to understand the cultural influences or specific
community; their community is usually determined by
requirements within that community. Demographic data
their referrers. Private organisations may be assisted
derived through the census can assist in understanding
in understanding the diverse needs and backgrounds
a geographic community, and assessing its needs.
of their community by contacting their referrers for
Following definition of its ‘community’, an organisation this information.
will be better equipped to determine the range of
services to be provided, and the information that
consumers / patients and the community will need in
March 2016 85
Criterion 1.2.1 ow the organisation will handle health information,

h
The community has information on health irrespective of whether consent is given. This
services appropriate to its needs. (continued) information should be provided at the earliest
opportunity and in line with relevant privacy legislation,
Defining its community may pose a challenge for some for example the Australian Privacy Principles (APP)
organisations, whose consumers / patients may be inclusion and/or exclusion criteria for admission to the
both local to the organisation and referred from much health service
greater distances; or, for some specialised services,
even from overseas. ollaborative links between the organisation and
c
specific community / advocacy / support groups
its schedule of programs and/or education sessions
Prompt points
transport and/or parking.
ow has the organisation defined its
H
community? Who did the organisation Consumers / patients being admitted to a specific
contact to do this? service should be provided with all necessary
information, and in an appropriate format and language.
How are the needs of the community addressed?
This should address:
the procedure, treatment, test or assessment that the
Providing information about
consumer / patient will undergo
healthcare services
ll necessary details about when and how to access
a
Organisations must provide enough information, and in the service
the appropriate formats, to inform consumers / patients
about services, treatments, options and costs in a clear what forms (if any) to fill in before doing so
and open way. what to bring.
Information on health services may be provided in many
different formats; the most appropriate formats will Organisations will have relationships with external
depend on the message and for whom it is intended. service providers who refer consumers / patients to the
Information about services may rely on: organisation, and who may later resume responsibility
for their ongoing care. In order to facilitate these
irectories or lists of organisational and community-
d processes, the organisation should provide its referrers
based services with all necessary information about:
brochures and handouts its access and admission processes
websites hours of operation
ews media (including items resulting from press
n access conditions
releases) and documentaries
location of specialty services
paid advertising
contact details
signage
the channel(s) by which it should receive referrals
ther forms of telecommunication, such as DVDs,
o
online video files, phone text reminders, etc. the means and timeframe within which it in turn will
transfer consumer / patient information to the referrer
Organisations should provide information about:
any other relevant information.
the services available within the organisation,
such as specialty medical services, emergency
services, outpatient services, pharmacy, counselling,
rehabilitation and education classes, as well as
auxiliary services such as cafes or onsite attached
accommodation for out-of-town relatives / carers
Prompt points Prompt points
ow is information on the health service
H ow are consumers / patients
H
provided to the community? In what and healthcare providers within the
formats? In what languages? How did the organisation informed about external health
organisation decide upon these languages? service providers? How does the organisation
ow often is the content and processes
H ensure the information is relevant?
for dissemination of information on services hat collaborations exist between the
W
evaluated? What recent changes have been organisation and external service providers in its
made to the content? What recent changes have community? Are these formal or informal?
been made to the system of dissemination?
ow does the organisation know whether its
H
If no changes have been made, explain the collaborations are helping it to meet the needs
reasons in relation to the results of any evaluation of its community?
of health service information?
Providing information about relevant The following evidence may help to

external healthcare service providers address criterion 1.2.1
In addition to providing information about their own
Information sheets provided for the community,
services, organisations should provide consumers /
including information on:
patients with information about related external services
and their providers, to ensure that the consumers / • public transport routes and timetables
patients can access these services, when appropriate. • available parking options
Organisations should also have this information available
for its own health professionals, in order to facilitate • locations of community or affiliated pharmacies
correct referrals. edia releases / advertising / newsletters /
M
Information about relevant external service open days / public displays
providers should: Results of consumer surveys
e available to consumers / patients and health
b Organisational service directory
professionals in the event of transfer of care /
discharge on weekends vidence of new or extended services provided
E
as a result of consumer feedback
e maintained in a central area, such as in a ‘Service
b
Directory’, either paper based or electronically ew community groups that are
N
accessing information
include community-based follow-up care for their
own services, such as a Women’s Hospital providing etails of other aligned service providers that
D
information about antenatal home visitation services assist with post-operative care
e known to staff, including where and how to access

b ontact numbers for referrers and processes of
C
the information and the organisation's links to various referral if requested
external service providers
include templates for referral letters, which contain
information identified by the referral organisation as
relevant for its service.
March 2016 87
Criterion 1.2.1
The community has information on health
services appropriate to its needs. (continued)
Suggested reading
The Australian Commission on Safety and Quality in Health
Care. The Australian Charter of Healthcare Rights. Available
from: http://www.safetyandquality.gov.au/wp-content/
uploads/2012/01/Charter-PDf.pdf Viewed 15 February 2016.
Healthdirect. The National Health Services Directory. For
health practitioners, the National Health Services Directory
is a joint initiative of all Australian governments, delivered by
Healthdirect Australia. It facilitates the coordination of ongoing
care for patients providing connection of care and referral
pathways for location based services. Available from: http://
www.healthdirect.gov.au/national-health-services-directory
March 2016 89
Implementation
Criterion 1.2.2 a) Policy / guidelines addressing the a) The organisation’s system for
prioritisation of admission / entry prioritising care meets the needs
Access and admission / entry to
to the health service are consistent of the consumer / patient.
the system of care are prioritised
with relevant legislation, standards,
according to healthcare needs. b) The organisation has a system to
guidelines and/or codes of
manage its waiting times / wait lists.
practice, and are readily available
to staff. c) There are policy / guidelines to
manage the referral of consumers /
b) The organisation has clear
patients who do not meet the
inclusion and/or exclusion criteria
inclusion criteria.
for admission to the service.
d) There are processes that ensure
c) Admission / entry processes meet
continuity of care between referrers
consumer / patient needs and
and health service providers.
minimise duplication.
d) Information in referral documents
received on admission of the
consumer / patient is utilised.

This criterion requires organisations to have processes Information on health services and how to access
in place to facilitate consumer / patient access to them should be readily available to the community
health care and services, and that consumer / patient (Criterion 1.2.1). Access to the health system begins
needs are considered during prioritisation of care and the consumer / patient’s journey of care (Standard
admission of the individual to the organisation. 1.1). However, before being admitted to a healthcare
organisation, the consumer / patient’s needs will be
Processes pertaining to access and admission will vary
assessed, and subsequent access may be subject to
according to the nature of the organisation, its location
inclusion / exclusion criteria and processes that ensure
and the sector in which it operates. Each organisation
the consumer / patient receives the appropriate care in
should interpret this criterion and the information in this
the most appropriate setting (Criterion 1.3.1). Following
guideline within its own context, while ensuring that it
admission, coordinated and effective systems facilitate
fulfills its duty of care towards its consumers / patients.
the ongoing care of the consumer / patient (Criterion
1.1.6), whose needs, both within the facility and
following transfer / discharge, will be addressed via the
processes for clinical handover (Criterion 1.1.5).
Access to the health system is a fundamental right
of the consumer / patient (Criterion 1.6.2). It is the
responsibility of the organisation to ensure that it meets
the requirements of consumers / patients with diverse
needs and from diverse backgrounds, according to the
demographic that it serves (Criterion 1.6.3), including
facilitating physical access through the provision of
appropriate entries and signage (Criterion 3.2.2), so that
access to health care is not hindered.
a) The system for prioritisation of care a) The organisation shows distinction a) The organisation demonstrates
is evaluated, and improvements in prioritisation and processes it is a leader in admission / entry
are made as required. for admission / entry and access processes and systems for
to care. prioritising access according to
b) A
dmission / entry processes are
healthcare needs.
made as required.
c) The organisation’s inclusion /
exclusion criteria, and the referral
of those not meeting the inclusion
criteria, are evaluated, and
as required.
This criterion requires healthcare Inclusion / exclusion criteria and systems to

organisations to: manage consumers / patients who do not
efine their inclusion / exclusion criteria and have
D meet the criteria
systems to manage consumers / patients who do not Inclusion and/or exclusion criteria are the conditions that
meet the criteria. determine eligibility or ineligibility for services provided
nsure that processes for access and admission /
E by a healthcare organisation. They should be formally
entry to the health service meet the needs of documented. The public hospital system operates
consumers / patients and health professionals. within a philosophy of universal inclusion, meaning that
consumers / patients should achieve access regardless
ave systems for prioritising access to care and
H of the nature or severity of their healthcare needs
services that consider implications on wait times. or their personal status or circumstances. Financial
considerations should not deny access to treatment in a
public hospital or other public facility.
The organisation should have policy and procedures
governing the response to specific consumer /
patient needs or service-specific limitations, including
circumstances in which a consumer / patient may be
transferred to another facility, in order to receive the
most appropriate care in a timely manner.
March 2016 91
Criterion 1.2.2 their duty of care to, at a minimum, provide advice

Access and admission / entry to the system as to an alternative point of care, or to re-direct the
of care are prioritised according to healthcare consumer / patient either back to the referrer or to
another appropriate health professional or service. In
needs. (continued) some circumstances, an assisted referral to another
organisation or service provider may be required.
There are a variety of reasons and circumstances that
may make an exclusion criterion necessary. Some
examples are:
Prompt points
strictly age-defined paediatric or youth services
oes the organisation have exclusion
D
s urgical facilities may determine their inclusion and criteria? On what basis were
exclusion criteria according to the scope(s) of practice they implemented?
of their staff and the availability of special equipment
ow does the organisation assist excluded
H
(see criterion 3.1.3 for further discussion)
consumers / patients to receive appropriate care?
n unacceptable anaesthesia risk may exclude
a
consumers / patients from day procedure centres
where overnight accommodation / observation is Access and admission / entry to the health
not available service that meets the needs of consumers /
s pecialty services in rural hospitals, such as obstetrics patients and health professionals
or oncology services, which are provisional upon From the perspective of the organisation, consumer /
staffing arrangements and/or availability of equipment, patient access may be planned or unplanned:
medications, etc.; if these conditions cannot be met,
consumers / patients may be excluded and transferred lanned access is when an appointment or booking has
p
to facilities in regional centres been made, and the consumer / patient attends at a
pre-arranged time to receive specific, agreed services
sychometric test scores and the outcomes of
p
other evaluative measures may be considered nplanned access is contact by a consumer / patient
u
when determining eligibility criteria for specific other than to make an appointment, or the arrival of
psychiatric programs a consumer / patient at a healthcare facility without
immediate prior contact, whose clinical need must
ommunity-based services may operate within age,
c then be determined.
severity of condition or catchment-based criteria to
meet funding obligations he pathway by which the consumer / patient gains
T
access to the health system will vary according to the
the unavailability of specialist medical officers or nature and urgency of his or her clinical need, and
specialty equipment may be a reason for consumer / the character and situation of the organisation
patient exclusion. being accessed.
The basis for, and implementation of, exclusion criteria Admission is the point in the care journey at which the
will vary according to the nature, sector and location of organisation acknowledges the consumer / patient as
the organisation. Organisations should consider: a client, and accepts responsibility for his or her care;
the needs and the wellbeing of the consumer / patient in some contexts, the term ‘registration’ may be used
when drafting such criteria, as this must at all times be rather than admission. The point at which admission
the overriding consideration is considered to have occurred, and the processes by
which it happens, will vary considerably according to the
ow the organisation would make it clear to the
h
nature of the organisation.
consumer / patient that any decision to exclude is
not made on a personal basis, but to avoid providing
inappropriate care, in an inappropriate setting, or
that it is due to other external factors, such as
funding conditions
In the first instance, admission refers to the administrative
process by which an individual’s details are entered into the Prompt points
organisation’s systems so that the care journey may begin.
However, it is important to recognise that, depending upon ow many ways may the consumer /
H
the nature and sector of the organisation, admission does patient access this organisation? Is referral
not necessarily require the provision of accommodation, or always necessary?
access to a specific facility. hen, in this organisation, is a consumer /
W
Access and admission processes should consider: patient considered to be ‘admitted’? Must a
consumer / patient attend at the organisation
the consumer / patient may not need to attend the to be admitted? Must he or she be admitted to
facility in order to be admitted; while the organisation’s receive a service?
duty of care towards the consumer / patient may
begin before there is any direct contact. Organisations ow does the organisation avoid duplication
H
should ensure that there is a policy that outlines when of information collection upon consumer /
a consumer / patient is considered to have been patient admission?
admitted to the health service and when the duty of ow is consumer / patient satisfaction with
H
care commences admission processes determined? How often is
in private hospitals, admission generally occurs when this done?
the consumer / patient attends at an appointed time.
The process may need to incorporate approval from
relevant private insurers and/or the confirmation of Prioritising access to care and services, and
alternative payment options implications on wait times
hen a consumer / patient self presents at an
w Prioritisation is the process by which the urgency of
emergency department, access may or may not the consumer / patient’s clinical need is determined.
be followed by admission. Triage will determine the It involves a risk assessment and a clinical judgment
organisation’s course of action, including prioritisation informed by the equivalent and comparable assessment
of care and admission where appropriate of the need of others seeking care of the same kind
or at the same facility. Prioritisation occurs at different
for a planned admission, pre-admission forms points in the healthcare journey, and may occur multiple
available online or by mail can facilitate admission times in the journey of a single consumer / patient. The
when the consumer / patient arrives at the facility process and its criteria will vary according to the nature
nplanned admissions, such as through an
u of the organisation, but clinical need should always be
emergency department, are more difficult to manage the overriding consideration.
smoothly due to the many variables involved. Triage is a form of prioritisation most commonly
There are some circumstances in which repetition associated with emergency situations. It is the process
of questioning is a deliberate and necessary safety of determining the priority of a consumer / patient’s
precaution, and consumers / patients should be treatment based on the severity of their condition.
advised of the importance of these processes. This Traditionally, emergency departments have used a
includes such aspects of care as consent, consumer / system of five categories of triage, from resuscitation
patient identification, and blood and blood component (i.e. action within seconds) to non-urgent; although
management, which are discussed within criteria 1.1.3, alternative approaches, including identifying urgent need
1.5.6 and 1.5.5, respectively. before dividing the remaining cases into ‘likely to be
admitted’ and ‘likely to be discharged’, have been trialed
and found effective.
March 2016 93
Criterion 1.2.2
Access and admission / entry to the system The following evidence may help to
of care are prioritised according to healthcare address criterion 1.2.2
needs. (continued) Policies on triage
Policies on prioritisation
Processes for prioritising access to care and
services include: dmission policy, including the documented
A
eligibility criteria
aiting lists, to provide a buffer between the demand
w
for elective surgery services and the capacity of the eferral information for ineligible consumers /
R
facilities system to provide those services patients in line with criteria
the process of referral, which can itself be an example ICU access policy
of prioritisation
Theatre lists
identifying the point(s) in the care journey where
Evaluated data from waiting lists
prioritisation will occur
esults of consumer / patient satisfaction
R
effective prioritisation strategies
surveys which have included questions on the
valuation of prioritisation processes, including
e admission process
consumer / patient satisfaction surveys and regular
esults of referrer satisfaction surveys on the
R
reviews of outcomes, or where appropriate with the
admission process and the transfer of information
use of collected performance indicators.
The unpredictability of acute care will sometimes result in
access block, that is, overcrowding and/or delay in care
provision. This may be a consequence of high occupancy
and non-availability of appropriate beds, excessive
demand on equipment or heavy staff workloads.
Although the circumstances that result in access block
may be beyond the control of the organisation, it is vital
that the organisation’s own processes do not contribute
to the problem.
Prompt points
ow does the organisation prioritise
H
consumer / patient care? At what point(s)
in the care journey does this occur?
hat staff members are responsible for
W
prioritising care?
hat documentation is available to demonstrate
W
appropriate prioritisation has taken place?
ow does the organisation evaluate its
H
prioritisation processes? What changes have
been made as the result of such an evaluation?
Is access block an issue for this organisation?
What means does the organisation employ to
reduce or overcome access block?
Suggested reading
Emergency Triage Education Kit. Triage Quick Reference
Guide. Australian Government, Department of Health.
Available from: http://www.health.gov.au/internet/main/
publishing.nsf/Content/casemix-ED-triage+Review+Fact+Shee
t+Documents Viewed 16 February 2016.
Australasian College for Emergency Medicine. Guidelines
on the Implementation of the Australasian Triage Scale
in Emergency Department. Available from: https://www.
acem.org.au/getattachment/d19d5ad3-e1f4-4e4f-bf83-
7e09cae27d76/G24-Implementation-of-the-Australasian-
Triage-Scal.aspx Viewed 16 February 2016.
Australasian College for Emergency Medicine. Policy on
the Australasian Triage Scale. Available from: https://www.
acem.org.au/getattachment/693998d7-94be-4ca7-a0e7-
3d74cc9b733f/Policy-on-the-Australasian-Triage-Scale.aspx
Siciliani, L., M. Borowitz and V. Moran (eds.) (2013). Waiting
Time Policies in the Health Sector: What Works? OECD Health
Policy Studies, OECD Publishing. Available from: http://dx.doi.
org/10.1787/9789264179080-en Viewed 16 February 2016.
Clinical Excellence Commission. Improving patient access
to acute care services: A practical toolkit for use in public
hospitals. Available from: http://www.cec.health.nsw.gov.au/__
data/assets/pdf_file/0006/258342/improvingaccesstoolkit.pdf
Viewed16 February 2016.
Department of Health & Human Services. Victorian
service coordination practice manual 2012. Available
from: https://www2.health.vic.gov.au/about/publications/
policiesandguidelines/victorian-service-coordination-practice-
manual-2012 Viewed 16 February 2016.
Ben-Tovim DI, Dougherty ML, O’Connell TJ and McGrath
KM. Patient journeys: the process of clinical redesign. Med J
Aust 2008; 188(6): S14–17. Available from: https://www.mja.
com.au/journal/2008/188/6/patient-journeys-process-clinical-
redesign Viewed 16 February 2016.
March 2016 95
1.3 Appropriateness Standard

The standard is:
Appropriate care and services are provided to
The intent of the Appropriateness standard and criterion
is to ensure that consumers / patients receive appropriate
and necessary care, interventions and services.
There is one criterion in this standard. This is:
1.3.1 A
ppropriate health care and services are delivered
in the most appropriate setting.
Appropriateness is doing the right treatment,
intervention or service in the right way and effectiveness
is the extent to which those treatments, interventions or
services achieve the desired outcomes.
March 2016 97
Standard 1.3: Appropriate care and services are provided to
Implementation
Criterion 1.3.1 a) Clinical guidelines are used to a) Service planning includes an

direct appropriate care delivery. evaluation of the appropriateness
Appropriate health care and
of the services to be provided.
services are delivered in the most b) Policy / guidelines addressing
appropriate setting. how the organisation assesses b) The organisation has a strategy to
the appropriateness of care and ensure the appropriateness of care
interventions are readily available and interventions.
to staff.
c) The organisation collects a
c) Policy / guidelines addressing how suite of key indicators relating
the organisation assesses the to appropriateness of care
appropriateness of the setting in and interventions.
which care is delivered are readily
d) Consumers / patients and carers
available to staff.
participate in decisions about
d) There are processes to manage the appropriate setting for
and minimise risk to consumers / care delivery.
patients accommodated outside
e) Relevant health professionals are
the specialty area.
educated about the appropriate
e) Policy / guidelines address the use of restraint.
organisation’s use of restraint,
including:
(i) physical restraint
(ii) chemical restraint
(iii) seclusion and/or locked doors.

This criterion highlights the importance of ensuring Appropriateness should be evident throughout the
that consumers / patients receive appropriate and journey of care (Standard 1.1). The processes of access
necessary care, interventions and services in the most and admission and the use of inclusion and exclusion
appropriate setting. criteria (Criterion 1.2.2) will ensure that care is delivered
in the most appropriate setting. Assessment (Criterion
In health care, appropriateness is about doing what
1.1.1) and care planning (Criterion 1.1.2) will determine
is necessary, and not doing what is not necessary.
what is appropriate for the consumer / patient; while the
Appropriate care is reflected in positive care outcomes,
care subsequently given will be not only appropriate,
and in the extent to which the consumer / patient’s
but delivered in the most effective way and with positive
needs and wants are met.
health outcomes (Criterion 1.4.1) by health professionals
who are credentialed and performing within their defined
scope of practice (Criterion 3.1.3).
a) T
he appropriateness of care, a) The organisation shows distinction a) The organisation demonstrates it
services and interventions is in its provision of appropriate care. is a leader in providing appropriate
evaluated by health professionals care and services in the
and management, and consumers appropriate setting.
as practicable, and improvements
b) T
he appropriateness of the
settings for care delivery is
made as required.
c) Processes for managing
consumers / patients
accommodated outside the
specialty area are evaluated,
as required.
d) The organisation’s use of restraint
is evaluated, and improvements
Research can help to determine the appropriateness This criterion requires healthcare
of specific health interventions (Criterion 2.5.1), while organisations to:
quality improvement programs may assist in promoting
adherence to best-practice clinical guidelines and ave a process for assessing the appropriateness of
H
broaden the delivery of appropriate care (Criterion 2.1.1). care and services.
Ensuring appropriateness of care is an aspect of the nsure that the delivery of care and interventions
E
organisation’s integrated risk management framework is appropriate.
(Criterion 2.1.2). Inappropriate care, or care delivered in nsure that the setting in which care and interventions
E
inappropriate settings, may lead to incidents (Criterion are delivered is appropriate.
2.1.3) and complaints (Criterion 2.1.4).
Measure and manage appropriateness.
March 2016 99
Criterion 1.3.1 hat backup is available if required, such as intensive

W
Health care and services are appropriate and care or a senior consultant?
delivered in the most appropriate setting. hat corporate and support structures and systems
W
(continued) are in place, such as clinical governance or quality
improvement mechanisms, clinical audits or a
Appropriateness of care and interventions credentialing system?
Appropriateness is the degree to which service is Appropriate care or treatment should:

consistent with a consumer / patient’s expressed
requirements and is provided in accordance with current e based on established and accepted
b
best practice. It refers to the relative weight of the standards, evidence-based clinical guidelines or
benefits and harms of a medical or surgical intervention. treatment protocols
An appropriate procedure is one in which the expected nly vary according to consumer / patient needs and
o
health benefit (e.g. increased life expectancy, relief of this may take other factors into account
pain, reduction in anxiety, improved functional capacity)
exceeds the expected negative consequences (e.g. ot be unnecessary or inappropriate, simply because
n
mortality, morbidity, anxiety, pain, time lost from work) the consumer / patient has requested it
by a sufficiently wide margin that the procedure is worth e needed and provide benefit to the
b
doing, exclusive of cost. consumer / patient
Inappropriate care can result from either: take into account any research or quality improvement
nderuse, such as the failure to provide a service
u work being undertaken that specifically relates to
which has a benefit that is greater than the risk appropriate use of interventions.
veruse, when a health service is provided even

o
though the risk outweighs the benefit. Prompt points
The question of appropriateness of care is applicable hat policies address appropriateness
W
to all healthcare settings and modes of service delivery. of services? Are there policies about
Many services already use criteria for the appropriate appropriateness of settings?
admission of consumers / patients to their service.
Further information on inclusion and exclusion criteria is ow does the organisation access evidence-
H
available within criterion 1.2.2. based guidelines? How are these made
available to relevant staff?
Systems that may support the assessment and
evaluation of appropriateness include the credentialing o service planning documents address
D
and scope of clinical practice system, peer review appropriateness? What evaluation of these
meetings and/or clinical audit reviews. documents has occurred?
As the delivery of appropriate care is dependent upon

many factors, aspects to consider include: An appropriate setting
What is the size of the organisation? The appropriateness of the setting in which care is
re health professionals with expertise in undertaking
A provided is determined by matching consumer / patient
specific procedures available? Are they correctly needs for treatment with the setting in which it should
credentialed with the necessary scope of practice? be provided; this may vary from individual to individual.
What supervision is available? This aspect of care is closely related to the processes of
credentialing and defining health professionals’ scope of
hat facilities and resources are required to ensure
W practice, as addressed within criterion 3.1.3.
that care is appropriate? For example, plant and
equipment, emergency department, inpatient care?
Appropriate services can be provided in inappropriate Consumers / patients accommodated outside the
settings. For example: specialty ward area are at greater risk of:
ajor surgery should not be undertaken in an
m eing forgotten or receiving the wrong treatment
b
environment where senior consultant and/or potential and/or medications, and of increased length of stay
intensive care backup is unavailable, or too far away and increased morbidity
n individual recently diagnosed with diabetes in
a eterioration that is not noticed, as the staff may be
d
most cases would appropriately receive care through less familiar with the condition for which the consumer /
ambulatory services patient is being treated
r ather than remaining in acute beds while awaiting aving requirements beyond the familiar expertise of
h
transfer, frail, aged consumers / patients who are the care unit.
assessed as requiring aged care rehabilitation or
When considering care settings, the assessment
residential care may be accommodated in a more
of appropriateness will depend on the availability of
appropriate transitional care unit or facility
alternative settings, such as moving new mothers
s upport for self-management of chronic conditions to hotel rooms, or delivering intravenous antibiotic
is most appropriately delivered in ambulatory care treatment for an acute but stable condition via a Hospital
or community settings, with the potential for some In The Home program if the home environment is
aspects to be provided in a sporting facility, such as assessed as suitable.
a gym or hydrotherapy pool, under the supervision of
allied health professionals.
A consumer / patient accommodated outside the
Prompt points
specialty ward area is one who is being treated in an hat processes are used to evaluate
W
area of the health service that normally treats a different the appropriateness of setting for the
casemix. A consumer / patient accommodated outside organisation’s procedures?
the specialty ward area may also be known as a ‘home-
ow is appropriateness of setting included
H
ward outlier’.
when any proposed change to a clinical service
For example: is assessed for feasibility?
consumer / patient with a medical condition such as
a ow does the organisation manage consumers /
H
diabetes may be admitted to a surgical ward because patients accommodated outside the home-
of a shortage of available beds ward area? What methods have been used to
evaluate these processes?
o-location of children and adolescents with adults in
c
health services is a common practice. Organisations hat changes have been made to the
W
should consider the medical and psychosocial needs processes following evaluation?
of children and adolescents as different from those of
adults when allocating beds / wards
it may be considered that a consumer / patient who
suffers from dementia is a ‘home-ward outlier’ in any
environment, especially if they are the only consumer /
patient in that area suffering from dementia
in a day procedure centre, a consumer / patient
undergoing orthopaedic surgery who is added to the
end of an ophthalmic surgical list is a ‘home-ward
outlier’ consumer / patient.
March 2016 101

Criterion 1.3.1
Health care and services are appropriate and The following evidence may help to
delivered in the most appropriate setting. address criterion 1.3.1
(continued) vidence-based policies, clinical
E
practice guidelines
Measuring and managing appropriateness Adherence to by-laws
Measuring and managing appropriateness is difficult Identification of common care processes of
with the use of a single variable or instrument. Individual principal conditions treated
indicators should be selected according to the specific
areas for review. Appropriateness of the service can be Information available on the use of clinical
examined on an individual consumer / patient basis or pathways / care maps
by taking an organisational approach. Audits of clinical pathways / care maps
Measuring and managing appropriateness should: vidence of the use of criteria of
E
nderpin clinical peer review activities, where care
u appropriateness, such as Criteria of
provided to an individual is compared against a Appropriateness of Blood Transfusions
normative standard of care. This may be documented (NHMRC guidelines)
in several ways including a clinical pathway, against Collection of clinical indicator data
intervention / care selection criteria
Changes in clinical indicators collected
e based on the best available evidence, a list of
b
criteria can be developed to determine when it is vidence of the use of indicators
E
appropriate to use a certain intervention of appropriateness
ake use of data that would indicate either overuse

m Clinical service plans
or underuse of services. The ability to determine Demographic / population studies and data
and identify which care is overused and which is
underused is essential. Incident management data Organisational profile
can also be utilised to assess appropriateness of care Consumer / patient pathways / care plans
rely on the identification of a suite of Consumer / patient feedback
performance indicators that are relevant to the
services provided. ontracts with other service providers such as
C
Home and Community Care (HACC)
Operational plan
Prompt points
New interventions policy
hat indicators are used to evaluate the
W
Staffing levels and skill mix
appropriateness of care?
Education
ow are health professionals involved in the
H
evaluation of appropriateness of care? What
other staff members are involved?
ow are consumers involved in the evaluation
H
of appropriateness?
Suggested reading
Australian Centre for Posttraumatic Mental Health. Australian
Guidelines for the Treatment of Adults with Acute Stress
Disorder and Posttraumatic Stress Disorder. Available
from: http://www.nhmrc.gov.au/_files_nhmrc/publications/
attachments/mh15.pdf%20 Viewed 16 February 2016.
Fitch K, Bernstein SJ, Aguilar MS, et al. Appropriateness Method
User's Manual. Available from: http://www.rand.org/pubs/
monograph_reports/MR1269.html Viewed 16 February 2016.
National Health and Medical Research Council. Australian
Clinical Practice Guidelines Portal. Available from: https://www.
clinicalguidelines.gov.au / Viewed 16 February 2016.
Runciman W, Hunt T, Hannaford N, Hibbert P, Westbrook
J, Coiera E, Day R, Hindmarsh D, McGlynn E, Braithwaite
J. CareTrack: assessing the appropriateness of health care
delivery in Australia. Med J Aust 2012; 197 (2): 100-105.
Available from: https://www.mja.com.au/journal/2012/197/2/
caretrack-assessing-appropriateness-health-care-delivery-
australia Viewed 16 February 2016.
Bureau of Health Information. Spotlight on measurement;
Describing and assessing performance in healthcare: an
integrated framework. April 2014. Available from: http://www.
bhi.nsw.gov.au/__data/assets/pdf_file/0013/217030/Spotlight_
on_measurement_APR_2013.pdf Viewed 16 February 2016.
Royal Australasian College of Physicians. Standards for
the care of children and adolescents in health services.
Available from: https://members.racp.edu.au/index.
cfm?objectid=393E4ADA-CDAA-D1AF-0D543B5DC13C7B46
Royal Australian and New Zealand College of Psychiatrists
(RANZCP). Clinical Memorandum #12: Guidelines on
the administration of electroconvulsive therapy (ECT).
Available from: http://www.electricshocktherapy.info/
uploads/4/0/7/6/4076267/the_royal_australian_and_nz_college_
of_psychiastrists_ect_memo.pdf Viewed 16 February 2016.
National Health and Medical Research Council (NHMRC),
Australasian Society of Blood Transfusion (ASBT). Clinical
practice guidelines on the use of blood components. Available
from: https://www.nhmrc.gov.au/guidelines-publications/cp78
Australian and New Zealand College of Anaesthetists (ANZCA).
PS29: Statement of anaesthesia care of children in healthcare
facilities without dedicated paediatric facilities. Available from:
http://www.anzca.edu.au/resources/professional-documents/
pdfs/ps29-2008-statement-on-anaesthesia-care-of-children-
in-healthcare-facilities-without-dedicated-paediatric-facilities.
pdf Viewed 16 February 2016.
The American Agency for Healthcare Research and Quality
(AHRQ). National Guidelines Clearing House. Evidence-based
clinical practice guidelines. Available from: http://www.
guideline.gov/ Viewed 16 February 2016.
March 2016 103

1.4 Effectiveness
The standard is:
The organisation provides care and services that
achieve effective outcomes.
The intent of the Effectiveness standard and criterion is
three fold. It is to ensure that:
ealthcare organisations use interventions that have
h
been proven to be effective
ll other care, services and interventions are based on
a
the best available evidence
care is provided in the most effective way possible.
There is one criterion in this standard. This is:
1.4.1 O
utcomes of clinical care, including individual care
episodes and the overall effectiveness of care, are
evaluated by healthcare providers.
Appropriateness is doing the right treatment,
intervention or service in the right way and effectiveness
is the extent to which those treatments, interventions or
services achieve the desired outcomes.
March 2016 105

Standard 1.4: The organisation provides care and services that achieve
effective outcomes.
Implementation
Criterion 1.4.1 a) Documented processes a) The organisation supports health

guide health professionals in professionals in the implementation
Outcomes of clinical care, including
implementing evidence-based of evidence-based care.
individual care episodes and the
clinical practice.
overall effectiveness of care, are b) Care process mapping is
evaluated by healthcare providers. b) Guidelines addressing how documented and undertaken
the organisation assesses the by a multidisciplinary team
overall effectiveness of care and where applicable.
interventions are readily available
c) The organisation collects key
to staff.
indicators relating to effectiveness
c) Guidelines addressing how of care and interventions.
the organisation assesses the
d) Individual consumer / patient
effectiveness of individual care
outcomes are assessed against:
episodes are readily available
to staff. (i) the agreed care plan
d) Consumers / patients and carers (ii) evidence-based guidelines.
are informed of how to give
e) Prior to discharge, health
feedback on the care provided.
professionals discuss the
outcomes of care with the
consumer / patient and their carer,
and this is documented.
f) Feedback is sought from
consumers / patients and carers
regarding the delivery of care
and services.

This criterion is designed to ensure that organisations The effectiveness of health care is significantly connected
evaluate the effectiveness of care and interventions and with all aspects of the care journey (Standard 1.1). Care
the outcomes of the care and services that they provide. planning and delivery (Criterion 1.1.2), consumer / patient
Care should be evaluated on a case-by-case basis, as access (Criterion 1.2.2) and processes for ongoing
well as organisation-wide. care (Criterion 1.1.6) will all impact upon effectiveness,
which is closely associated with, but distinct from,
Effective care comprises interventions that have been
appropriateness. While appropriate care (Criterion 1.3.1)
proven to be effective and are based on current best
relates to providing the right treatment, intervention
available evidence. Outcomes of care evaluation
or service in the right way, effectiveness addresses
must be communicated to key clinical staff in senior
the extent to which those treatments, interventions or
nursing, medical and allied health roles, to ensure that
services achieve desired outcomes.
appropriate responses are identified and implemented,
to improve the quality of care provided. Consumers / patients, their families and/or carers have
the right to participate actively in the planning, delivery
and evaluation of care (Criterion 1.6.1) and to comment
on any aspect of the care provided (Criterion 1.6.2).
Feedback and complaints from consumers / patients
a) T
he results of organisation-wide a) The organisation shows distinction a) The organisation demonstrates
clinical audits are reviewed by in care evaluation and the overall it is a leader in the evaluation of
relevant health professional groups effectiveness of its care. consumer / patient outcomes and
and used to support the evaluation the overall effectiveness of care.
and improvement of health care.
b) T
he organisation evaluates
the effectiveness of care and
interventions, including through
the use of key indicators,
as required.
c) Individual consumer / patient
outcomes are evaluated, and
improvements to care processes
d) Feedback from consumers /
patients and carers informs
the organisation’s evaluation of
the effectiveness of its care
and services.
(Criterion 2.1.4) may provide insight into areas of care This criterion requires healthcare
requiring improvement. Evidence-based care should be organisations to:
embedded in the organisation’s policies and procedures
(Criterion 3.1.5). Planning, development and delivery of rovide support to implement
P
effective care based upon the best available evidence evidence-based practice.
is an aspect of the organisation’s integrated risk ave a process to assess the overall effectiveness
H
management framework (Criterion 2.1.2), and failures of care and interventions.
in this area may lead to incidents (Criterion 2.1.3) and
complaints (Criterion 2.1.4). ave a process to assess the effectiveness of
H
individual care and interventions.
tilise consumer / patient feedback in the assessment
U
of the effectiveness of care and interventions.
March 2016 107

effective outcomes.
Criterion 1.4.1 Typical steps in such a process might include:

Outcomes of clinical care, including individual apping the existing care process (sometimes
m
care episodes and the overall effectiveness of described as the ‘as is’ stage)
care, are evaluated by healthcare providers. nalysing where problems exist in that process and
a
(continued) questioning why each step is done, by whom, where,
in what sequence, and whether there is a better way
Implementing evidence-based practice imagining what ‘an ideal process’ might look like
Healthcare organisations should focus on three key identifying practical changes to the current process to
strategies underpinned by evidence demonstrating a make it closer to the ideal process
contribution to more effective care and service delivery.
They are: testing these changes and evaluating whether they
result in improvement.
sing interventions / treatments that are determined to
u
be most effective
sing evidence in the development and delivery
u Prompt points
of care and services and in the development and hat is the process for appraising and
W
implementation of policy and other practices implementing best available evidence into
apping and documenting key processes to ensure
m clinical practice?
that they will be undertaken in a consistent manner in hat methods are used to support and
W
order to minimise variation. encourage the implementation of evidence-
based care?
Implementing evidence-based practice involves:
ow are these evaluated? What improvements
H
ealth professionals not relying solely on experience,
h have been made from this evaluation?
rationale and opinion-based processes
ow are key care processes identified and
H
nsuring policy development, care processes and
e mapped? Who is involved?
services are based on the best available evidence
ow are they evaluated? What improvements
H
olicy that clearly describes how to identify, access,
p have resulted from evaluation?
critically select, implement, monitor and review the
application of current, relevant best practice for
all clinical practice that is provided by the Assessment of the effectiveness of care
healthcare organisation
and interventions
lear processes and procedures that guide the
c
introduction and ongoing utilisation of evidence-based The effectiveness of health care relates to the extent
guidelines to support health professionals in putting to which a treatment, intervention or service achieves
such guidelines into practice the desired outcome, and follows on from the
appropriateness of that treatment, intervention or service.
the availability of current clinical practice guidelines
which should be used whenever available The best way for healthcare organisations to ensure that
they provide care and services in the most effective way
the assessment of which proven interventions are is to:
appropriate to the case mix and how their consistent
use in all relevant circumstances will be ensured. nderstand their most common care processes,
u
including the admission and pre-operative processes
In larger organisations, process redesign is a way
to achieve effective care from a consumer / patient document the best way to carry out those processes
perspective. This means identifying where delays, ut mechanisms in place to ensure that all who are
p
unnecessary steps or potential threats are built into the involved understand and carry out the process in this
process and then redesigning the process to remove expected way.
them, thus improving the quality of care.
Organisations should consider the following questions:
What is the right thing to do? Prompt points
Did we do the right thing? (appropriateness) hat processes are used to evaluate
W
clinical care in the organisation?
Did we do the right thing 100% right? (effectiveness)
ow are data reconciled across the continuum
H
Organisations can use formalised data collection and of care?
tracking processes to monitor their performance. A
range of indicators are tracked by health departments escribe how a review of care led to a change
D
and other organisations. ACHS offers its members a in consumer / patient management with the
clinical indicator data collation and analysis service objective of reducing an identified risk?
through its Performance and Outcomes Service. an the organisation track its performance
C
Before committing to collection of any indicator, its against specific measures over time? What
usefulness to the organisation should be considered: precautions are taken to protect the integrity of
these measures?
oes the indicator measure an important aspect of
D
clinical practice? Is there a policy or guidelines on communicating
clinical care outcomes to consumers /
ill the data collected on this indicator assist in
W patients? What guidance, if any, does the
improving clinical care? organisation’s policy on feedback provide to
ill the information be useful and meaningful to health
W health professionals?
professionals in demonstrating how the service is
performing and ways that it may be improved?
Assessment of the effectiveness of
ill the data be accessible to health professionals to
W
individual care episodes
allow for monitoring of the indicator?
Individual care evaluation, including review of the care
re existing resources sufficient for ongoing
A
processes provided, should take place to determine
monitoring of the indicator?
whether the best possible outcomes were achieved for a
It can be challenging to draw conclusions when consumer / patient. Subsequently, the aggregate results
comparisons are made between different sites / for many consumers / patients should be evaluated,
organisations (benchmarking). To facilitate possibly refining the information by grouping consumers /
legitimate conclusions: patients according to their demographic parameters
(for example, gender, age, ethnicity), disease state
terminology should be carefully defined
and/or procedures.
the size and selection of samples of records for
Some important considerations for healthcare
analysis should be considered with care
providers include:
v ariation should be minimised, for instance by stratifying
whether the care plan worked
contributors by size, or other relevant criteria.
hether healthcare providers made a difference in the
w
health status of the consumer / patient
hat the organisation measures to determine whether
w
the care made a difference
the reliability of data collected from clinical pathways
hether the care plan was followed and the care
w
goals were met
hen appropriate, whether requirements for seamless
w
integrated care provision were met.
March 2016 109

effective outcomes.
Criterion 1.4.1
Outcomes of clinical care, including individual Prompt points
care episodes and the overall effectiveness of Is there a record of what information
care, are evaluated by healthcare providers. about outcomes of care has been
(continued) discussed with the consumer / patient (in the
health record, discharge summary, care plans,
In assessing the effectiveness of care episodes, case management reviews)?
organisations should: oes discharge planning at the organisation
D
evelop and adopt models for review according to
d permit / encourage a discussion regarding the
their specific needs outcomes of clinical care?
nsure the reviewers have authority; they should
e ow variable is the manner in which outcomes
H
ideally be senior, multidisciplinary and independent of care are discussed with consumers / patients?
What impact does the individual personality of the
identify at-risk consumers / patients. These consumer / patient and/or health professional play
consumers / patients have been recognised early in in discussions about outcomes of care?
their care as having a higher likelihood of an adverse
outcome, based on their identified risk factors ased on single cases or episodes of care, can
B
the organisation demonstrate that the service
ommunicate findings in reviews to health
c made a difference to the consumer / patient’s
professionals in a manner that leads to recognition of health status? Were the care goals met? Were
a problem and its impact, and to a commitment to consumer / patient-oriented goals met? Did the
implement identified strategies where indicated consumer / patient understand and participate
ommunicate recommended changes to relevant staff
c in his or her care?
and implement those changes hat systems are in place to encourage,
W
valuate whether the incidence of the adverse
e enable, record, monitor and respond to
outcomes among the at-risk group was reduced to consumer / patient feedback?
levels similar to those for consumers / patients without ow does the organisation manage the
H
this risk factor. communication of information to consumers /
patients following an adverse event?
Suggested reading
The following evidence may help to Houser J, Oman K. Evidence-Based Practice. An
address criterion 1.4.1 Implementation Guide for Healthcare Organizations. Available
from: http://sgh.org.sa/Portals/0/Articles/Evidence-based%20
Evidence-based policies, clinical
Practice%20-%20An%20Implementation%20Guide%20for%20
practice guidelines Healthcare%20Organizations.pdf Viewed 16 February 2016.
Identification of common care processes of LaVela, Sherri L. PhD, MPH, MBA and Gallan, Andrew S. PhD
principal conditions treated Evaluation and measurement of patient experience. Patient
Experience Journal: Vol. 1: Iss. 1, Article 5. Available from: http://
rocesses to access information on non-
P
pxjournal.org/journal/vol1/iss1/5 Viewed 16 February 2016.
principal conditions treated
National Health and Medical Research Council. Australian
Information available on the use of clinical Clinical Practice Guidelines Portal. Available from: https://www.
pathways / care maps clinicalguidelines.gov.au / Viewed 16 February 2016.
Audits of clinical pathways / care maps The American Agency for Healthcare Research and Quality
(AHRQ). National Guidelines Clearing House Evidence-based
Review of unplanned readmissions clinical practice guidelines. Available from: http://www.
rocesses for consumer / patient /
P guideline.gov / Viewed 16 February 2016.
carer feedback Schembri S. Experiencing health care service quality: through
Policy / guidelines on care evaluation patient's eyes. Australian Health Review 39(1) 109-116.
Available from: http://dx.doi.org/10.1071/AH14079. Published:
Evaluation of care plans and delivery 16 October 2014 Viewed 16 February 2016.
Collection of clinical indicator data

Changes in clinical indicators collected
Clinical outcome reviews
linical indicators or other performance
C
indicators, ideally tracked over time
and benchmarked against other
departments / organisations
valuation of instances of adverse events and
E
the circumstances surrounding them
inutes or notes taken at review
M
committee meetings
emonstrated changes made in response to
D
a problem identified by consumer / patient
complaints or a review of care
March 2016 111

1.5 Safety Standard 1.5.7 The organisation ensures that the nutritional
needs of consumers / patients are met.
The standard is:
The organisation provides safe care and services. Healthcare organisations should recognise that ensuring
safety for both consumers / patients and all staff requires
This standard should be read in conjunction with criteria
a far broader focus than the seven issues covered by
1.1.5 clinical handover / transfer of care / discharge, 2.1.2
this standard, and that efforts to improve safety within
risk management, 2.1.3 incident management, 2.1.4
an organisation should therefore extend beyond these
complaints management and 3.2.5 security management.
seven criteria.
A degree of flexibility is provided in this standard.
Potential for consumer / patient harm should be
Some of the criteria will be more relevant to some
identified and prevented with barriers built into the
healthcare organisations than to others. The flexibility in
system, making it resilient to the impact of errors.
these criteria is explained in the guidelines under each
Opportunities for staff harm should be managed in the
criterion. Organisations should determine the level of
same way.
achievement required in each of these criteria.
Several aspects of safety are dealt with in other EQuIP
Further, organisations should determine those issues
standards and criteria. These include:
that pose the biggest safety risks in their organisations.
These should be managed effectively under an Standard 1.1 continuity of care
alternative criterion, for example the risk management riterion 2.1.2 the risk management criterion, which
C
criterion or the security management criterion for the provides the basis of an effective safety system
management of aggression in mental health services.
riterion 2.1.3 the incident management criterion,
C
The intent of this standard is to ensure that healthcare which provides the cornerstone to any good
organisations focus efforts on reducing harm to consumer / patient safety system
consumers / patients and staff. This standard expects
that organisations will develop a system for reducing the Criterion 2.2.3 performance review
incidence of harm, specifically the most common causes Criterion 2.2.4 staff education
of harm in health systems.
Criterion 2.3.3 data and information use
There are seven criteria in this standard. They are:
riterion 3.1.3 credentialing and defining the scope of
C
1.5.1 M
edication management systems support the clinical practice
safe and effective use of medicines.
Criterion 3.1.4 external service providers.
he infection control system supports safe
1.5.2 T
practice and ensures a safe environment for
he incidence and impact of breaks in skin
1.5.3 T
integrity, pressure ulcers and other non-
surgical wounds are minimised through wound
prevention and management programs.
he incidence of falls and fall injuries is
1.5.4 T
minimised through a falls management program.
he system to manage blood, blood
1.5.5 T
components / products, sample collection
and consumer / patient blood administration
ensures safe and appropriate practice.
he organisation ensures that the correct
1.5.6 T
consumer / patient receives the correct
procedure on the correct site.
March 2016 113

Standard 1.5: The organisation provides safe care and services.
Implementation
Criterion 1.5.1 a) Policy / guidelines for medication a) A multidisciplinary body oversees

management are consistent with the organisation-wide medication
Medication management systems
relevant legislation, standards, management system.
support the safe and effective use
guidelines, and/or codes of
of medicines. b) A standardised system for
practice, and are readily available
medication management,
This is a mandatory criterion to staff.
including the safe use of high-
b) Health professionals have access risk medications, is implemented
to published guidelines for throughout the organisation.
medication management.
c) Medication review and
c) A standardised list of approved reconciliation occurs as soon as
abbreviations for medications is practicable following admission of
used throughout the organisation. the consumer / patient.
d) Medication documentation is d) Procedures are implemented to
in an appropriate and reduce the risk and severity of
standardised format medication incidents.
throughout the organisation.
e) The organisation supports health
e) Medications, including professionals, consumers /
temperature-sensitive medications, patients and carers in the
are distributed, stored and identification and reporting of
disposed of securely and safely medication incidents, near misses
in accordance to manufacturer’s and adverse drug reactions.
instructions, legislation and
f) Health professionals are trained
organisational guidelines.
in medication management
f) Consumer / patient current practices relevant to their role
medications are documented and responsibilities.
as soon as practicable following
g) Education is available for
admission, and prior to transfer of
care / discharge.
their carers about prescribed
g) Health professionals are provided medications, to encourage
with orientation and ongoing ongoing safe use of medications
education on medication and compliance after discharge.
management, including safe
practice, risk reduction and
correct documentation.
h) Written and verbal information is
about their medications.
a) T
he organisation-wide medication a) The organisation shows distinction a) The organisation demonstrates
management system is evaluated, in its management of medications. it is a leader in medication
and improvements are made management systems and
as required. processes.
b) M
edication documentation is
made as required.
c) Processes for timely medication
review and reconciliation are
made as required.
d) The system for distribution,
storage and disposal of
medications is evaluated,
as required.
e) Medication incidents, near misses
and adverse drug reactions are
analysed and trended, and further
strategies to reduce medication
incidents are implemented.
f) Education and training in
medication management are
evaluated in consultation with
relevant staff, and improvements
g) The information and education
provided for consumers /
patients and carers is evaluated,
as required.
h) Outcomes of evaluation of
the medication management
system, including incident
management, are reported to
the governing body.
March 2016 115

Criterion 1.5.1 Medication management

Medication management systems support The use of medication remains the most common
the safe and effective use of medicines. intervention in health care. At the same time, medication
(continued) incidents are one of the most frequently reported event
categories. In 2015, medication misuse, underuse,
Overview overuse and adverse reactions resulted in an estimated
5-8% of unplanned hospital admissions in the United
This criterion requires organisations to ensure that Kingdom and 2-3% in Australia. Organisations should
medications are managed to: therefore develop and implement a comprehensive
reduce the incidence of error in the prescription, medication management system, with the aim of
dispensing and administration of medications to delivering safe, high quality care while actively reducing
consumers / patients the risk of errors associated with the use of medication.
The system should reflect the priorities and guidelines
reduce the harm caused to consumers / patients in of jurisdictions and relevant health authorities including
healthcare organisations by medication errors. Departments / Ministries of Health, national associations
Safe, high quality care and effective consumer / patient of pharmacists, and similar bodies.
outcomes depend upon the correct management The medication management system should:
of medications.
e based upon a medication safety plan
b
This criterion relates to all healthcare organisations that which addresses:
prescribe, dispense and/or administer medications.
Support service providers will need to consider the • medication safety across the consumer / patient’s
medications prescribed by other services when entire continuum of care
assessing their consumers / patients. • medication prescribing and dispensing, delivery
devices, and the associated risk of error
Relationships of 1.5.1 with other criteria
• medication storage, transport, labelling processes,
Medications and their management are relevant packaging, information transfer and destruction
throughout the care journey of the consumer / patient
reflect all relevant legislation, standards, guidelines,
(Standard 1.1). Medication management is an important
and codes of practice, and all jurisdictional medication
aspect of the organisation’s integrated risk management
management and safety priorities
framework (Criterion 2.1.2), and errors in this area may
result in incidents, including sentinel events (Criterion e supported by policy and procedures that define
b
2.1.3), which may lead to complaints (Criterion 2.1.4). responsibility and accountability for medication
management, and ensure effective governance
This criterion requires healthcare be overseen by a multidisciplinary body
organisations to:
e linked to the organisation’s risk management system
b
Implement a standardised, organisation-wide and specifically the incident management system
medication management system, which is supported
by standardised medication documentation s trive to reduce error through standardisation of
and abbreviations. processes, including (but not limited to) the use of:
anage medication risks, support error reporting and

M • standardised forms in medication review
use the investigation of errors and near misses to and reconciliation
improve medication safety. • standardised medication charting across
Store, transport and distribute medications safely. the organisation
rovide access to information and education about

P • standardised abbreviations in prescribing and
medications to staff and consumers / patients. health records
• standardised symbols, colour-coding and alerts
organisation-wide
include a medication distribution system appropriate
for the size and function of the organisation Prompt points
include processes for monitoring the correct storage, hat body oversees the management
W
transportation and destruction of medications of medication safety in the organisation?
se appropriate guidelines to achieve continuity of
u How is membership determined? What are the
medication management, and ensure that staff have responsibilities of this group?
ready access to these guidelines hat guidelines does the organisation
W
se audits and ongoing education to ensure that
u draw upon in its medication management
staff prescribing medications comply with current system? Who is responsible for ensuring that
best-practice guidelines organisational practices are based on current
best-evidence?
mploy current best-practice medication management
e
strategies including (but not limited to): ho undertakes medication reviews in
W
the organisation?
• obtaining the best possible medication history for all
consumers / patients ow does the organisation use standardisation
H
to reduce error?
• conducting individual medication reviews
ow does the organisation monitor staff
H
• undertaking medication reconciliation at the time compliance with policy, procedures and
of admission and the time of discharge of the guidelines? What is the organisational response
consumer / patient to an identified instance of non-compliance?
• facilitating uninterrupted focus during dispensing ow often does the organisation conduct
H
• employing automated dispensing throughout the medication safety self-assessments? What
organisation, particularly when linked to bar-coding changes to medication management have been
made as a result of these assessments?
rovide guidance to medical and allied health
p
professionals via position statements on topics
including (but not limited to): Medication risk management and
• the dispensing of medications at discharge error reporting
• support for and access by pharmaceutical The identification and mitigation of the risks associated
representatives with the use of medications should be a fundamental
aspect of the organisation’s medication management.
• selection of medications (including generic vs
All practices within the medication management system
branded items)
should be based upon current best-practice guidelines
• off-label prescribing and strive to streamline tasks and eliminate variation, in
• the use of complementary medicines order to reduce the possibility of error. When incidents
and near misses occur, they should be thoroughly
• specific medications or conditions investigated and the outcomes of the investigation used
include regular medication safety self-assessments. as a basis for improvement.
March 2016 117

Criterion 1.5.1
Medication management systems support Prompt points
the safe and effective use of medicines. hat high-risk medications are used
W
(continued) in this organisation? How has the
organisation minimised the risks associated the
The organisation should ensure that it has a robust use of these medications and their storage /
system for investigating and responding to medication handling / disposal?
errors and near misses, and strive to create a culture
ow does the organisation encourage
H
in which staff are encouraged to report all medication
reporting of medication-related incidents and
errors, near misses and adverse drug events and/or
near misses?
reactions. This is essential if potential risks are to be
identified, evaluated and acted upon. Incident reports ho is responsible for the investigation of
W
provide valuable information about incidents and near medication-related incidents and near misses?
misses; while additional systems should be in place to How does the organisation ensure that those
gather information about adverse drug events including individuals with responsibilities in this area are
health record reviews, audits, reviews of the literature appropriately trained?
and reports from relevant health authorities.
hat is the membership of the committee that
W
Medication risk management should: reviews medication incident data? How often
does this committee meet?
include identification of systemic risks and
the development and implementation of ow does the organisation use the outcomes
H
mitigation strategies of incident investigation to improve its systems
and educate staff?
recognise and respond to the challenges associated
with identified high-risk medications
e responsive to external bulletins, updates and
b Storage, transport and distribution
recommendations for medication safety
In addition to managing the safe use of medications,
se standardisation of processes and documentation
u the organisation must identify and manage the risk
to reduce variation and the risk of error associated with the storage, transport and distribution
ncourage reporting of medication incidents, near
e of medications. Many jurisdictions have developed
misses and adverse events and/or reactions, by staff, standards and guidelines addressing the physical
consumers / patients and carers management of medications, and these should be
reflected in the organisation’s storage, transport and
include investigation of medication incidents and near distribution systems. The organisation must ensure that
misses by appropriately trained staff appropriate processes are in place for each individual
nsure that incident data are reviewed by a committee
e medication, and that these include monitoring / audits
that includes pharmacists and clinical staff, and that: to ensure staff compliance with policy and procedures.
Safe, efficient processes for the storage, transport and
• shortcomings in systems and processes are distribution of medications will reduce the risk of error
identified and addressed and wastage.
• appropriate remedial action is taken in the event of The medication storage, transport and distribution
staff non-compliance system should:
• outcomes of investigations are appropriately omply with all legislative requirements,
c
disseminated and used as the basis of improvement jurisdictional standards and guidelines, and
activities and education. manufacturers’ instructions
where practicable, be managed with pharmacist input
e designed to reduce the risk of error associated
b
with the storage and handling of medications
e supported by policy and procedures that define
b
responsibility and accountability for the physical Prompt points
management of medications
ho is responsible for overseeing the
W
include all necessary cold chain and security / access organisation’s systems for the storage,
restriction arrangements, in all relevant areas of the transport and distribution of medications?
organisation, including (but not limited to):
hat legislation, standards and/or guidelines
W
• the pharmacy has the organisation drawn upon in designing
• wards its systems for the physical management
of medications?
• the emergency department
hat monitoring / audit processes does the
W
• surgical theatres organisation use to ensure the efficiency of its
• all sections of the organisation-wide physical management of medications?
distribution system ow does the organisation ensure that staff
H
onitor and audit staff compliance with policy and
m are aware of their responsibilities with respect
procedures, and ensure appropriate remedial action in to the storage, transport and distribution of
the event of non-compliance medications? How does the organisation
respond to instances of staff non-compliance?
rovide data on medication utilisation, preferably to
p
the level of the individual consumer / patient ow does the organisation ensure that its cold
H
chain is maintained?
identify unusual medication usage patterns.
ow does the organisation use the data on
H
medication usage generated by its storage,
transport and distribution system?
as evaluation of the organisation’s storage,
H
transport and distribution system identified any
unusual medication usage patterns? What is
done with this information?
Medication information and education

The provision of appropriate information about safe,
effective use of medications is a significant factor in the
organisation’s reduction of medication-associated risk.
The World Health Organization (WHO) recommends that
health professionals, “Encourage patients to be actively
involved in their own care and the medication use
process” by:
ducating consumers / patients about their
e
medication and any associated hazards
communicating plans clearly to consumers / patients
remembering that consumers / patients and their
carers are highly motivated to avoid problems and,
if properly informed, can contribute significantly to
improving the safety of medication use.
March 2016 119

Criterion 1.5.1 Staff should:

Medication management systems support e informed at orientation of the organisation’s
b
the safe and effective use of medicines. medication management system and its processes for
(continued) medication risk management and error reporting
e orientated, by a member of the same profession
b
Consumers / patients and their carers should be whenever possible, to:
involved in medication reconciliation and review, and
encouraged to keep a written record of medications • the organisation’s medication recording /
taken and details of any past allergy / reaction. All effort documentation system
should be made by the organisation to ensure that • all approved, standardised forms and abbreviations
there is clear understanding of the effects of prescribed
medications and their correct use prior to consumer / • the storage, transport and distribution system
patient discharge. • high-risk medications and all related safety processes
Medication safety should be addressed during staff • equipment used for medication delivery, including
orientation, and should also be the subject of ongoing devices such as infusion pumps
staff education. On a day-to-day basis, staff should
have ready access to all relevant guidelines and other • processes for clinical handover
resources to support the safe use and handling of ave ready access to all relevant medication
h
medications. Clinical pharmacology and medication guidelines and related resources, such as
management are areas that are constantly changing pharmaceutical handbooks and practice standards
as new medications and treatment modalities become
available, and there should be regular review of the here relevant, receive ‘refresher’ training in
w
content of staff education to ensure that it remains up- prescribing, dispensing and administering medications
to-date and reflects current best-practice. receive ongoing education in medication safety
Consumers / patients and carers should: and management, the content of which is regularly
updated to reflect current information and
e actively involved in the recording of medication
b best-practice
histories, medication reconciliation and
medication review e informed of the outcomes of medication incident
b
investigations and any associated practice changes
e encouraged to ask questions, and to report any
b
side-effects or other reactions here necessary, for example with junior or newly-
w
appointed staff, be supervised and monitored to
e provided with information and/or education about
b ensure compliance with the organisation’s systems
all prescribed medications in verbal and/or written and processes.
form, which should address:
• the name of the medication
• the purpose and action of the medication
• the correct dose, route and administration schedule
• storage requirements
• any special instructions, directions
and/or precautions
• common side-effects and interactions
• any necessary follow-up.
Prompt points The following evidence may help to
ow does the organisation involve
H
consumers / patients are carers in its Policy and procedures reflecting jurisdictional
medication management? How does it ensure standards, guidelines and priorities
that consumers / patients understand their
Medication chart reviews
medications prior to discharge?
Audits of standardised medication
ow does the organisation make medication
H
documentation and abbreviations
guidelines and other resources readily
accessible to its staff? Written / printed information on medications for
ow often does the organisation review and
H
update its medication education program? Who Evidence of medication safety self-assessments,
is responsible for ensuring the currency of the and related changes to processes
information provided?
Monitoring of medication storage and cold
ow does the organisation use the outcomes of
H chain systems
incident investigation in its staff education?
Minutes of meetings of committees / bodies
ow does the organisation ensure that new /
H responsible for medication incident review /
junior staff are familiar and compliant with its oversight of medication storage, transport
processes for medication safety? and distribution
Audits of:
• medication error rates
• adverse reaction rates
• prescribing choices
• medication usage / wastage
March 2016 121

Criterion 1.5.1 •Q
uick guide: Facilitating the continuity of medication
management on transition between care settings
Medication management systems support
the safe and effective use of medicines. •Q
uick guide: Medication Reconciliation
(continued) •S
tandards of Practice for the Provision of Consumer
Medicines Information by Pharmacists in Hospitals
Suggested reading •S
tandards of Practice for the Distribution of Medicines in
Australian Hospitals
esources from the Australian Commission on Safety and
R
Quality in Health Care (ACSQHC) including: •G
uidelines for Medicines Prepared in Australian Hospital
Pharmacy Departments
•P
BS Hospital Medication Chart
•S
tandards of Practice for Medication Safety
•M
edication charts
Available from: http://www.shpa.org.au/Practice-Standards
•M
edication reconciliation
•M
edication administration
Lauri R. Graham; Laurie Scudder, DNP, NP; Laura Stokowski,
•M
edication safety and quality education and training RN. Seven (potentially) deadly prescribing errors. Available
from: http://www.medscape.com/features/slideshow/
•S
afer naming, labelling and packaging of medicines
prescribing-errors#page=1 Viewed 17 February 2016.
•N
ational Medication Management Plan
Coombes ID, Stowasser DA, Coombes JA and Mitchell CA.
•E
lectronic medication management Why do interns make prescribing errors? A qualitative study.
Med J Aust 2008; 188(2): 89-94. Available from: https://
Available from: http://www.safetyandquality.gov.au/our-work/ www.mja.com.au/journal/2008/188/2/why-do-interns-make-
medication-safety/medication-reconciliation/nmmp / Viewed 17 prescribing-errors-qualitative-study Viewed 17 February 2016.
February 2016.
World Health Organization. Patient Safety: Topic 11: Improving
Clinical Excellence Commission. Medication Safety Self medication safety. Available from: http://www.who.int/
Assessment. Tools for hospital medication safety self patientsafety/education/curriculum/who_mc_topic-11.pdf
assessments. Available from: http://www.cec.health.nsw.gov. Viewed 17 February 2016.
au/programs/mssa Viewed 17 February 2016.
Clinical Excellence Commission (CEC). High Risk Medicines
Royal Pharmaceutical Society. The Pharmaceutical Journal, Program. Available from: http://www.cec.health.nsw.gov.au/
20 October 2014. News. Available from: http://www. programs/high-risk-medicines Viewed 17 February 2016.
pharmaceutical-journal.com/news-and-analysis/news/
medication-errors-cost-the-nhs-up-to-25bn-a-year/20066893. Australian Government. Department of Health and Ageing.
article Viewed 17 February 2016. National Vaccine Storage Guidelines, Strive for 5. Available
from: http://www.health.gov.au/internet/immunise/publishing.
SHPA Fact Sheet. Risk factors for medication-related nsf/content/D7EDA378F0B97134CA257D4D0081E4BB/$File/
problems. June 2015. Available from: http://www.shpa.org. strive-for-5-guidelines.pdf Viewed 17 February 2016.
au/SHPA/ccms.r?Pageid=6008&DispMode=goto%7C10478
Australian Pharmaceutical Advisory Council (APAC). Guiding
principles to achieve continuity in medication management.
publishing.nsf/content/nmp-guiding Viewed 17 February 2016.
The Society of Hospital Pharmacists of Australia (SHPA)
Practice Standards, including, but not limited to:
•S
tandards of Practice for Drug Use Evaluation in
Australian Hospitals
•S
tandards of Practice for Clinical Pharmacy Services
•Q
uick guide: Assessment of current medication management
•Q
uick guide: Clinical review, therapeutic drug monitoring
(TDM) and adverse drug reactions (ADR)
March 2016 123
Implementation
Criterion 1.5.2 a) Policy / guidelines addressing infection a) T

he infection control system,
control are consistent with relevant legislation, including the infection control plan,
The infection control system
standards, guidelines and/or codes of is managed and monitored by a
supports safe practice and practice, and are readily available to staff. multidisciplinary infection control
ensures a safe environment
b) The infection control plan includes: committee and/or team.
for consumers / patients
and healthcare workers. (i) h
and hygiene and aseptic technique b) Infection prevention strategies
are integrated into all stages of
This is a mandatory (ii) a
ntimicrobial stewardship and appropriate healthcare planning, including
criterion use of antibiotics health facility planning,
(iii) notifiable diseases construction and refurbishment.
(iv) o
utbreak management c) There is a planned and
documented schedule of regular
(v) transmission precautions and
maintenance and/or monitoring
occupational exposure prevention and
management of the environmental factors
associated with infection control.
(vi) s terilisation and reprocessing of
instruments and devices. d) There are documented risk
reduction and containment
c) T
he infection control plan addresses measures for identified infections.
environmental factors, including:
e) Health professionals and other
(i) c
leaning services staff are trained in infection
(ii) food safety and kitchen cleaning prevention and control strategies
relevant to their
(iii) linen handling and laundry services
role and responsibilities.
(iv) relevant equipment and plant.
f) Infection risks, control strategies
d) The infection control plan is approved, and safety requirements are
supported and properly resourced by communicated to consumers /
the governing body and/or its patients and carers.
delegated authority.
eT
here is an effective surveillance
system to monitor and report
healthcare-associated infections.
f) H
ealth professionals are supplied with
equipment and an environment that enables
them to comply with the infection control
policy / guidelines.
g) H
ealth professionals and other staff are
provided with orientation and ongoing
education about infection risks and their
responsibilities in preventing infection.
h) E
xternal service providers, students and
visitors are advised of the organisation’s
infection safety requirements.
a) C
ompliance with the infection a) The organisation shows distinction a) The organisation demonstrates it
control policy / guidelines is in its management of infection is a leader in infection prevention
monitored and evaluated, prevention and control. and control systems.
as required.
b) T
he infection control system,
including all aspects of the
infection control plan, is evaluated,
as required.
c) Maintenance and monitoring of
environmental factors relevant to
infection control are evaluated,
as required.
d) The organisation collects a
suite of infection control
indicators and evaluates the
results, and improvements are
made as required.
e) Education and training in infection
prevention and control are
evaluated in consultation with
relevant staff, and improvements
f) The effectiveness of
communication of infection risks,
control strategies and safety
requirements to consumers /
patients, carers, visitors, students
and external service providers is
made as required.
g) Outcomes of the evaluation
of the organisation’s infection
control system are reported to the
governing body.
March 2016 125

Criterion 1.5.2 anage infection control in the general organisational

M
The infection control system supports safe environment as well as in clinical areas.
practice and ensures a safe environment for rovide information and education on infection control
P
consumers / patients and healthcare workers. and infection risks to consumers / patients, staff,
(continued) contractors, and visitors.
Overview Infection prevention and management

This criterion requires that, whenever possible, infections Infection control in healthcare organisations is a
are prevented from occurring in health services; and key area for safe practice. Because of the nature of
that where prevention is not possible, infections are health care, consumers / patients and staff can be
managed effectively. sources and recipients of infection. Infections can be
transmitted from person to person or may be sourced
from the environment, including consumer / patient
Relationships of 1.5.2 with other criteria
care equipment. Consumers / patients, staff and any
Strategies to address the risk of infection in healthcare visitors to the facility may be a source of or a receiver of
settings should be an aspect of the organisation’s infection-causing organisms.
maintenance of a safe environment for its consumers /
An organisation-wide infection prevention and
patients and staff (Standard 3.2). Facility design,
management system should therefore be implemented,
cleaning protocols (Criterion 3.2.2) and waste
which will be based upon a comprehensive,
management systems (Criterion 3.2.3) may impact upon
multidisciplinary infection control plan addressing all
the control of infection.
relevant aspects of infection control. It is vital that the
The organisation will help to protect staff via its plan be supported by organisation’s governing body,
immunisation program (Criterion 2.2.5). Where and that all necessary resources are made available.
sterilisation is outsourced to an external service provider Infection represents a significant risk for the organisation,
(Criterion 3.1.4), processes must ensure the quality of and there must be effective systems in place to minimise
the service. as far as possible the occurrence of healthcare-
Infection presents a significant challenge to the provision associated infections, to respond to outbreaks and
of safe care and services (Standard 1.5). Appropriate manage consumers / patients with infections and
care delivered in the most appropriate setting will help infectious diseases, and to create and maintain a safe
to reduce the incidence of infection (Criterion 1.3.1). The environment for consumers / patients, carers, staff,
organisation must address infection control through its contractors and other visitors.
integrated risk management framework (Criterion 2.1.2), The infection prevention and management
and failure to do so effectively may lead to incidents system should:
(Criterion 2.1.3) and complaints (Criterion 2.1.4).
e actively supported by the organisation’s
b
governing body
This criterion requires healthcare
organisations to: e based upon a comprehensive infection control plan
b
which addresses, at a minimum:
ave an organisation-wide infection prevention and
H
management system based upon a comprehensive, • healthcare-associated infections
multidisciplinary infection control plan that is • notifiable diseases
supported by the governing body.
• outbreak management
Reduce risk and implement controls for identified:
• transmission precautions
• infectious diseases
• sterilisation and reprocessing of devices
• healthcare-associated infections.
• hand hygiene
anage infection risks, support error reporting and
M
use the investigation of errors and near misses to • antibiotics and antimicrobials
improve infection prevention and management. • facility design, renovations and refurbishment
• cleaning
• food handling Prompt points
• linen management hat body oversees the management
W
of infection control in the organisation?
• plant and equipment How is membership determined? What are the
...and which reflects the organisation’s unique responsibilities of this group?
circumstances, including (but not limited to) its: hat guidelines does the organisation draw
W
• facility design upon in its infection control system? Who is
responsible for ensuring that organisational
• casemix practices are based on current best-evidence?
• procedural and service profile ow does the organisation’s size, function and
H
• staff, contractors and other visitors casemix influence its infection control plan?
• location and environmental conditions oes the organisation employ staff specifically
D
to manage infection control? If not, who is
reflect all relevant legislation, standards, guidelines, responsible for the practical implementation and
and codes of practice, and all jurisdictional infection monitoring of the infection control plan?
prevention, management and safety priorities
H
b compliance with policy, procedures and
responsibility and accountability for infection prevention guidelines? What is the organisational response
and management, and ensure effective governance to an identified instance of non-compliance?
be overseen by a multidisciplinary body
nsure that the practical implementation and
e Organisational infection control
operation of the infection control plan is the
responsibility of personnel with the appropriate skills, Effective infection prevention and management requires
training and experience the organisation-wide implementation of systems,
processes and controls, and regular monitoring and
b auditing to ensure compliance and allow remedial
and specifically the incident management system action to be taken where necessary. In addition, the
se appropriate guidelines on infection prevention
u organisation should measure its performance in infection
and management and other relevant resources, and control by strategies such as benchmarking and the
ensure that staff have ready access to these collection of clinical indicator data.
se audits and ongoing education to ensure that staff
u In its management of infection control, the organisation
comply with organisational policy and procedures and will be required to respond to external priorities and
current best-practice guidelines. emergencies, as well as having in place a series of
standard precautions to minimise infection risks and
prevent as far as possible the occurrence of healthcare-
associated infections.
Organisational infection control should focus upon the
creation of ‘barriers’ to infection, including (but not
limited to):
limination of potential exposures, e.g. restricted entry
e
for staff and visitors who are unwell
ngineering controls, e.g. partitioning triage areas,
e
isolation rooms, closed suctioning systems on airways
of intubated consumers / patients, limiting movement
of consumers / patients for diagnostic procedures
March 2016 127

Criterion 1.5.2 Prevention and management of healthcare-associated

The infection control system supports safe infections should:
practice and ensures a safe environment for e based upon an organisation-wide program of
b
consumers / patients and healthcare workers. prevention strategies, which draw upon relevant
standards and guidelines
(continued)
s appropriate for the organisation, draw upon recent
a
dministrative controls, e.g. vaccination, surface
a case studies describing successful infection reduction
disinfection, managing consumer / patient flow, hand in a variety common healthcare situations including
hygiene, respiratory etiquette (but not limited to):
behavioural controls, e.g. aseptic technique • surgical wound infections
ersonal protective equipment, e.g. surgical masks,
p • catheter-associated bloodstream infections
respirators, goggles
• infections in dialysed consumers / patients
dditional precautions tailored to the specific
a
• chest infections in ventilated consumers / patients
infectious agents / modes of transmission.
• urinary tract infections
Transmission precautions should:
fulfil all legislative and other health authority
e based upon current best-practice and
b requirements for surveillance and reporting
implemented organisation-wide
e addressed during staff orientation and ongoing
b
be included in staff orientation and ongoing education education, which should be regularly reviewed to
e communicated where relevant to consumers /
b ensure that the content reflects current best-practice
patients, carers, contractors and other visitors via nsure that staff have ready access to relevant
e
verbal and written information and signage guidelines and other resources
ddress standard situations in the healthcare setting,
a valuate the organisation’s performance via the use
e
including (but not limited to): of clinical indicators, benchmarking, infection cluster
• hand hygiene analysis and other appropriate measures
• respiratory etiquette onitor and audit compliance with policy and

m
procedure, and ensure that remedial action is taken
• the use of personal protective equipment when necessary.
• handling and disposal of sharps, including needles
and scalpel blades Notifiable disease and outbreak management should:
• decontamination of the physical environment, include reporting to jurisdictional authorities according

including consumer / patient care equipment to legislation and case definitions
• sterilisation e managed as described in policy and procedures,

b
with clear lines of responsibility and accountability
• where necessary, the reprocessing of instruments
and other medical devices follow jurisdictional policy directives and/or guidelines
for isolation and containment
• management of blood and body substance spills
e responsive to all directives from public
b
• the correct response to biological exposure health authorities
• testing for previous exposure / carrier status for nsure that staff have access to all necessary
e
some specific diseases personal protective equipment
llow for the extension of precautions when a specific
a
infectious agent is identified or suspected, without
waiting for confirmation of the agent.
implement all necessary protective measures, based include monitoring and auditing of compliance, and
upon risk assessment, including (but not limited to): ensure that remedial action is taken when necessary.
• safety / barrier equipment
Antimicrobial stewardship should:
• diagnostic testing
r aise awareness about antimicrobial resistance and
• a comprehensive occupational vaccination program the increased risk to consumers / patients
• post-exposure prophylactic measures e part of an antibiotic use management strategy
b
appropriate for the organisation’s size, location, care
• relevant education and training programs
and services and casemix
include preplanning and contingency testing, to
reflect the guidelines and priorities of jurisdictional
identify potential system weaknesses
authorities and other public health authorities
following an outbreak or the management of
e managed by personnel with relevant training and
b
a notifiable disease, be subject to a review of
expertise, including infectious disease experts, clinical
processes, with improvements made as required.
microbiologists and pharmacists
Hand hygiene management should: se training and ongoing education to change
u
antibiotic prescribing behaviour, including (but not
e based upon strategies outlined by the World
b
limited to):
Health Organization, including (but not limited to):
• eliminating unnecessary prescribing of antibiotics
• making hand hygiene convenient through easy
access to alcohol-based handrubs and/or water • promoting the choice of agents less likely to select
and soap resistant bacteria, in accordance with guidelines and
demonstrated patterns of antibiotic resistance
• including hand hygiene in ongoing staff education
nsure that staff have ready access to relevant
e
• installing voice prompts, signage and other
guidelines and other resources
reminders in the workplace
ncourage consumers / patients and carers to report
e
• promoting and facilitating skin care for staff
any instance of apparent ineffectiveness of antibiotics
• employing routine monitoring and feedback
include monitoring and auditing of compliance, and
• promoting active participation at individual and ensure that remedial action is taken when necessary.
institutional levels
Management of sterilisation and reprocessing of
• avoiding overcrowding, understaffing, and excessive
devices should:
workloads across the organisation
e in accordance with all relevant legislation,
b
• empowering consumers / patients and carers
jurisdictional guidelines and standards
fulfil all requirements of jurisdictional authorities
e supported by policy and procedures, which define
b
nsure that hygiene products are available at
e responsibility for sterilisation and reprocessing and
point-of-care ensure effective governance
include provision of information to consumers / include an alert system to ensure that sterilisation staff
patients, carers, contractors and other visitors, along are informed when instruments and other materials
with access to appropriate facilities may have been in contact with consumers / patients
nsure that reminders about hand hygiene are given
e with confirmed or suspected conditions requiring
to consumers / patients, carers and visitors over additional precautions, including (but not limited to):
prolonged episodes of care • tuberculosis
e promoted and facilitated throughout the
b • measles
organisation, not only in clinical settings
• Creutzfeldt-Jakob disease
March 2016 129

Criterion 1.5.2
The infection control system supports safe Prompt points
practice and ensures a safe environment for escribe how the organisation uses
D
consumers / patients and healthcare workers. ‘barriers’ to prevent infection?
(continued) ow does the organisation respond in the event
H
of a healthcare-associated infection? What
nsure that staff responsible for the reprocessing of
e system or process changes have been made as
medical devices have the necessary skills, training a result of a healthcare-associated infection?
and experience, and that sterilisation / disinfection
processes are: hat notifiable diseases is this organisation
W
required to report on? Who is responsible for
• thorough ensuring that reporting is carried out?
• carried out using the correct products and hat contingency testing does the
W
handling techniques organisation conduct to prepare for potential
• carried out for the prescribed times disease outbreaks?
nsure that all purchased sterile disposables
e ho is responsible for monitoring hand hygiene
W
comply with the specifications of relevant legislation, throughout the organisation? How does the
standards and guidelines organisation respond when compliance rates
fall in a particular area?
e supported by a comprehensive monitoring,
b
auditing and review process, and ensure that all ow does the organisation communicate the
H
instances of post-surgical infection are investigated. necessity, and correct techniques, for hand
hygiene and respiratory etiquette to consumers /
patients, carers and other visitors?
ow has the organisation addressed the
H
unnecessary prescribing of antibiotics?
hat standards and guidelines does the
W
organisation draw upon in its management
of sterilisation?
hat reprocessing of instruments and medical
W
devices occurs in this organisation? How
does the organisation ensure compliance
with policy and procedures for reprocessing?
What action is taken in the event of identified
non-compliance?
Environmental infection control e overseen by the organisation’s infection control
b
and cleaning officer / committee, including with respect to:
While infection prevention and management often • signing-off on planned works, and at each stage of
focuses upon the clinical areas of the organisation, and the completed process
upon consumer / patient care, it is also vitally important • minimisation of associated infection risks
that infection control is considered in the design and
management of the entire organisation, and that • liaison with clinical staff
appropriate control strategies, hygiene requirements and • management of dust and debris
cleaning schedules are implemented organisation-wide.
The organisation should have policy, procedures and • arranging for certification of compliance by an
guidelines to direct: infection control consultant.
construction and renovation Cleaning / sterilisation of equipment and plant should:

cleaning / sterilisation of equipment and plant e carried out according to a documented schedule
b
general cleaning that is alignment with the organisation’s schedule for
preventive maintenance
food handling
nsure that each individual piece of equipment /
e
linen management device is appropriately cleaned and/or sterilised, by
...and ensure that the associated infection risks are specialist contractors if necessary
identified, minimised and managed. include arrangements for the cleaning and/or
sterilisation of plant according to the manufacturer’s
Facility construction / renovation should: instructions, and by appropriately trained contractors.
nsure that when new facilities are built, infection
e
control is considered from the design stage onwards, Management of general cleaning should:
and that the layout will assist with the implementation nsure that an appropriate standard of cleanliness is
e
of all standard precautions maintained throughout the organisation
include furnishings and equipment that are chosen to be adequately staffed and resourced
facilitate infection control (e.g. their manufacture, ease
of cleaning, etc.) nsure that cleaning occurs according to a schedule
e
that describes all areas / surfaces / objects to be
aim to reduce infections via: cleaned (e.g. floors, toilets, desk tops, computer
• airborne transmission screens) and the frequency of cleaning
• surface contamination and transmission s pecify what areas / surfaces / objects should not
be cleaned (e.g. medical devices, plant) due to
• water-borne contamination and transmission associated risks or the need for specialty services
involve consideration of new or exacerbated risks of nsure that appropriate cleaning products are
e
infection, for example due to: selected, and stored and used as per manufacturer’s
• relocating staff and consumers / patients instructions to reduce any associated risk
• altered access include monitoring of the standard of cleaning, and
ensure that remedial action is taken if necessary
• different supply procedures
nsure that complaints about cleanliness from staff,
e
• the presence of additional people, unaware of consumers / patients or visitors are addressed.
infection precautions
March 2016 131

Criterion 1.5.2 here linen cleaning is carried out onsite, provide

w
The infection control system supports safe guidelines addressing washing, drying and
practice and ensures a safe environment for ironing practices.
(continued) Prompt points
Management of food and food handling should: as the organisation recently built
H
any new facilities or refurbished existing
fulfil the requirements relevant legislation, standards facilities? How were infection risks managed
and guidelines for the storage, preparation and during these processes? Who was responsible
distribution of food for overseeing this risk management?
include risk assessment for reheating, use of pre- ow does the organisation ensure that cleaning
H
prepared food and other associated risks, and ensure standards are maintained throughout the
that staff are given clear guidance organisation, including in:
nsure that food handling, preparation and distribution
e • waiting areas?
is undertaken by staff who have been trained in
processes to minimise associated infection risks • food preparation areas?
nsure that equipment and storage facilities for food,
e • staff meal-rooms?
including refrigerators, are used for no other purpose • toilets?
rovide guidance for staff in instances when visitors
p hat standards / guidelines does the
W
bring food for consumers / patients, or when ‘nil by
organisation draw upon in its management
mouth’ is ordered
of food handling? How does it ensure that
respond to complaints about the quality of food, staff involved in food handling understand the
its temperature and/or its delivery / removal from associated infection risks and their
consumers / patients and visitors own responsibilities?
nsure that any instance of food-related illness
e re consumer / patient meals prepared
A
is investigated and remedial action taken where onsite or by an external contractor? In either
necessary, including staff training / education or case, how does the organisation ensure that
changes made to systems / processes. standards are maintained with respect to
storage and heating of food?
Linen management should:
ow are staff involved in linen collection /
H
be carried out according to guidelines which address: transport informed of associated infection
• separation of clean and dirty linen risks due to contamination? What protective
equipment does the organisation provide?
• collection of dirty linen
ow does the organisation ensure the
H
• transfer of dirty linen to the laundry or to an segregation of clean and dirty linen?
external contractor
• storage, distribution and management of clean linen
nsure that all necessary precautions are taken with
e
respect to the handling of linen contaminated with
bodily fluids or other substances during care delivery
nsure that relevant staff are trained in appropriate
e
procedures, to minimise the risk of infection
transmission to themselves and others
Infection control information External contractors should:
and education e informed via contractual arrangements of their
b
One of the organisation’s strategies for minimising risks and responsibilities, and the organisation’s
infection risk should be the provision of appropriate expectation of compliance, including:
information to staff, consumers / patients, carers, • appropriate infection control procedures (e.g. hand
contractors and other visitors. While staff will receive hygiene, use of personal protective equipment)
training and education, the organisation should also
ensure that consumers / patients and visitors to the • appropriate behaviour within the organisation (e.g.
organisation understand that they may be both the ward areas, sterile areas)
cause of and at risk of infection. Encouraging simple receive training from trained personnel if necessary.
precautionary actions such as hand hygiene and
respiratory etiquette can have a significant effect in Staff should:
reducing the risk of infection transmission.
e informed at orientation of the organisation’s
b
Infection prevention and management should be infection prevention and management system and its
addressed during staff orientation, and should also be processes for infection risk management
the subject of ongoing staff education. On a day-to-day
receive ongoing education in infection prevention
basis, staff should have ready access to all relevant
and management, the content of which is regularly
guidelines and other resources to support infection
updated to reflect current information and
control and reduce risk, both to consumers / patients
best-practice
and themselves. The content of staff education should
be regularly reviewed to ensure that it reflects current ave ready access to all relevant guidelines and
h
best-practice. related resources on infection control
Consumers / patients, carers and visitors should: here relevant, receive ‘refresher’ training in infection
w
prevention and management relevant to their positions
e informed of infection risks and controls relevant to
b
their situation, which may vary according to: e informed of the outcomes of investigations into
b
healthcare-associated infections, and any system or
• the consumer / patient’s condition (e.g. infectious,
practice changes.
immunocompromised)
• the consumer / patient’s care delivery area (e.g. high Students should:
dependency, intensive care)
e advised of their infection control obligations prior to
b
be given the opportunity to ask related questions their first clinical visit
e encouraged to practice good hand hygiene and
b receive clear written guidance in relation to key
respiratory etiquette, with reminders as required infection control policies (e.g. hepatitis B, healthcare
waste disposal, hand hygiene).
receive necessary information verbally, in written or
printed form when necessary or where more detailed
information is requested, and via signage, which may
help to overcome cultural or language barriers by
using visual elements.
March 2016 133

Criterion 1.5.2
The infection control system supports safe The following evidence may help to
practice and ensures a safe environment for address criterion 1.5.2
consumers / patients and healthcare workers. Infection control plan
(continued) Policy and procedures reflecting jurisdictional
standards, guidelines and priorities
Prompt points Staff immunisation records

H Education programs reflecting current
consumers / patients and carers understand best-practice
relevant infection risks and controls? How does Steps taken to promote hand hygiene, and
the organisation encourage consumers / patients, evidence of compliance and/or remedial action
carers and visitors to practice good hand hygiene
and respiratory etiquette? Sterilisation / reprocessing audits
In high-risk areas such as intensive care, how Cleaning schedules and evidence of monitoring
are family members informed about infection of cleanliness
risks and their management? Training records for staff involved in food
ow does the organisation ensure that external
H handling, preparation and distribution
contractors comply with all requirements for Printed information for consumers / patients and
infection control? carers explaining infection control
H Minutes of meetings of committees / bodies
update its infection education program? Who responsible for oversight of infection control
is responsible for ensuring the currency of the
ow does the organisation use the outcomes
H
of investigation into healthcare-associated
infections in its staff education?
Suggested reading Queensland Department of Health. Centre for Healthcare
Related Infection Surveillance and Prevention. Infection Control
Hand Hygiene Australia. Resources for Healthcare Workers. Resources. Available from: www.health.qld.gov.au/chrisp
Available from: http://www.hha.org.au/ForHealthcareWorkers. Resources include:
aspx. Viewed 29 February 2016.
• Signal Infection Surveillance Manual. Available from: https://
World Health Organization (WHO). Evidence of hand hygiene www.health.qld.gov.au/chrisp/signal_infection/manual.asp
to reduce transmission and infections by multidrug resistant
organisms in health-care settings: Results of a systematic • Disinfection and Sterilization Infection Control Guidelines.
literature review. Available from: http://www.who.int/gpsc/5may/ Available from: https://www.health.qld.gov.au/chrisp/
MDRO_literature-review.pdf. Viewed 29 February 2016. sterilising/large_document.pdf
Australian Commission on Safety and Quality in Health Care Viewed 29 February 2016.
(ACSQHC). Healthcare Associated Infection. Available from: World Alliance for Patient Safety. WHO Guidelines on Hand
http://www.safetyandquality.gov.au/our-work/healthcare- Hygiene in Health Care. Available from: http://apps.who.
associated-infection/ Viewed 21 March 2016. int/iris/bitstream/10665/44102/1/9789241597906_eng.pdf
National Health and Medical Research Council. Australian Viewed 29 February 2016.
guidelines for the prevention and control of infection in healthcare. Food Standards Australia and New Zealand. Food Standards.
Available from: https://www.nhmrc.gov.au/guidelines- Available from: http://www.foodstandards.gov.au/Pages/
publications/cd33 Viewed 29 February 2016. default.aspx Viewed 29 February 2016.
Australian Health Infrastructure Alliance. Australian Health World Health Organization. Infection Control Information.
Facility Guidelines (AusHFG). Available from: http:// Available from: http://www.who.int/topics/infection_control/en /
healthfacilityguidelines.com.au/default.aspx Viewed 29 Viewed 29 February 2016.
February 2016.
Centre for Health Protection. Department of Health. The
Australian Government. The Department of Health. Australian Government of Hong Kong Special Administrative Region.
National Guidelines for the Management of Health Care Infection Control Corner. Available from: http://www.chp.gov.
Workers known to be Infected with Blood-Borne Viruses. hk/en/guideline_infection/346.html Viewed 29 February 2016.
publishing.nsf/Content/cda-cdna-bloodborne.htm Viewed 29
February 2016.
Australian Government. The Department of Health. The
Australian Immunisation Handbook. 10th Edition. June 2015.
Available from: http://www.immunise.health.gov.au/internet/
immunise/publishing.nsf/Content/Handbook10-home Viewed
29 February 2016.
Australian Society for Infectious Diseases (ASID). ASID Refugee
Health Guidelines Writing Group. Diagnosis, management and
prevention of infections in recently arrived refugees. In: Murray
RJ, et al., (eds.) Sydney: Australian Society for Infectious
diseases (ASID); 2009. Available from: https://www.asid.net.
au/documents/item/134 Viewed 29 February 2016.
March 2016 135

Implementation
Criterion 1.5.3 a) Policy / guidelines addressing a) Multidisciplinary wound prevention

the preservation of skin integrity, and management programs are
The incidence and impact of
and the management of pressure implemented and adapted to local
breaks in skin integrity, pressure
ulcers and other wounds, are needs and healthcare settings.
ulcers and other wounds are
readily available to staff.
minimised through wound prevention b) Risk assessment processes occur:
and management programs. b) Strategies for the prevention
(i) on admission
of pressure ulcers and
preservation of skin integrity are (ii) at transitions of care
evidence-based.
(iii) following changes in health status
c) Processes for the management of
(iv) p
rior to commencement of
wounds include consideration of,
high-risk procedures.
and strategies for, managing pain.
c) Wound documentation systems
d) Health professionals are provided
that support continuity of care and
with orientation and ongoing
assessment of progress towards
education on the preservation
goals are implemented.
of skin integrity and wound
prevention and management. d) Health professionals are trained in
the correct use of evidence-based
e) Written and verbal information is
risk assessment processes / tools
to assess skin integrity.
and carers about recognising
potential risks to skin integrity or to e) Consumers / patients and carers
wounds, including wound infections. are advised how they can alert
relevant staff to any changes
in skin integrity or to wounds,
including wound infections.
Overview However, consumers / patients may present with

compromised skin in any healthcare setting.
This criterion aims to ensure that the occurrence of
Assessment and management of pre-existing breaks in
healthcare-associated, non-surgical breaks in skin
skin integrity must be built into the consumer / patient’s
integrity is prevented whenever possible and minimised
care plan whether or not they are the primary cause of
at all times.
his or her admission.
This criterion is applicable to all organisations across the
spectrum of health care, as a break in skin integrity can
occur as the result of health care itself, can affect a wide
variety of consumers / patients (neonates, the frail aged,
the immobile and/or insensate, those with reduced
sensory perception, individuals undergoing lengthy
procedures), and can occur in all environments and
situations involving bed care, the use of support devices
or physical interaction (emergency departments, wards,
transport vehicles, operating theatres, day hospitals,
community nursing).
a) T
he system for skin integrity a) The organisation shows distinction a) The organisation demonstrates it is
preservation and wound in the preservation of skin a leader in the preservation of skin
management is evaluated, integrity and wound prevention integrity and wound prevention
and improvements are made and management. and management programs.
as required.
b) T
he incidence of skin integrity
breaks, including pressure ulcer
rates where applicable, is analysed
and trended, and improvements
are made to wound prevention
and management strategies
as required.
c) Education and training in the
preservation of skin integrity,
wound prevention and
management, and the use of
evidence-based processes / tools
Relationships of 1.5.3 with other criteria This criterion requires healthcare

The process of health care itself may result in a organisations to:
compromise of skin integrity. It is therefore essential Identify and treat consumers / patients with pre-
that the consumer / patient is assessed during each existing wounds or other breaks in skin integrity.
phase of care (Criterion 1.1.1), and at each transfer of
care (Criterion 1.1.5). When consumers / patients are Identify consumers / patients at risk of suffering a loss
managed in an inappropriate setting, it is more likely of skin integrity.
that skin breaks will occur, or that a skin break will not ave strategies for the preservation of skin integrity
H
be detected (Criterion 1.3.1). An appropriate diet will and the prevention of pressure ulcers during episodes
promote wound healing. Conversely, malnutrition is a risk of care.
factor for a loss of skin integrity, and moderate- to high-
risk consumers / patients should undergo nutritional ave processes to manage pressure wounds, skin
H
assessment (Criterion 1.5.7). tears and other skin breaks.
Breaks in skin integrity are a risk that must be managed rovide relevant information and education to
P
throughout the healthcare process (Criterion 2.1.2), and consumers / patients, staff and visitors.
when control processes fail, incidents and complaints
may result (Criteria 2.1.3 and 2.1.4).
March 2016 137

Criterion 1.5.3 e repeated as necessary during the episode of

b
The incidence and impact of breaks in skin care, to assess the efficacy of care / prevention
integrity, pressure ulcers and other non- strategies, and in response to any change in the
physical condition, overall care plan, or transfer of the
surgical wounds are minimised through wound consumer / patient.
(continued)
Prompt points
Assessment of consumers / patients for ow often during a care episode are
H
skin breaks and skin-break risk consumers / patients assessed for skin
The organisation’s assessment procedures (discussed integrity? What determines this schedule?
in detail in criterion 1.1.1) should include processes for ow does the organisation ensure that the
H
the identification of pre-existing conditions in which there outcomes of assessment are included in the
is a loss of skin integrity, including acute / traumatic consumer / patient’s care plan?
wounds such as lacerations or abrasions, or chronic
wounds such as ulcers. These may be the reason for hat screening / risk assessment tools are
W
the consumer / patient’s admission to the organisation, used in this organisation?
or unrelated; in either case, treatment of the identified
condition must be part of the consumer / patient’s
care plan (discussed in criterion 1.1.2). In addition, the
Strategies for the preservation of
organisation should have processes to identify when a skin integrity and the prevention of
consumer / patient is at risk of developing a break in skin pressure ulcers
integrity, and ensure that during their episode of care, all
Loss of skin integrity has a number of serious
reasonable steps are taken to prevent the development
consequences for the consumer / patient, including
of pressure ulcers, skin tears and other wounds.
increased morbidity and mortality, prolonged length of
Assessment of consumer / patient skin integrity should: stay, and retardation of recovery from unrelated health
conditions; furthermore, these negative outcomes
e part of the assessment process for all consumers /
b
significantly increase the cost of care for both the
patients upon admission
consumer / patient and the organisation. The presence
include the use of screening / risk assessment or absence of skin breaks, including but not confined to
tools, which are used in a consistent manner pressure ulcers, is often seen as an indicator of quality
organisation-wide of care, as they are one of the most common causes
of harm to consumers / patients in health services. The
identify those consumers / patients with a pre-existing
organisation must ensure that processes are implemented
loss of skin integrity
to prevent wherever possible the loss of skin integrity
identify those consumers / patients at risk of a loss of during the consumer / patient’s episode of care.
skin integrity during their care episode, due to known
Skin integrity preservation strategies should:
risk factors including (but not limited to):
e based upon current best-evidence, including
b
• the pathophysiology of older skin
international and jurisdictional guidelines
• urinary and/or faecal incontinence
be multidisciplinary in scope
• prolonged and/or inappropriate use of medical
devices, including beds and transport equipment
• malnutrition
• length of time in surgery / immobilised
e recorded in the consumer / patient care plan,
b
to ensure that all necessary care is delivered, and
prevention strategies implemented
e supported by policy and procedures, which
b Management of wounds
address mitigation of the major risk factors and
While the primary focus of this criterion is on prevention of
related approaches to management including (but not
healthcare-associated skin breaks, the organisation must
limited to):
ensure that if a consumer / patient is admitted with a
• risk assessment pre-existing wound, or if a wound subsequently develops,
it is managed in the most effective way. An appropriate
• wound documentation
treatment regime must encompass a pain management
• care planning strategy. Certain categories of consumers / patients, such
as young children or those suffering dementia, may be
• pressure relief
unable to provide verbal information regarding their pain
• appropriate equipment levels, and other forms of assessment must be employed.
• staff education Conversely, it is recognised that in some consumers /
patients the loss of, or reduction in, sensory perception
• consumer / patient and carer education may play a significant role in the breakdown of skin
• auditing and reporting integrity and the development of wounds.
• appropriate referral to medical, nursing and allied Wound management should:

health professionals be comprehensive and evidence-based
include the consumer / patient and their carer in the include initial assessment and regular reassessment
development of individual wound prevention and
management plans require monitoring and surveillance by staff of at-risk
consumers / patients, across the care continuum
e subject to regular evaluation, via incident
b
reports, health record audits, clinical indicator data, include appropriate pain management, according to
benchmarking, etc., to assess the overall efficacy of consumer / patient assessment
implemented strategies mploy appropriate consumer / patient positioning
e
e revised if necessary following the trending of
b and/or pressure relief or pressure redistribution devices
organisational outcomes. include strategies for reducing associated risk, such as
appropriately increasing consumer / patient mobility,
improving nutrition, managing incontinence, staff
Prompt points training in correct consumer / patient handling, etc.
hat documentation (legislation,
W nsure relevant referrals for ongoing care, for
e
guidelines, current evidence) did the example, to physiotherapists, podiatrists, dietitians,
organisation draw upon when drafting its skin equipment suppliers, etc.
integrity preservation policy?
hat departments / disciplines were consulted
W
in the development of the organisation’s policy?
Prompt points
ow does the organisation ensure that a
H
hat practical action(s) has the organisation
W
consumer / patient with an existing wound
taken to reduce the incidence of iatrogenic
is managed correctly throughout their
wounds? How are improvements in this
care journey?
area determined?
ow is pain assessed in consumers / patients
H
who are unable to describe their pain levels?
hat strategies does the organisation use to
W
reduce a consumer / patient’s risk of developing
a wound during a care episode?
March 2016 139

Criterion 1.5.3 assist consumers / patients and carers to:

The incidence and impact of breaks in skin • understand the risk factors for a loss of skin integrity
integrity, pressure ulcers and other non-
• recognise compromises to skin integrity, and what
surgical wounds are minimised through wound steps to take
• understand how to continue wound care
(continued) post-discharge.
Information and education for consumers /

patients, staff and visitors Prompt points
Organisations should ensure that all staff members ho is involved in the development of
W
involved in assessment and management of skin the organisation’s information / education
integrity have access to clinical expertise in wound on skin integrity?
management and ongoing education where applicable.
Consumers / patients and carers should be provided ow often are wound management education
H
with information about recognising compromises to skin sessions held? Who participates in the
integrity, and how to alert staff before an injury occurs. organisation’s education sessions?
Where a wound has been treated, consumers / patients hat information about maintenance of skin
W
and carers should be provided at discharge with all integrity is provided for consumers / patients
necessary information for ongoing care. and carers at the time of discharge?
Information and education in skin integrity should:
be based upon current, evidence-based best practice
e developed and evaluated by a multidisciplinary
b
team, and draw upon experience in wound address criterion 1.5.3
management from a variety of care situations, Policy on admission of consumers / patients
including aged care, spinal units, incontinence with pre-existing wounds
nursing, etc.
Policy on management of at-risk consumers /
have consumer / patient and carer input patients during surgical procedures
nsure that screening / risk assessment tools are
e Healthcare-associated wound
used in a consistent manner organisation-wide management systems
ddress organisation-based risk factors including (but
a Pressure area assessment tools, including
not limited to): the use of these in all areas of care such
• consumer / patient positioning as paediatrics, ICU, general surgical wards,
medical wards, rehabilitation units,
• beds and equipment community-based services
• friction from casts, medical devices, tape, etc. Equipment register
• staff handling of consumers / patients Health record audits
ddress appropriate related facets of the prevention of
a Information / education for staff and
iatrogenic skin breaks, such as the most appropriate consumers / patients
cleaning regimes for incontinent consumers / patients
ddress the practical aspects of wound care, such
a
as the correct use of pressure-relieving equipment
and positioning
Suggested reading
Wounds International. A wound management resource, raising
awareness and sharing best practice worldwide. Available
from: http://www.woundsinternational.com Viewed 25
February 2016.
Stephen-Haynes J & Carville K. Skin tears made easy. Wounds
International. Volume 2, Issue 4, November 2011. Available
from: http://www.woundsinternational.com/media/issues/515/
files/content_10142.pdf Viewed 25 February 2016.
Joanna Briggs Institute. Access to evidence-based guidelines.
Available from: http://joannabriggs.org /
Wounds Australia. Access to relevant standards and guidelines
for wound management. Available from: http://www.awma.
com.au/home Viewed 25 February 2016.
The National Pressure Ulcer Advisory Panel (NPUAP).
Resources. Available from: http://www.npuap.org/resources/
Viewed 21 March 2016.
Pan Pacific Guideline for the Prevention and Management of
Pressure Injury (2012). Published by the Australian Wound
Management Association in collaboration with the New
Zealand Wound Care Society, Hong Kong Enterostomal
Therapists Association and the Wound Healing Society
(Singapore). Available from: http://www.awma.com.au/
publications/2012_AWMA_Pan_Pacific_Guidelines.pdf Viewed
25 February 2016.
Graves N. & Zheng H. (2014) Modelling the direct health care
costs of chronic wounds in Australia. Wound Practice and
Research 1, 20–33. Available from: http://www.awma.com.
au/journal/2201_02.pdf Viewed 25 February 2016.
March 2016 141

Implementation
Criterion 1.5.4 a) Policy / guidelines addressing falls a) A

ppropriate evidence-based
prevention / minimisation, including multidisciplinary falls reduction
The incidence of falls and fall
where applicable the minimal use of strategies are implemented
injuries is minimised through a falls
restraint, are readily available to staff. according to identified risk factors.
management program.
b) Healthcare providers use an b) C
onsumers / patients and,
evidence-based risk assessment where practicable, carers are
process / tool to assess consumers involved in the development of an
/ patients for risk of falls: individualised falls prevention /
management plan which
(i) on admission
addresses risk factors identified
(ii) following a change of risk factor / during assessment.
clinical status
c) Relevant health professionals
(iii) after a fall are trained in falls injury risk
and the level of risk is conveyed to assessment, prevention and
the consumer / patient, carer and management, and the use of falls
clinical team. prevention equipment.
c) H
ealth professionals and other d) The organisation supports staff,
relevant staff are provided with consumers / patients and carers in
orientation and ongoing education in the identification and reporting of
falls prevention / minimisation. falls incidents and near misses.
d) Written and verbal information is e) Falls and fall injury prevention
provided to consumers / patients equipment is available for
and carers on falls prevention. consumers / patients following
appropriate education and training
for use.
f) Falls risk is considered as part
of discharge planning for at-risk

Falls-related injury is a leading cause of morbidity and The risk of a fall should be considered throughout all
mortality amongst older Australians. This criterion phases of the care journey (Standard 1.1). In particular,
requires organisations to implement a comprehensive falls risk should be included as part of the consumer /
falls prevention and management program, supported patient assessment process (Criterion 1.1.1). Falls can
by appropriate training and education, with the goals of: be reviewed in the evaluation of a consumer / patient’s
care (Criterion 1.4.1) and the ongoing risk of falls
whenever possible, preventing falls from occurring
considered in ongoing care (Criterion 1.1.6) and planning
hen falls cannot be prevented, minimising
w for transfer of care or discharge (Criterion 1.1.5). The
fall-related injuries. use of restraint in preventing falls should be considered
within the framework of the organisation’s delivery of
appropriate care (Criterion 1.3.1).
a) T
he system for falls prevention / a) The organisation shows distinction a) The organisation
minimisation is evaluated, in its management of falls and fall demonstrates it is a leader in
and improvements are made injury prevention. falls prevention, minimisation
as required. and management systems.
b) Individual falls prevention and
management plans are reviewed,
their effectiveness is evaluated,
as required.
c) Falls and fall injury data are
analysed and trended, and
improvements are made to falls
prevention strategies as required.
d) Education and training in falls
prevention / minimisation and falls
injury management are evaluated,
as required.
e) The information, education and
training provided to consumers
/ patients and carers on falls
prevention and management is
made as required.
Building arrangements and the equipment used at a This criterion requires healthcare
facility can impact on the type, severity and number of organisations to:
falls (Criterion 3.2.2), and addressing this issue is an
aspect of the organisation’s safety management system ave strategies for the prevention or reduction in
H
(Criterion 3.2.1). Falls within a facility are a significant incidence of falls.
healthcare incident (Criterion 2.1.3), which must be Identify consumers / patients at increased falls risk.
managed within the organisation’s integrated risk
management framework (Criterion 2.1.2). ave falls prevention management plans for
H
consumers / patients at risk.
rovide information and education to consumers /
P
patients, staff and visitors.
March 2016 143

Criterion 1.5.4 ave processes to identify, eliminate and mitigate

h
The incidence of falls and fall injuries is environmental factors which may increase the
minimised through a falls management probability of falls
program. (continued) nsure that all consumers / patients, regardless
e
of the reason for admission or attendance at the
Falls prevention / minimisation organisation, are assessed for falls risk and that,
where appropriate, a falls-risk management plan is
Falls-related injury is one of the leading causes of included in the consumer / patient’s overall care plan
morbidity and mortality in older people; falls and fall-
related injuries are the reason for four in every five reduce the risk of a consumer / patient falling during
injury-related hospital admissions among people aged an episode of care by:
65 years and over. However, not only older people • delivering care in an environment free of trip hazards
are at risk of falling. Young and/or relatively fit people
can suffer falls due to a variety of factors, including • implementing processes to facilitate staff vigilance
environmental trip hazards and the side-effects of and assistance, such as ward ‘rounding’, to prevent
medication. Consequently, all organisations must have increased falls risk due to inappropriate consumer /
a falls prevention and management plan and system, patient behaviour
regardless of their size or the services delivered, to • providing falls prevention equipment, and ensuring
ensure an appropriate response in the event of a that consumers / patients understand how to use it
consumer / patient fall.
nderstand and employ current best-practice
u
The organisation should strive to prevent falls in the strategies for minimising falls risk and reducing
first instance by creating and maintaining a safe fall-related injuries, including (but not limited to):
environment, free of potential trip hazards. Beyond this,
the organisation should take action to minimise the • medication review
occurrence of falls and reduce the severity of falls-related • environmental review
injury by identifying those at increased risk of falling,
• walking aids and hip protectors
ensuring that staff are vigilant to the possibility of falls,
making available appropriate equipment, and providing • vitamin D with calcium supplementation
consumers / patients, carers and staff with information
• different combinations of supervised exercise and
and education on falls risk and falls prevention. Falls risk
balance training
should be part of the organisation’s assessment process
(discussed in criterion 1.1.1), and identified falls-risk include the training of relevant staff in falls injury risk
factors should be addressed in the consumer / patient assessment, prevention and management, and the
care plan (discussed in criterion 1.1.2). When a fall does use of falls prevention equipment
occur, the organisation should respond with immediate
nsure communication of all relevant information
e
injury assessment and care, develop a remedial care
during transfer of care, and appropriate referrals
plan to assist recovery and minimise the risk of future
following discharge
falls, and investigate the circumstances of the fall to
determine whether systems failure or environmental implement processes to ensure that, in the event
factors were a contributing factor. of a consumer / patient fall, there is an immediate
response including appropriate care and injury
The falls prevention and management system should:
management
b
nsure that all incidents of consumer / patient falls
e
or near-falls are investigated, contributing factors
e supported by policy and procedure that define
b identified, and appropriate remedial action taken
responsibility and accountability for falls prevention
e subject to regular evaluation, via review of care
b
and management, and ensure effective governance
plans, incident reports, health record audits, clinical
b indicator data, benchmarking, etc., to assess the
and specifically the incident management system overall efficacy of implemented strategies
e revised if necessary following the trending of
b The system for managing at-risk consumers /
organisational outcomes patients should:
here appropriate, have policy and procedures to
w recognise and respond to the various factors which
govern controversial falls-prevention techniques such change and heighten falls risk, including (but not
as the use of restraint. limited to):
• intrinsic factors, such as a previous fall, postural
instability / muscle weakness, cognitive impairment,
Prompt points delirium, disturbed behaviour, urinary frequency,
hat documentation (legislation,
W incontinence, postural hypotension, some
guidelines, current evidence) did the medications and/or visual impairment
organisation draw upon when developing • extrinsic factors, in particular an admission of longer
and implementing its falls prevention and than 18 days
management system?
• environmental factors, such as particular areas
ho was consulted in the development of the
W of the ward (e.g. the bedside, the bathroom) and
organisation’s falls prevention and management times of potentially decreased vigilance (meal times,
system? Who has responsibility for oversight of shower times, after visiting hours)
the system?
include reassessment of the consumer / patient when
ow does the organisation ensure that the falls
H circumstances change, including (but not limited to):
risk assessment is integrated into the consumer
/ patient’s overall care plan? • variations in medication(s)
hat strategies does the organisation use to
W • relocation of the consumer / patient
reduce the risk of consumer / patient falls • deteriorating or improving physical strength
during care?
itigate risk factors through appropriate,
m
ow does the organisation respond when a
H multidisciplinary care
consumer / patient falls during an episode
of care? nsure that staff have ready access to documented
e
risk assessments, and are aware of those factors
impacting individual consumers / patients and any
Identifying and managing consumers / changes to their circumstances / care plan
patient at increased risk of falls rovide for consumer / patient surveillance appropriate
p
Any consumer / patient accessing the organisation may to the identified falls risk
have a heightened risk of falling. The organisation should nsure communication of falls risks to consumers /
e
be aware of the factors that increase falls risk, and patients and carers, and encourage their active
ensure that an appropriate assessment is carried out; participation in mitigating risk.
this assessment should be reflected in the consumer /
patient’s care plan. As the falls risk may vary over the
course of an episode of care, including the development
of a risk factor not present at the outset of care or a
different degree of risk associated with different areas
of the organisation, there should be reassessment of
the consumer / patient, with alteration to the care plan,
the provision of equipment, the rehabilitation plan, etc.,
as appropriate. The organisation should implement
processes that facilitate surveillance of consumers
/ patients and allow for an immediate response to
identified risk factors.
March 2016 145

Criterion 1.5.4 • condition of feet and footwear

The incidence of falls and fall injuries is • any visual impairment
minimised through a falls management • cognitive impairment
program. (continued)
• balance and mobility
• blood pressure
Prompt points
• dizziness and vertigo
t what points during an episode of care
A
is the consumer / patient assessed / • incontinence
reassessed for falls risk? How does the • current medications
organisation ensure that staff are aware of any
change in falls risk and/or to the care plan? nsure that the design / layout of the care area
e
does not increase falls risk, for example, through
hat strategies does the organisation employ
W inappropriate bed design, or poor placement of call-
to reduce the impact upon consumers / patient buttons, meal trays or mobility equipment
of environmental factors, for example, the layout
of the ward, staffing levels at different times / on onsider the appropriateness of bed-railings and, in
c
different days? certain defined circumstances, the use of restraint
(discussed in criterion 1.3.1)
ow are consumers / patients and carers
H
encouraged to take an active role in falls nsure that appropriate multidisciplinary care
e
risk mitigation? and/or referrals are used to mitigate identified risk
factors, for example, referral to a podiatrist, review of
medications, vision assessment
Strategies for the prevention or reduction include proven falls reduction processes such as
in the incidence of falls ward ‘rounding’, and ensure that staff understand
the potential risk of a lack of vigilance or a
Any consumer / patient can be at risk of falling,
delayed response
often due to factors unrelated to their health, and
the organisation should be vigilant for identified risk aintain an environment clear of fall hazards, by
m
factors. Simple interventions can significantly reduce the ensuring that consumers / patients, carers, other
incidence of falls. In addition, admission to a healthcare visitors and staff including cleaners and food deliverers
organisation itself carries an increased risk of falling, understand the necessity of returning equipment,
due to the environment and the potential physical furniture, etc., to its correct storage position, and that
impact of the admission. During an episode of care, the any spills are cleaned up as soon as possible
organisation should strive to eliminate all general factors include mobility / strengthening exercises for the
that may heighten the risk of falling, and implement consumer / patient, as appropriate, with management
processes to ensure that not only the immediate cause of the associated risk
of admission is addressed but, if heightened falls risk
factors are identified, appropriate action is taken. This include the provision of, or facilitation of access to,
may require adding to the consumer / patient’s care appropriate equipment to protect against falls injury
/ recovery plan specific activities to increase strength and/or assist mobility
or mobility, and providing or facilitating access to nsure that all instances of transfer of care / discharge
e
appropriate equipment. include communication of falls risk information, and
Strategies for reducing the incidence of falls should: where appropriate include arrangements for further
falls-risk care and/or exercise programs, for example
recognise and respond to factors which may be through community health services / home visits.
unrelated to the episode of care, but which may
increase falls risk for the consumer / patient, including
(but not limited to):
Consumers / patients and carers should:
Prompt points be informed of identified risk factors for falls
hat strategies does the organisation
W e made aware of behaviours that will reduce falls
b
employ to reduce the consumer / patient’s risk during the care episode, for example, waiting
falls risk, separate from risks associated with for assistance rather than attempting to walk to the
the episode of care? bathroom alone
ow does the organisation ensure that the
H e encouraged to maintain the care area so that it is
b
ward environment does not increase the risk of clear of trip hazards
consumer / patient falls?
e referred to allied health services as required, which
b
ow are consumers / patients encouraged
H may help with ongoing falls risk reduction
to take action to reduce their falls risk, for
example, by increased exercise? e encouraged to alert staff to identified falls risks in
b
the consumer / patient’s environment, or related to the
H consumer / patient’s health or physical condition
consumers / patients have access to falls injury
prevention / mobility equipment as required? receive all necessary instruction in the correct use of
falls injury prevention / mobility equipment.
Information and education on falls Staff should:

prevention and management e informed at orientation of the organisation’s falls
b
The organisation should ensure that all consumers / prevention and management system, including falls
patients are alerted to their various falls risks, whether risk assessment, and the correct processes for risk
associated with their reason for admission or not, and management and incident reporting
encouraged to reduce risk by eliminating / mitigating receive ongoing education in falls prevention and
hazards and altering behaviour, including increasing management, the content of which is regularly
exercise as appropriate. Carers should be included in updated to reflect current information and
the provision of information wherever practicable and best-practice
appropriate, as they will often have responsibilities and
opportunities for action outside of the care environment. ave ready access to all relevant guidelines and
h
Conversely, carers may be in the position to observe related resources
falls risks and bring them to the attention of health nderstand the importance of surveillance and prompt
u
professionals. Written information may also be made responses in preventing consumer / patient falls
available at the bedside to alert individual visitors to falls
risks, and ensure that they do not create hazards, for here relevant, be trained in falls injury risk assessment
w
example by leaving chairs in walkways. and the correct use of falls prevention equipment
Falls prevention and management should be addressed e informed of the outcomes of falls-related incident
b
at orientation and included in ongoing staff education. investigations and any associated practice changes.
There should be regular review of the content of
staff education to ensure that it remains up-to-date
and reflects current best-practice, and there should
be regular ‘refreshers’ in the importance of staff
vigilance and correct behaviour in reducing falls risk
for consumers / patients. In addition, staff should
have ready access to all relevant guidelines and other
resources to support falls prevention and management.
Designated staff should be trained in falls injury risk
assessment, prevention and management, and the use
of falls prevention equipment.
March 2016 147

Criterion 1.5.4 Suggested reading

The incidence of falls and fall injuries is The Australian Commission on Safety and Quality in Health
minimised through a falls management Care has a number of resources available, including:
program. (continued) • Preventing Falls and Harm From Falls in Older People: Best
Practice Guidelines for Australian Hospitals
• Preventing Falls and Harm from Falls in Older People: Best
Prompt points Practice Guidelines
H • Guidebook for Preventing Falls and Harm from Falls in
consumers / patients understand their falls Older People
risks, and how their behaviour can reduce risk? • Implementation Guide for Preventing Falls and Harm from
ow does the organisation ensure that staff and
H Falls in Older People for Hospitals and Residential Aged
visitors maintain a trip hazard-free environment Care Facilities
in the ward areas? • Falls Fact Sheets
ow does the organisation make falls risk-
H • A Register of the Latest Falls Prevention Research
related guidelines and other resources readily and Practice
accessible to its staff? Available from: http://www.safetyandquality.gov.au/our-work/
H falls-prevention/falls-prevention-resources / Viewed 25
February 2016.
update its falls prevention and management
education program? Who is responsible for Australian and New Zealand Fall Prevention Society.
ensuring the currency of the information provided? TRIPP - Translation of Research into Policy and Practice.
Available from: http://www.anzfallsprevention.org/tripp
H Viewed 25 February 2016.
Joanna Briggs Institute. Access to evidence-based guidelines.
Available from: http://joannabriggs.org /
The following evidence may help to Falls in older people: assessing risk and prevention. NICE
guidelines [CG161]. Available from: https://www.nice.org.uk/
address criterion 1.5.4 guidance/cg161 Viewed 25 February 2016.
Policy and procedures reflecting jurisdictional Falls prevention for older people. A resource for consumers /
and other standards, guidelines and priorities patients and carers. Available from: https://www.betterhealth.
Care plans including strategies for addressing / vic.gov.au/health/healthyliving/falls-prevention-for-older-people
mitigating falls risk
James KH Luk, Chan TY and Daniel KY Chan. Falls prevention
Proactive processes for falls prevention, such in the elderly: translating evidence into practice. Hong Kong
as ward ‘rounding’, the use of volunteers to Med J 2015;21:165–71. Available from: http://www.hkmj.org/
observe / assist consumers / patients, inclusion system/files/hkmj144469.pdf Viewed 21 March 2016.
of mobility / strengthening exercises in care plans
National Ageing Research Institute. Information on research
for consumers / patients at risk of falling into falls and balance, and access to resources. Available
Availability of falls injury prevention / from: http://nari.net.au/research/current-projects/falls-and-
mobility equipment balance. Viewed 25 February 2016.

responsible for falls-related incident review
Evidence of changes to processes as a result of
falls incident review
March 2016 149
Implementation
Criterion 1.5.5 a) Policy / guidelines addressing blood a) The sample and blood and blood product
management are consistent with relevant management system ensures:
The system to legislation, standards, guidelines and/or codes
manage sample (i) v erification of consumer / patient
of practice, and include: identification at the time of sample collection
collection,
(i) consumer / patient identification at the time (ii) timely and safe collection and labelling
blood, blood
of sample collection of samples
components /
blood products (ii) completion of the request form, safe (iii) d
ocumented indication and prescription for
collection, identification and labelling of the blood and blood products
and consumer /
consumer / patient sample
patient blood (iv) the consumer / patient and carer are
management (iii) prescription and documentation of blood informed of the risks, benefits and
ensures safe and blood product therapy appropriateness of the blood and blood
and appropriate (iv) obtaining and documenting product for their clinical situation, and
practice. informed consent consent for administration is obtained
(v) managing consumers / patients who refuse (v) timely availability of blood and
administration of blood or blood products blood products
(vi) the timely availability and safe administration (vi) v erification of correct consumer / patient
of blood and blood products and blood or blood product, and safe
(vii) monitoring and review of the administration of blood and blood products.
appropriateness of blood and blood b) T
he system for the safe transportation and
product therapy storage of samples and blood and blood
(viii) consumer / patient blood management products includes:
including blood conservation strategies (i) a blood and blood products inventory register
and alternatives to blood or blood (ii) a
llocated responsibilities for responding to
product therapy storage alarms and taking corrective action
(ix) reporting and management of adverse (iii) d
ocumentation accompanying samples and
effects of blood and blood product therapy. blood and blood products
b) Policy / guidelines addressing storage (iv) labels being checked each time the blood or
conditions and transportation of samples and blood product is handled
blood and blood products include:
(v) p
olicy for monitoring blood and blood
(i) validating, monitoring and recording of product usage and wastage.
temperature for all blood fridges
c) R
elevant health professionals are provided
(ii) maintenance standards for all blood fridges with orientation and ongoing education on
(iii) the response to blood fridge alarms procedures for safe sample and blood and
(iv) delivery, placement and removal of blood blood product management, including:
and blood products from any blood fridge / (i) c
onsumer / patient identification and
controlled storage / pneumatic tubes / other sample collection
transportation systems (ii) s torage and transportation of samples and
(v) monitoring of blood and blood product blood and blood products
usage and wastage (iii) b
lood and blood product therapy
(vi) a documented audit trail. prescription and safe administration.
d) T
he organisation supports health professionals,
consumers / patients and carers in the
identification and reporting of blood-related
incidents, near misses and adverse reactions.
a) T
he sample and blood and blood a) The organisation shows distinction a) T
he organisation demonstrates it is
product management system is in its management of samples and a leader in management of samples
evaluated, and improvements are blood and blood products. and blood and blood products,
made as required. and consumer / patient blood
b) T
he system for transportation and administration systems.
storage of samples and blood and
blood products is evaluated, and
improvements are made as required.
c) T
he blood and blood products
inventory register is evaluated, and
d) The appropriateness of transfusion
decisions is evaluated, and
e) S
ample and blood and blood product
errors, near misses and adverse
events are analysed and trended,
and further strategies to reduce
sample and blood and blood product
f) E
ducation and training in safe
sample and blood and blood product
management are evaluated in
consultation with relevant staff, and
g) Outcomes of the evaluation of the
blood management system, including
incident management, are reported
to the governing body.
March 2016 151

Criterion 1.5.5 Administration of blood and blood components /

The system to manage sample collection, products has associated risks (Criterion 2.1.2) that, if not
managed correctly, are likely to lead to adverse events
blood, blood components / blood products (Criterion 2.1.3).
and consumer / patient blood management
External service providers such as private pathology
ensures safe and appropriate practice.
services are frequently subcontracted to manage blood
(continued) collection or inventory, and this arrangement must be
managed by the organisation (Criterion 3.1.4).
Overview
This criterion requires all organisations responsible This criterion requires healthcare
for transfusing blood, blood components or blood organisations to:
products, regardless of how infrequently it occurs,
ave an organisation-wide system for the
H
to have effective systems that promote safe and
management of blood, blood component or blood
appropriate blood management.
product transfusion.
This criterion is not applicable where organisations:
afely store and transport blood, blood components
S
o not collect blood samples from consumers /
d and blood components.
patients for the purposes of transfusion of blood or
Implement processes to ensure appropriate decisions
blood components / products
about transfusion.
o not store, transport or administer blood or blood
d
anage transfusion risks, support error reporting and
M
components / products.
use the investigation of incidents and near misses to
In this criterion: improve blood management safety.
‘blood’ refers to homologous and autologous rovide information and education about blood, blood
P
whole blood components / products and transfusion to consumers /
‘blood component’ refers to fresh components (red patients and staff.
cells, platelets, fresh frozen plasma, cryoprecipitate,
cryodepleted plasma) Management of blood, blood components /
products and transfusion
‘blood product’ refers to plasma derivatives and
recombinant products The transfusion of blood or blood components /
products is a high-risk procedure and the organisation
‘sample’ refers to blood collected from a consumer /
must have systems in place that support safe and
patient to enable human-derived blood or blood
effective blood management and actively reduce the risk
component / product transfusion, or for other blood
of errors. Many evidence-based standards, guidelines
grouping procedures; ‘sampling’ is the collection of a
and circulars have been developed in recent years by
blood sample from a consumer / patient.
individuals, organisations and associations and experts
in the field of blood and blood component / product
Relationships of 1.5.5 with other criteria management and blood component therapy, who have
Complete and accurate consumer / patient identification, also defined the appropriate use of red blood cells,
and the matching of consumer / patient, sample, test and platelets, fresh frozen plasma (FFP) and cryoprecipitate.
test results, is critical for pathology sample collection and The organisation should draw upon these while also
also for administration of blood components / products ensuring that its systems are in accordance with
(Criterion 1.5.6). Another vital aspect of blood management all relevant jurisdictional legislation, standards and
is ensuring informed consent for the transfusion is obtained guidelines. The organisation should also have a local
prior to administering blood or any blood components / emergency blood management plan in accordance
products (Criterion 1.1.3). Blood components / products with the requirements of its jurisdiction and/or relevant
may play a critical role in managing a deteriorating health authorities.
consumer / patient (Criterion 1.1.4).
The blood, blood component, blood product and se appropriate guidelines to support decision
u
transfusion management system should: making, achieve standardisation of practice and
reflect all relevant legislation, standards, guidelines, reduce the risk of error, and ensure that staff have
and codes of practice, and all jurisdictional blood ready access to these guidelines
management and safety priorities nsure that relevant staff are trained in the correct
e
e supported by policy and procedures that
b techniques and procedures for sample collection
define responsibility and accountability for blood and the administration of blood and blood
management and ensure effective governance, and components / products
which address at a minimum: include competency assessment of staff directly
• consumer / patient blood management involved in sample collection and/or blood and blood
component / product administration
• consumer / patient identification
se audits and ongoing education to ensure
u
• prescription, documentation, and administration of that staff responsible for managing blood and
blood and blood components / products blood components / products comply with current
• adverse event management best-practice guidelines
• blood and blood component / product storage include regular audit of health records to ensure the
and transportation complete documentation of sample collection and/or
blood and blood component / product administration.
• the minimum information required (as a standardised
data set) for samples and request forms, sampling
and sample labelling
• timeliness, including the handling of urgent requests
• obtaining and documenting consent for transfusion,
and procedures in the event of failure to gain consent
for blood or blood component / product therapy
• the appropriateness of blood component therapy
• blood conservation strategies and alternatives
to transfusion
• rare but high-risk situations, such as
massive transfusion
e overseen by a Transfusion Committee or
b
equivalent body wherever possible; at a minimum,
blood management and transfusion-related issues
must be a standing agenda item for an appropriate
alternative committee
e linked to the organisation’s risk management
b
system and specifically the incident
management system
include processes for monitoring the correct
storage and transportation of blood and blood
components / products
include an inventory register to monitor usage and
avoid expiry of blood components / products
onitor wastage of blood and blood components /
m
products, and record the reasons for discard
March 2016 153

Criterion 1.5.5 Blood risk management and

The system to manage sample collection, error reporting
blood, blood components / blood products The identification and mitigation of the risks associated
and consumer / patient blood management with the use of blood and blood components / products
ensures safe and appropriate practice. should be a fundamental aspect of the organisation’s
(continued) overall blood management. All practices within the blood
management system should be based upon current
best-practice and strive to streamline tasks and eliminate
Prompt points variation, in order to reduce the possibility of error.
The following steps in the transfusion chain have been
hat body oversees blood management
W identified as most frequently associated with errors:
in the organisation? How is membership
determined? What are the responsibilities of the decision to transfuse
this group? transfusion requests and prescriptions
ho is accountable in the event of a rare
W sampling, particularly wrong blood in the tube
and/or controversial blood-related situation,
such as massive transfusion or refusal of laboratory testing, particularly after-hours
consent for transfusion? ollection of blood components / products from the
c
hat guidelines does the organisation draw
W blood bank or satellite refrigerator
upon in its blood management system? Who blood or blood component / product administration.
is responsible for ensuring that organisational
The organisation should ensure that it has a robust
practices are based on current best-evidence?
system for investigating and responding to errors and
ow often do staff involved in sample
H near misses associated with sample collection, blood
collection and/or blood administration transportation, and the administration of blood or blood
undergo competency reassessment? Who is components / products, and strive to create a culture
responsible for ensuring that all relevant staff in which staff are encouraged to report all errors, near
undergo reassessment? misses and adverse events. When incidents and near
ow does the organisation avoid wastage of
H misses occur, they should be thoroughly investigated
blood and blood components / products? and the outcomes of the investigation used as a basis
for improvement.
H
compliance with blood management policy, Blood risk management should:
procedures and guidelines? What is the include identification of systemic and process
organisational response to an identified instance risks and the development and implementation of
of non-compliance? mitigation strategies
oes the organisation have a perioperative
D se standardisation of processes and documentation
u
blood management program? In the lead up to reduce variation and the risk of error
to elective surgery, how does the organisation
include necessary repetition of consumer / patient
identify consumers / patients who are anaemic
identification, with verification at every stage of the
or confirm that this check has been done by the
administration process
referring health professional?
ncourage reporting of blood-related incidents, near
e
misses and adverse events by staff, consumers /
patients and carers
include investigation of blood-related incidents and
near misses by appropriately trained staff
nsure that all incident data are reviewed by an
e The organisation should implement a documented ‘audit
appropriate committee, and that: trail’ to ensure that blood and blood components /
products can be traced from their initial receipt, along
• shortcomings in systems and processes are each step in the transfusion chain, and finally to their
identified and addressed recipient or to destruction, if not administered. Blood
• appropriate remedial action is taken in the event of and blood components / blood products should be
staff non-compliance transported in validated containers only.
• outcomes of investigations are appropriately The blood storage and transportation system should:
disseminated and used as the basis of improvement omply with all legislative requirements, jurisdictional
c
activities and education. standards and guidelines, other relevant standards
and guidelines, and manufacturers’ instructions
Prompt points e supported by policy and procedures that define
b
responsibility and accountability for the security,
ow often, and at what steps, in the
H storage and transportation of blood and blood
blood transfusion chain is consumer / components / products and monitoring of the system
patient identity verified?
e designed to reduce the risk of error associated
b
ow does the organisation encourage reporting
H with the storage and transportation of blood and
of blood-related incidents and near misses? blood components / products
ho is responsible for the investigation of
W include appropriate back-up systems in the event of
blood-related incidents and near misses? power loss, or similar event
How does the organisation ensure that those
individuals with responsibilities in this area are nsure that refrigerators are located where they can
e
appropriately trained? be constantly monitored and/or equipped with alarms,
with staff designated to respond to alerts and alarms
hat is the membership of the committee that
W
reviews blood incident data? How often does include a register associated with each refrigerator,
this committee meet? which is regularly reviewed
ow does the organisation use the outcomes
H include a documented ‘audit trail’ for each stage
of incident investigation to improve its systems in the process of receiving, storing, transporting
and educate staff? and administering or destroying of blood and blood
components / products, and ensure that these
documents are regularly reviewed
Storage and transportation include verification processes for blood and blood
The safe and effective storage and transportation of components / products
blood and blood components / products requires that nsure that blood and blood components / products
e
the risk involved in each aspect of the process be are transported only in containers validated for
identified and mitigated. Blood and blood components / that purpose
products should be stored in dedicated, temperature-
controlled transfusion refrigerators, with specifications include processes for preventing the use of blood or
as described in relevant standards, and be subject to blood components / products in the event of expiry,
regular monitoring and audits. Appropriate security or if there is any question about their source, identity,
systems should also be in place, and access for storage or handling
removal, collection, transport and delivery restricted onitor and audit staff compliance with policy and
m
to authorised staff. Refrigerators located outside of a procedures, and ensure appropriate remedial action in
transfusion laboratory, for example in operating theatres, the event of non-compliance
may require additional or varied security processes and
monitoring, such as the inclusion of a 24-hour alarm rovide data on blood and blood component /
p
system, but the goals should be identical. product utilisation
identify wastage and/or unusual usage patterns.
March 2016 155

Criterion 1.5.5 Blood information and education

The system to manage sample collection, Safe management of blood and blood component /
blood, blood components / blood products product administration requires the organisation to
and consumer / patient blood management provide consumers / patients are carers with all relevant
ensures safe and appropriate practice. information, and to obtain informed consent from the
consumer / patient. Brochures and similar materials,
(continued) in addition to verbal explanations and responses to
question, may be helpful in ensuring that consumers /
patients are properly informed and able to give consent.
Prompt points Correct procedures in the event that consent cannot
hat legislation, standards and/or
W be given are usually subject to jurisdictional legislation,
guidelines has the organisation drawn otherwise organisational policy must address this issue.
upon in designing its systems for the security, Consent for administration must be documented on a
storage and transportation of blood and blood consent form or in the health record by the appropriate
components / products? health professional, if consent is verbal. Refusal of
consent should also be documented. In organisations
ho is responsible for overseeing the
W
where consent for transfusion is covered under the
organisation’s systems for the security,
general consent for surgery, it should be separately
storage and transport of blood and blood
noted that the subject of transfusion was covered in
components / products?
pre-surgery discussions whenever operative
oes the organisation have a blood refrigerator
D haemorrhage was considered to be a risk.
located outside the transfusion / laboratory
Safe and effective blood management should be
service (such as in the operating theatres)? If so,
addressed during orientation and be the subject of
who is responsible for maintaining this register?
ongoing staff education, in addition to the provision of
an the organisation demonstrate a
C training for relevant staff and the regular assessment
documented audit trail for blood and blood of competence. There should be regular review of the
components / products? How often are these content of staff education to ensure that it remains up-
documents reviewed? to-date and reflects current best-practice. In addition,
staff should have ready access to all relevant guidelines
hat is the correct procedure in the event that
W
and other resources to support the safe sampling,
these is a doubt about the source, identity,
storage, transport and administration of blood and blood
storage or handling of blood or a blood
components / products.
component / product?
ow does the organisation ensure that staff
H
are aware of their responsibilities with respect e informed of the risks and benefits of, and
b
to the storage and transportation of blood and alternatives to, transfusion, and the risks from
blood components / products? How does non-administration
the organisation respond to instances of staff
be encouraged to ask questions
non-compliance?
e given information in verbal and/or printed form,
b
ow does the organisation monitor blood
H
with the use of appropriate languages / formats and
and blood component / product usage and
the assistance of an interpreter when required, to
wastage? How does it use these data?
ensure that the consumer / patient is able to give
informed consent, or refuse consent.
Staff should:
e informed at orientation of the organisation’s blood
b
management system, and the correct processes for
risk management and error reporting
receive all necessary training, and be regularly
reassessed for competence with respect to, The following evidence may help to
at a minimum: address criterion 1.5.5
• consumer / patient identification Policy and procedures reflecting jurisdictional
• consent processes and other standards, guidelines and priorities
• sample collection Written / printed information on blood

administration for consumers / patients
• correct blood and blood component / product
procedures, including prescription, collection, Audits of informed consumer / patient consent to
transportation and administration blood-related procedures
• management of adverse events Records of completed staff training in

blood management
ave ready access to all relevant guidelines and
h
related resources Records of staff competency reassessment
receive ongoing education in blood safety and Documented ‘audit trail’ for all steps in
management, the content of which is regularly blood management
updated to reflect current information and Blood refrigerator registers
best-practice
e informed of the outcomes of blood-related incident
b responsible for blood-related incident review /
investigations and any associated practice changes. oversight of blood storage, transport
and distribution
Prompt points
H
consumers / patients understand the risks
and benefits of blood administration, prior to
giving consent? In what different formats /
languages is relevant information available?
ow does the organisation identify what
H
blood-related training is required for different
categories of staff? How does it ensure that all
training is completed?
ow often does the organisation reassess the
H
competency of its staff in all aspects of blood
management?
ow does the organisation make blood-
H
related guidelines and other resources readily
accessible to its staff?
H
update its blood management education
program? Who is responsible for ensuring the
currency of the information provided?
H
March 2016 157

Criterion 1.5.5 Tran HA, Chunilal SD, et al. An update of consensus guidelines
for warfarin reversal. Med J Aust 2013; 198 (4): 198-199.
The system to manage sample collection, Available from: https://www.mja.com.au/journal/2013/198/4/
blood, blood components / blood products update-consensus-guidelines-warfarin-reversal Viewed 29
and consumer / patient blood management February 2016.
ensures safe and appropriate practice. The Australasian Society of Blood Transfusion. Guidelines for
(continued) Autologous Blood Collection. Topics in Transfusion Medicine
2002. 9(2): 1-54. Available from: http://www.anzsbt.org.au/
publications/documents/2002_Vol9_2.pdf
Standards Viewed 29 February 2016.
AS 3864.1 2012 Medical refrigeration equipment—For the
storage of blood and blood products.
Suggested reading
National Health and Medical Research Council. Clinical
Practice Guidelines for the use of Blood Components.
Available from: http://www.nhmrc.gov.au/publications/
synopses/cp77syn.htm Viewed 29 February 2016.
National Pathology Accreditation Advisory Council (NPAAC).
Requirements for Transfusion Laboratory Practice. Canberra
ACT; 2013. Available from: http://www.health.gov.au/internet/
main/publishing.nsf/Content/health-npaac-docs-transfusion.
htm Viewed 29 February 2016.
Australian & New Zealand Society of Blood Transfusion
Inc. and Royal College of Nursing Australia. Guidelines for
the Administration of Blood Components. Available from:
http://www.anzsbt.org.au/publications/documents/anzsbt_
guidelines_administration_blood_products_2nded_dec_2011_
hyperlinks.pdf Viewed 29 February 2016.
Australian Red Cross Blood Service (ARCBS). Label and
Component Information Ver 4.0. Available from: http://www.
transfusion.com.au/blood_products/blood_component_label
Updated January 2016. Viewed 29 February 2016.
Australian Health Ministers' Advisory Council (AHMAC).
Evidence-based clinical practice guidelines for the use of
recombinant and plasma-derived FVIII and FIX products.
Available from: http://www.anzsbt.org.au/resources/documents/
fviiiandfixguidelines2006.pdf Viewed 29 February 2016.
Australian Health Ministers' Conference. Criteria for the Clinical
Use of Intravenous Immunoglobulin in Australia. Available
from: http://www.blood.gov.au/pubs/ivig/index2.html Viewed
29 February 2016.
Gallus A, Baker R, Chong B et al. Consensus guidelines for
warfarin therapy: recommendations from the Australasian
Society of Thrombosis and Haemostasis. Med J Aust 2000;
172: 600-605. Available from: https://www.mja.com.au/
journal/2000/172/12/consensus-guidelines-warfarin-therapy
March 2016 159
Implementation
Criterion 1.5.6 a) Policy / guidelines addressing a) The system to ensure correct

correct consumer / patient identification of consumers /
The organisation ensures that the
identification, correct procedure patients, correct procedure
correct consumer / patient receives
and correct site prior to any clinical and correct site in any medical
the correct procedure on the
intervention are consistent with intervention includes:
correct site.
relevant legislation, standards,
(i) v erification of consumer /
guidelines and/or codes of practice.
patient information
b) Policy / guidelines addressing
(ii) m
atching the information
the management of instruments,
against documentation
accountable items and other items
used for surgery or procedures are (iii) m
arking the correct site / side
consistent with relevant legislation, for intervention
standards, guidelines and/or
(iv) taking time out for team
codes of practice.
verification prior to
c) The organisation has documented the intervention
systems for standardisation of
(v) post-procedure confirmation,
consumer / patient identification.
counting and documentation
d) Health professionals and other
and mitigates the associated risks.
relevant staff are provided with
orientation and ongoing education b) T
he organisation supports staff,
in correct consumer / patient consumers / patients and carers
identification, correct procedure in the identification and reporting
and correct site policy / guidelines of incidents and near misses
and processes. involving correct consumer /
patient, correct procedure and
e) Written and verbal information is
correct site identification.
and carers about correct consumer /
patient, correct procedure and
correct site processes.
Overview to harm, including procedures performed in settings

outside operating theatres, the administration of
This criterion expands the use of the Correct Patient,
medications, transfusions and diagnostic testing.
Correct Site, Correct Procedure Protocol into other
In addition, organisations that provide any service
therapeutic areas, requiring that consumer / patient
to a consumer / patient that may require referral to
identification procedures are implemented and adhered
information recorded from a previous service provision
to throughout the organisation.
should ensure that they have the correct consumer /
Ensuring the correct consumer / patient receives the patient before providing their service.
correct service is relevant for all organisations that
undertake surgical and/or interventional procedures. It
applies to all operative and other invasive procedures
that could potentially expose consumers / patients
a) Compliance with policy / guidelines a) The organisation shows a) The organisation demonstrates
on correct consumer / patient distinction in its management it is a leader in correct consumer
identification, correct procedure of correct consumer / patient, / patient identification, correct
and correct site is monitored and correct procedure and correct procedure and correct
evaluated, and improvements are site processes. site systems.
made as required.
b) C
ompliance with the organisation’s
correct consumer / patient, correct
procedure and correct site system
is monitored and evaluated, and
improvements are made to related
education programs as required.
c) Compliance with the organisation’s
policy / guidelines on the
management of instruments,
accountable items and other items
used for surgery or procedures
is monitored and evaluated, and
as required.
d) Incidents involving incorrect
consumer / patient, procedure
or site are analysed and trended,
and further strategies to reduce
e) Outcomes of the evaluation of
the system for ensuring correct
consumer / patient identification,
correct procedure and correct site,
including incident management, are
reported to the governing body.
Relationships of 1.5.6 with other criteria identifier, will be recorded in the consumer / patient
health record (Criterion 1.1.8).
Safe care and service provision (Standard 1.5) depends
upon correct identification of the consumer / patient Systems for ensuring correct identification, correct
and correct documentation of the procedure and site. site and correct procedure are an aspect of the
While these issues predominantly affect the conduct of organisation’s integrated risk management framework
surgical and other interventional procedures, they also (Criterion 2.1.2). Failures in this area will lead to
impact upon medication management (Criterion 1.5.1) incidents, including adverse events and sentinel events
and all aspects of blood and blood component / product (Criterion 2.1.3), and to complaints (Criterion 2.1.4).
management (Criterion 1.5.5). All documentation
associated with correct identification / site / procedure,
including the issuing of the unique consumer / patient
March 2016 161

Criterion 1.5.6 e implemented organisation-wide, in a

b
The organisation ensures that the correct consistent manner
consumer / patient receives the correct include a clear statement of the forms of identification
procedure on the correct site. (continued) required, and how many are required
result in the issuing of a unique identifier, which is tied
This criterion requires healthcare to all aspects of the consumer / patient’s care and to
organisations to: all aspects of the health record
ave a system of consumer / patient identification
H here a system of visual identification is used, such
w
that is standardised throughout the organisation. as the issuing of a coloured wristband, ensure that
the unique identifier and all other legislated / required
ave systems to ensure the correct consumer / patient
H
information is included, as defined by policy
receives the correct care or intervention, on the correct
site, in both surgical and non-surgical settings. include processes for managing:
Manage all accountable items, including instruments. • identical names for different consumers / patients
P • phonetic duplication (i.e. names that sound alike but
patients, carers, staff and visitors. are spelled differently)
• identification in an emergency situation
Standardised consumer /
patient identification se monitoring and auditing to ensure staff
u
compliance, with remedial action taken as required.
Correct identification of the consumer / patient is
fundamental to the delivery of safe, high quality care
and services, and a major aspect of organisational Prompt points
risk management. The organisation must ensure that
it fulfils all legislated obligations and other jurisdictional hat legislation, jurisdictional requirements
W
requirements with respect to its processes for identifying and/or guidelines does the organisation
the consumer / patient, and that it has robust processes draw upon in managing consumer /
for identification, issuing a unique identifier, and patient identification?
eliminating duplication or confusion of identity. hat forms of consumer / patient identification
W
Correct identification of consumers / patients is required: does the organisation require? How does
the organisation ensure that relevant staff
at admission or registration understand these requirements?
rior to commencement of care / intervention,
p ow does the organisation ensure consistency
H
and at relevant points during the process of in the management of consumer / patient
care / intervention names, for example, the ordering of first and
hen handover, transfer of care or discharge
w surnames, duplicated names, phonetically
processes and related documentation occurs. similar names?
oes this organisation use wristbands? What
D
Systems for identifying the consumer / patient should: information is included on the wristband?
fulfil the organisation’s legislated obligations and ow is the system for consumer / patient
H
jurisdictional and other requirements identification monitored for correctness
b and consistency?
responsibility and accountability for consumer / patient
identification, and ensure effective governance
b
and specifically the incident management system
Correct consumer / patient, correct care or • actions to be taken in the event of a wrong
intervention, correct site. consumer / patient, wrong procedure, wrong
site incident
Correct consumer / patient, correct intervention,
correct site procedures are a major aspect of the • any exceptions to the use of the policy
organisation’s management of risk, since failures in this • dispute resolution procedures
area of management may result in sentinel events. The
organisation should ensure that it has robust implemented e linked to the organisation’s risk
b
processes for consumer / patient identification in the management system and specifically the
first instance, and that these are supported by further incident management system
processes to ensure correct intervention and site. nsure that all incidents of wrong consumer / patient,
e
Monitoring of compliance and urgent action taken in the wrong care or intervention and/or wrong site are
event of any identified instance of non-compliance should investigated, contributing factors identified, and
support the implementation of consistent processes and appropriate remedial action taken
relevant staff training and education.
e subject to regular evaluation, via review of care
b
In the surgical setting, a checklist such as that designed plans, incident reports, health record audits, clinical
by the World Alliance for Safer Patient Care, which indicator data, benchmarking, etc., to assess the
was recently reviewed and endorsed by the World overall efficacy of implemented strategies
Health Organization, may be adopted, and should
be supported by strict procedures and compliance e revised if necessary following the trending of
b
monitoring. Where the organisation adapts an existing organisational outcomes.
checklist for its particular circumstances, it must not
compromise the consistency of the checklist process or
the team participation aspects of the checklist.
Prompt points
or what care / intervention situations
F
Such checklist procedures should not apply only to
other than surgery does the organisation use
surgical situations, however, but may be adapted as
checklists or similar?
appropriate for other high-risk care situations, such
as medication management, blood transfusion or ow does the organisation ensure consistency
H
radiation therapy, and any situation involving the use of of action and staff compliance with the
instruments or any other accountable items. processes for correct consumer / patient,
correct care or intervention and correct site?
Systems for the management of correct consumer /
How does the organisation respond to any
patient, correct care or intervention, and correct
identified instance of non-compliance?
site should:
ho is responsible for investigating incidents
W
b
related to wrong consumer / patient, wrong
care or intervention and/or wrong site? How
b does the organisation use the outcomes of
responsibility and accountability for management such investigations to improve its systems?
of correct consumer / patient, correct care or
intervention and correct site and ensure effective
governance, and which address at a minimum:
• consumer / patient identification
• the correct procedure(s) to be followed
• compliance monitoring
• the responsibilities of all team members
• actions to be taken when there are discrepancies or
disagreements during the surgical timeout
March 2016 163

Criterion 1.5.6 include the four core principles of correct consumer /

The organisation ensures that the correct patient, correct procedure, correct site, namely:
consumer / patient receives the correct • confirmation of consumer / patient identity
procedure on the correct site. (continued) • confirmation of consent
Correct consumer / patient, correct • identification of site

procedure, correct site in the • a mandatory final verification (i.e. a timeout)
surgical setting require consistency in how the surgical site is marked,
The surgical setting is associated with a high risk of including (but not limited to) with respect to:
adverse and sentinel events due to incorrect consumer / • what procedures must be marked
patient identification, wrong procedure and/or wrong site.
Standardised preparation for surgery, in which stepwise • what type of marking is used
preparations are made and which involve all members of • marking of ‘left’ and ‘right’
the team, can significantly reduce the risk of error.
nsure that all team members understand their
e
The World Alliance for Safer Patient Care’s Surgical responsibilities for correct consumer / patient, correct
Safety Checklist, which was developed to ensure procedure, correct site
that no incorrect procedures are performed, and
that no procedures are undertaken on the incorrect include procedures to be followed in emergency
consumer / patient, or at an incorrect site, has recently situations, including full documentation of any
been reviewed and endorsed by the World Health exceptions to standard protocol
Organization. The Surgical Safety Checklist specifies nsure that all incidents of wrong consumer / patient,
e
questions to be asked and/or tasks to be performed in wrong procedure and/or wrong site are investigated,
a prescribed sequence during each phase of a surgical contributing factors identified, and appropriate
procedure, namely: remedial action taken
the period before induction of anaesthesia include monitoring and auditing of compliance, and
the period after induction and before surgical incision ensure that remedial action is taken when necessary.
the period during or immediately after wound closure

but before removing the consumer / patient from the Prompt points
operating room.
oes the organisation use the Surgical
D
In organisations where surgical procedures are Safety Checklist? If so, has it altered it in
performed, the Surgical Safety Checklist should be any way? How did the organisation ensure
adopted or adapted; if adapted, the organisation must that these changes would not decrease the
ensure that no alteration is made to the components effectiveness of the checklist?
addressing the checklist process or the team
participation aspects of the checklist, which are crucial. ow does the organisation monitor compliance
H
with correct consumer / patient, correct
Systems to manage correct consumer / patient, correct procedure, correct site protocols? What action
procedure, correct site in the surgical setting should: is taken in the event of an identified instance of
e based upon internationally recognised and
b non-compliance, for example, failure to conduct
endorsed processes for the mitigation of risk a ‘timeout’ prior to surgery?

b ho is responsible for investigating incidents
W
responsibility and accountability for management of related to wrong consumer / patient, wrong
correct consumer / patient, correct procedure, care or intervention and/or wrong site? How
correct site in the surgical setting and ensure does the organisation use the outcomes of
effective governance such investigations to improve its systems?

b
Managing accountable items,
including instruments Prompt points
During all procedures, all instruments and other hat does this organisation consider an
W
accountable items must be monitored and verified, ‘accountable item’?
including (but not limited to): ho is responsible for verification of
W
soft goods, such as sponges and towels accountable items in the surgical setting?
needles and other sharps re accountable items used outside of the
A
surgical setting? Who is responsible for
instruments, most commonly malleable retractors
counting in these situations?
s mall miscellaneous items, including unretrieved
ho is responsible for investigating incidents
W
device components or fragments (such as broken
related to incorrect counting / lost item? How
parts of instruments), stapler components, parts
does the organisation use the outcomes of
of laparoscopic trocars, guidewires, catheters, and
such investigations to improve its systems?
pieces of drains.
At the end of every procedure, all of the health
professionals within an operating room or treatment area Correct consumer / patient, correct care
should jointly sign off on the procedure. This will be done or intervention and correct site in the
during or immediately after wound closure but before nonsurgical setting
removing the consumer / patient from the operating
room or treatment area. Verification of all accountable While discussion of correct consumer / patient, correct
items should be part of the sign-off procedure. care or intervention and correct site tends to focus upon
the surgical setting, due to the likelihood of a sentinel
Systems for managing accountable items should: event occurring as a result of error in this setting, the
e supported by policy and procedures, which should
b organisation should ensure that correct alignment of
define responsibility consumer / patient and treatment is effectively managed
in all care delivery situations. While the risk associated
b with surgery is well-identified, the role of consumer /
and specifically the incident management system patient identification in other high-risk areas, such as
include a sign-off process to be conducted at the end medication management or blood transfusion, should
of every procedure and which requires: not be overlooked or minimised. Furthermore, incorrect
identification may result in errors in related processes
• confirmation of the procedure
such as blood sampling and pathology testing, which
• completion of item counts in turn may have a significant negative impact upon
consumer / patient care. Consequently, the organisation
• completion and checking of specimen labelling
should ensure that it has robust processes for
• noting any equipment problems managing correct consumer / patient, correct care or
intervention and correct site in non-surgical as well as
require the nomination of an individual responsible
surgical settings.
for accountable item verification at the end of
any procedure Systems for managing correct consumer / patient,
correct care or intervention and correct site in the
nsure that any incident of incorrect counting / lost
e
non-surgical setting should:
item is investigated, contributing factors identified, and
appropriate remedial action taken e supported by policy and procedures, which
b
define responsibility
include monitoring and auditing of post-procedural
compliance, and ensure that remedial action is taken nsure that verification of consumer / patient
e
when required. identification and matching of consumer / patient to
care / intervention / sampling / test is standard in all
intervention situations
March 2016 165

Criterion 1.5.6 Information and education on correct

The organisation ensures that the correct consumer / patient, correct care or
consumer / patient receives the correct intervention and correct site
procedure on the correct site. (continued) The organisation should ensure that consumers /
patients and carers are aware of the importance
include standard processes for labelling of sample / of correct identification, and why identification will
biopsy tubes, etc. sometimes be repeated, perhaps several times.
e supported by standardised documentation for
b Increased understanding will prevent consumers /
recording of test results, etc. patients becoming frustrated with what may appear to
be duplication, and encourage them to take an active
b role in preventing mismatches.
Systems developed to manage consumer / patient
e addressed during staff education, to ensure
b identification and correct matching of procedures to the
that the potential for harm through non-compliance consumer / patient require compliance and consistency
is understood to be effective. Staff training and education should be
include processes for accountable item verification, aimed at ensuring not only that staff understand what
where appropriate behaviour is required, but the reasons for it, and the
vital importance of consistency and completeness in
ensure that any incident of incorrect care / intervention / all checking and verification procedures, in both the
sampling / test is investigated, contributing factors surgical and non-surgical setting.
identified, and appropriate remedial action taken
Information and education on correct consumer / patient,
include monitoring and auditing of compliance, and correct care or intervention and correct site should:
ensure that remedial action is taken when necessary.
ssist consumers / patients and carers to understand
a
the identification process and the need for repetition
Prompt points ncourage consumers / patients and carers
e
H to be active in correct identification and
matching of correct consumer / patient to preventing mismatches
correct care / intervention / sampling / test is nsure that staff understand the organisation’s
e
standardised in all settings? systems and processes for correct consumer /
oes verification of accountable items occur
D patient, correct care or intervention, and correct site
outside of the surgical setting? Who is s upport staff in striving for consistency and
responsible for this? completeness of verification procedures
ow does the organisation ensure that the
H include ‘refresher’ training for staff, to ensure that a
correct consumer / patient has the correct culture of non-compliance (short-cuts, omission of
tests, and that the correct test results are necessary repetition, less stringency in non-surgical
recorded in the correct health record? settings, etc.) does not develop.
ow would the organisation respond in the
H
event that mislabelling of pathology samples
occurred, or an instance of wrong blood /
wrong tube was identified?
Suggested reading
Prompt points The Australian Commission on Safety and Quality in Health
ow does the organisation encourage
H Care. Resources include:
consumers / patients to be actively involved • Review of Technology Solutions to Patient Misidentification
in the identification process?
• Specification for a standard patient identification band
ow often are staff given ‘refresher’ training in
H • Surgical Safety Checklist
the correct verification processes relevant to
their role(s)? • Ensuring Correct Patient, Correct Site, Correct
Procedure Protocol
• Ensuring Correct Patient, Correct Site, Correct Procedure
Protocols for other clinical areas
The following evidence may help to Available from: http://www.safetyandquality.gov.au Viewed 29
address criterion 1.5.6 February 2016.
Policy and procedures describing requirements World Health Organization. Resources include:
for consumer / patient identification and • WHO Surgical Safety Checklist
verification.
• Implementation Manual Surgical Safety Checklist
Audits of surgical checklists, health records,
Available from: http://www.who.int/patientsafety/safesurgery/
consumer / patient pathology results, etc.
ss_checklist/en Viewed 29 February 2016.
Records of completed staff training in correct Attorney-General’s Department. Healthcare Identifiers Act
identification and matching procedures 2010. Available from: https://www.comlaw.gov.au/Details/
Evidence of changes to processes as a result C2010C00440 Viewed 29 February 2016.
of wrong consumer / patient, wrong care or Attorney-General’s Department. Healthcare Identifiers
intervention, wrong site incidents Regulations 2010. Available from: https://www.comlaw.gov.
au/Details/F2010L01829 Viewed 29 February 2016.
The Joint Commission. Sentinel Event Alert. Issue 51, October
17, 2013. Preventing unintended retained foreign objects.
Available from: http://www.jointcommission.org/assets/1/6/
sea_51_urfos_10_17_13_final.pdf Viewed 29 February 2016.
Stawicki SP, Moffatt-Bruce SD, Ahmed HM, et al. Retained
surgical items: a problem yet to be solved. J Am Coll Surg.
2013 Jan;216(1):15-22. Available from: http://www.ncbi.nlm.
nih.gov/pubmed/23041050 Viewed 29 February 2016.
Verna C. Gibbs M.D. Sponge ACCOUNTing Practice.
No Thing Left Behind. 2011. Available from: http://www.
nothingleftbehind.org/uploads/Sponge_ACCOUNTing_
Practice.pdf Viewed 29 February 2016.
March 2016 167

Implementation
Criterion 1.5.7 a) Policy / guidelines addressing a) A multidisciplinary team oversees

the delivery of nutritional care are the organisation’s nutrition
The organisation ensures that the
consistent with relevant legislation, management strategy to ensure that
nutritional needs of consumers /
standards, guidelines and/or the provision of food and fluid to
patients are met.
codes of practice. consumers / patients is consistent
with good nutritional care.
b) The organisation has a strategic and
coordinated approach to delivering b) The nutrition policy / guidelines
consumer / patient-centred are adapted to local needs
nutritional risk screening and care and implemented across
for those with malnutrition. the organisation.
c) Food, fluid and nutritional care is c) Relevant health professionals
considered as part of an intervention use a validated nutrition risk
and medical treatment plan. screening tool to assess
consumers / patients:
d) Health professionals and other
relevant staff are provided with (i) on admission
orientation and ongoing education
(ii) weekly thereafter
about their roles and responsibilities
in delivering nutritional care and (iii) following a change of
preventing malnutrition. health status.
e) Nutritional care is incorporated into d) Strategies to deliver food and
the consumer / patient care plan, fluids to consumers / patients
in collaboration with the consumer requiring physical assistance are
/ patient and, when practicable, implemented, according to the
their carer. consumer / patient requirements.
e) Referrals to nutrition-related
services occur in a timely manner.
f) The organisation supports staff,
in the identification and reporting
of nutrition-related incidents and
near misses.
Overview responsibility to optimise the nutrition of their consumers /

patients, so as to support wellbeing and recovery, and to
As nutritional care can affect a wide variety of
prevent malnutrition.
consumers / patients across the spectrum of health
care, this criterion is applicable to all organisations, A key focus of this criterion is on prevention of
although there will be different degrees of involvement malnutrition whilst in the healthcare setting. However,
depending on the nature of the organisation and the if a consumer / patient enters the organisation with
length of consumer / patient stay. malnutrition, or it subsequently develops, it should be
managed as per established guidelines.
This criterion requires organisations to ensure that
the nutritional needs of consumers / patients are met
during their healthcare journey. Organisations have a
a) C
ompliance with policy / a) The organisation shows distinction a) The organisation demonstrates it
guidelines for the delivery of in its management of consumer / is a leader in strategies to ensure
nutritional care is monitored and patient nutrition. that the nutritional needs of
evaluated, and improvements are consumers / patients are met.
made as required.
b) T
he nutritional care of consumers /
patients is evaluated, and
as required.
c) Education on nutritional care
and malnutrition is evaluated,
as required.
d) Incidents contributing to
deterioration in consumer / patient
nutritional status are analysed and
trended, and improvements are
made to the nutritional policy /
guidelines as required.
e) Outcomes of the evaluation of the
system for delivering nutritional
care and preventing malnutrition,
including incident management, are
reported to the governing body.
Relationships of 1.5.7 with other criteria 1.5.3). The organisation must also consider the dietary
requirements of consumers / patients with diverse needs
Good nutrition is essential to the wellbeing and recovery
and from diverse backgrounds (Criterion 1.6.3).
of the consumer / patient, and to ensure that the length
of stay is not unnecessarily lengthened. Nutritional needs Preventing malnutrition in the healthcare setting is
should be determined during assessment (Criterion an aspect of the organisation’s management of risk
1.1.1), and nutritional care should be planned and (Criterion 2.1.2). The development of malnutrition in a
delivered (Criterion 1.1.2). Good nutrition is an aspect consumer / patient is a reportable incident (Criterion
of appropriate (Criterion 1.3.1) and effective (Criterion 2.1.3) that should be investigated.
1.4.1) care delivery, and integral in promoting resistance
to infection (Criterion 1.5.2) and skin integrity (Criterion
March 2016 169

Criterion 1.5.7 omprise a series of strategies aimed at ensuring

c
The organisation ensures that the nutritional the delivery of high quality nutritional care, the
needs of consumers / patients are met. maintenance of good nutritional status, and the
prevention and/or treatment of malnutrition, including
(continued) (but not limited to):
This criterion requires healthcare • nutrition risk screening on admission and at agreed
and documented intervals during stay
organisations to:
• documented nutrition care plans, including current
Have a nutrition management strategy.
weight and target weight
Provide nutritional care as part of the overall care plan.
• identified roles and responsibilities of staff with
Identify at-risk consumers / patients. respect to nutritional care of consumers / patients
Provide information and education to staff, consumers / • access to safe, acceptable and appropriate
patients and carers. food services
• meal / menu planning to suit the organisation’s
Nutrition management population, and individual consumer / patient needs
Good nutrition is a vital aspect of consumer / patient • monitoring of consumer / patient food intake and
wellbeing. Poor nutrition during an episode of care nutritional status
can significantly retard recovery and prolong length of
stay and, in extreme cases, cause the development • referral to other health professionals where required
of malnutrition. While food services are sometimes • implementation of artificial nutrition support
viewed as an appropriate area for ‘cost-cutting’, the therapy when oral intake is inadequate, as per
organisation should consider both the health impact agreed procedures
of poor nutritional care and the increased expenditure
associated with longer episodes of care. • a mealtime environment conducive to eating
Good nutrition management, conversely, will support • provision of timely assistance
consumer / patient recovery and wellbeing, and should • nutritional care discharge planning and ongoing care
be considered an aspect of consumer / patient care.
The organisation should develop and implement an • multidisciplinary staff education
overall management plan for nutrition, appropriate • consumer / patient and family education
to the size and scope of the organisation, and which
include strategies for the treatment and prevention of e implemented organisation-wide, in a
b
malnutrition. Delivering quality nutritional care can be consistent manner
a complex process, and may require multidisciplinary nsure that staff understand their responsibilities with
e
oversight. While dietitian involvement is preferable, respect to nutrition care
at a minimum the organisation should draw upon
current best-evidence when developing its nutrition treat deterioration in nutritional status as a
management policy / guidelines and procedures. reportable incident.
Nutrition management should:

be an aspect of the organisation’s quality management
b
responsibility and accountability for the management
of nutrition, and ensure effective governance
e subject to appropriate oversight (dietitian,
b
multidisciplinary committee, etc.)
im at integrating nutrition into the overall care of the
a
consumer / patient
• the mealtime environment and assistance to eat
Prompt points and drink
ho was involved in the development of

W • consumer / patient information and communication
the organisation’s nutrition management plan e designed to prevent the development of
b
and strategies? malnutrition during the episode of care
oes the organisation employ a dietitian?
D here malnutrition is identified during assessment, be
w
Who within the organisation is responsible for a major aspect of the overall care plan, and subject to
nutrition management? regular reassessment / adjustment
hat nutrition management strategies does
W include oversight of mealtimes to facilitate monitoring
the organisation employ? How was it decided of consumer / patient food and fluid intake
that these strategies were appropriate for the
organisation and its consumers / patients? e supported by practical assistance for the consumer /
b
patient where required, including with respect to:
ow does the organisation ensure that its
H
nutrition strategies are implemented in a • choosing from the menu
consistent manner, organisation-wide? • opening portion-control food packaging
• cutting up food
Nutritional care delivery • feeding
The organisation’s nutrition management strategies ave the option of artificial nutrition where required,
h
should be reflected in the individual consumer / patient which should be based upon current best-practice
care plan; organisations should aim at optimising guidelines and overseen by a dietitian.
nutrition for consumer / patient wellbeing and recovery,
and to prevent malnutrition.
Many factors may contribute to poor nutritional Prompt points
status, however the organisation must ensure that its ow does the organisation ensure that
H
own processes do not do so. Health care itself may the consumer / patient’s nutritional status is
negatively impact the consumer / patient’s nutritional considered during care planning?
status, and/or compromise the organisation’s ability to
meet the consumer / patient’s nutritional needs, and this ow often / at what points during an episode of
H
should be addressed throughout the episode of care via care is nutritional status reassessed?
regular reassessment. ow is consumer / patient food and fluid
H
Delivery of nutritional care should: intake monitored?
e based upon jurisdictional and/or other relevant

b hat assistance does the organisation offer
W
best-practice guidelines consumers / patients at mealtimes?
e appropriate for the size and scope of the

b ow does the organisation respond if a
H
organisation, while still ensuring correct nutrition consumer / patient develops malnutrition
during an episode of care? Is this treated as a
e supported by policy and procedures, which
b reportable incident?
address at a minimum:
• nutrition as an aspect of care planning
• risk screening, assessment, monitoring and
discharge planning
• planning and provision of food, fluids, and
nutritional supplements
March 2016 171

Criterion 1.5.7
The organisation ensures that the nutritional Prompt points
needs of consumers / patients are met. hat nutritional screening tool does the
W
(continued) organisation use?
ow is nutritional status recorded in the
H
Identifying at-risk consumers / patients health record?
The organisation should implement nutrition risk How often is the consumer / patient reassessed?
screening in order to identify consumers / patients with
existing nutritional issues or at risk due to poor nutrition. ow does the organisation respond to a
H
These consumers / patients should have a documented detected deterioration in a consumer / patient’s
nutritional care plan, developed either individually health status?
or through agreed processes such as flowcharts or
standards, and in consultation with a dietitian.
Information and education on nutrition
At-risk consumers / patients should:
Consumers / patients and carers should be provided
e screened using a validated screening tool,
b with information related to the importance of nutrition
appropriate to the setting for recovery and, if necessary, assisted to understand
be subject to nutrition assessment that includes: the value of artificial nutrition in maintaining nutritional
status / managing malnutrition. Appropriate assistance
• the condition of the mouth and teeth services should be provided at mealtimes, and
• use of, and condition of dentures consumers / patients should be made aware of these
and encouraged to access them.
• capacity to swallow effectively
Where nutritional issues and risks are identified during
• ability to open packages assessment, the organisation should ensure that
• ability to self-feed consumers / patients and carers are informed of the
situation and how it will be addressed during the
• dietary requirements, such as vegetarian meals or
episode of care. Consumers / patients should also be
avoidance of allergens
provided with appropriate referrals, such as to dietitians.
• cultural requirements, such as halal or kosher meals
Consumer / patient nutrition should be addressed at
ave a care plan that addresses identified nutritional
h orientation and be an aspect of ongoing staff education;
issues and risk factors while staff with specific responsibilities in this area should
receive all necessary training. Education and training for
e subject to regular reassessment throughout
b
staff should be developed, implemented and evaluated
the episode of care, with the care plan updated
by a multidisciplinary team including consumers /
as required
patients. There should be regular review of the content
e provided with appropriate referrals for ongoing
b of staff education to ensure that it remains up-to-date
nutritional care. and reflects current best-practice. In addition, staff
should have ready access to all relevant guidelines and
other resources to support the delivery of high quality
nutritional care.
e given general information about the importance
b
of nutrition address criterion 1.5.7
e informed of specific nutritional issues / risks which
b Policy and procedures reflecting jurisdictional
may impact the care episode and other standards, guidelines and priorities
receive all necessary information regarding specific Assessment protocols including

nutritional care, including artificial nutrition, and be nutrition assessment
encouraged to ask questions Care plans addressing specific
be referred to appropriate allied health services. nutritional requirements
Use of a validated nutrition screening tool
Staff should:
Assistance available to consumers / patients
e informed at orientation of the organisation’s
b at mealtimes
nutrition management system
Monitoring of consumer / patient food and
receive ongoing education in nutrition management, fluid intake
the content of which is regularly updated to reflect
current information and best-practice, and Evidence of consumer / patient deterioration due
which addresses: to poor nutrition being reported and investigated
as an incident
• the benefits of good nutritional care for recovery
• the organisation’s nutritional care processes, including
how the food / meal service system operates
• malnutrition and its adverse effects on consumer /
patient outcomes
• assessment and management of at-risk
e trained in specific nutritional responsibilities, as
b
appropriate to their role(s)
ave ready access to all relevant guidelines and
h
related resources.
Prompt points
ho is responsible for ensuring that
W
consumers / patients understand their
nutritional care?
hat training in nutritional care and related
W
responsibilities does the organisation provide for
different categories of staff?
hat education on nutrition does the organisation
W
provide for relevant non-clinical staff?
March 2016 173

Suggested reading
Dietitians Association of Australia. Evidence based practice
guidelines for the nutritional management of malnutrition
in adult patients across the continuum of care. Nutrition &
Dietetics 2009; 66: S1-S34. Available from: http://onlinelibrary.
wiley.com/doi/10.1111/ndi.2009.66.issue-s3/issuetoc Viewed
29 February 2016.
The Agency for Clinical Innovation (ACI) Nutrition Standards:
For Adult Patients in NSW Hospitals. 2011. Available from:
http://www.aci.health.nsw.gov.au/__data/assets/pdf_
file/0004/160555/ACI_Adult_Nutrition_web.pdf Viewed 29
February 2016.
Food Safety Standards Information. Food Service to Vulnerable
Persons. Standard 3.3.1. Available from: http://www.
foodstandards.gov.au/industry/safetystandards/service/pages/
default.aspx Viewed 29 February 2016.
Queensland Health Nutrition Standards for Meals and Menus.
Department of Health. 2012. Available from: https://www.
health.qld.gov.au/nutrition/resources/hphe_nutritionstd.pdf
Nutrition Standards for Adult Inpatients in WA Hospitals
(Metropolitan). Available from: http://www.health.wa.gov.au/
circularsnew/circular.cfm?Circ_ID=13270
Queensland Health. Welcome to nutrition education materials
online (NEMO). Available from: http://www.health.qld.gov.au/
nutrition / Viewed 19 February 2016.
Department of Human Services, Victoria. Nutrition Standards
for Menu Items in Victorian Hospitals and Residential Aged
Care Facilities. Available from: http://health.vic.gov.au/
patientfood/nutrition_standards.pdf Viewed 29 February 2016
Department of Human Services, Victoria. Healthy choices: food
and drinks guidelines for Victorian public hospitals. Available
from: https://www2.health.vic.gov.au/hospitals-and-health-
services/quality-safety-service/healthy-choices Viewed 29
February 2016.
1.6 Consumer Focus Standard

The standard is:
The governing body is committed to consumer /
patient participation.
The intent of this standard and criteria is to promote
consumer participation and the involvement of
consumers / patients in their health care, and to ensure
their rights, responsibilities and needs are met.
This standard has three criteria. They are:
1.6.1 C
onsumers / patients, carers and the
community participate in the planning, delivery
and evaluation of the health service.
onsumers / patients are informed of their rights
1.6.2 C
and responsibilities.
1.6.3 T
he organisation meets the needs of consumers /
patients and carers with diverse needs and from
diverse backgrounds.
Consumers are those who directly or indirectly make use
of health services, including carers and other support
people and representatives of consumer organisations,
as well as consumers / patients.
The term ‘consumer’ incorporates women, men, people
from diverse cultural experiences, class positions and
social circumstances, sexual orientations, health and
illness conditions and ages.
March 2016 175

Standard 1.6: The governing body is committed to
consumer / patient participation.
Implementation
Criterion 1.6.1 a) Policy / guidelines addressing a) Consumers / patients and, when

consumer / patient, carer and relevant, carers are involved in
Consumers / patients, carers and
community participation are readily policy / guideline development and
the community participate in the
available to staff. health services planning.
planning, delivery and evaluation of
the health service. b) The organisation has identified b) Consumers and consumer groups
its community and main are consulted about effective
consumer groups. ways of participating with the
organisation and partnerships
c) Consumer participation is
are established.
representative of the community
that the organisation serves. c) Relevant staff are trained in how to
implement and evaluate consumer /
d) The organisation identifies
patient, carer and community
ways of encouraging consumer
group participation strategies.
participation in the planning,
delivery and evaluation of care d) Consumers / patients, carers and
and services, and implements other stakeholders are provided
relevant training. with relevant information to enable
them to fully participate in the
e) Relevant staff are educated in how
activities of committees.
can participate in the planning,
delivery and evaluation of the
health service.
f) The governing body demonstrates
its commitment to consumer /
patient, carer and
community participation.

This criterion addresses the importance of consumer / An important aspect of participation of consumers /
patient, carer and community participation in health patients, their carers and the wider community in the
care. This participation ranges from inclusion of planning, delivery and evaluation of the health service
consumers / patients and, where appropriate, their is the involvement of consumers / patients and, where
carers in decisions about care and services, through to appropriate, carers in planning and delivery of care
community involvement in policy decisions. (Criterion 1.1.2); and the provision of appropriate
information to the community by the organisation
(Criterion 1.2.1). In collaborating with consumers /
patients, their carers and the community, organisations
should display an understanding of the diverse needs
and diverse backgrounds of the the populations they
serve (Criterion 1.6.3).
a) The consumer / patient, carer and a) The organisation shows a) The organisation demonstrates it
community participation program distinction in consumer / patient is a leader in consumer / patient,
is evaluated with consumer / and carer participation. carer and community participation
patient and carer involvement, in the planning, delivery and
and improvements are made evaluation of the health service.
as required.
b) T
he organisation’s facilitation of
consumer participation, including
committee membership, is
made as required.
c) Education and training of staff
in consumer / patient, carer and
community group participation
and the involvement of staff in
participation strategies is evaluated,
as required.
d) O
utcomes of consumer / patient,
carer and community involvement
in the evaluation of the health
service are communicated to the
governing body.
This criterion requires healthcare Defining the community

organisations to: Within the scope of this criterion, a consumer is defined
Identify their community and main consumer groups. as someone who makes either direct or indirect use of
health services - that is, a current or potential user of
ncourage consumer / patient and community
E the health system, and/or their carer(s). The definition
participation in planning of services. is wide-ranging, encompassing both consumers with
rovide opportunities for consumer / patient and
P specific health needs, or who may at some time have
community participation in service planning. them, and those who have a general interest in the
health system and health funding.
P
patients, staff and the community. A carer is not necessarily a family member, but anyone
who gives unpaid, informal care to an individual in need of
assistance because of their physical or mental condition.
Within this criterion, a carer is also a consumer.
March 2016 177

Criterion 1.6.1 Encouraging consumer / patient and

Consumers / patients, carers and the community participation
community participate in the planning, Consumer and community participation is the process
delivery and evaluation of the health service. of involving health consumers and the community
(continued) meaningfully in decision making about their own health
care, health service planning, policy development and
In defining the community, organisations should consider: setting priorities and quality issues in the delivery
of services.
community is a group of people who share a
a
common interest or background (e.g. cultural, social, Some organisations use the words ‘engagement’ or
political, economic, health), which may also be, but is ‘involvement’ rather than ‘participation’.
not necessarily, geographic Within the organisation, commitment to consumer /
n individual consumer will belong to a number of
a patient and community participation should be
different communities, while any community will be integrated into the operation at three key levels:
made up of consumers t the level of management, with a focus upon the
a
the community from which a healthcare organisation decision makers, and how participation can be
attracts participating consumers may be the promoted and increased
community at large, that is, they may be members of t the program or development level, with staff
a
the general population with an interest in health care; developing and providing information, care, treatment
or it may be the specific community needing health and research with consumers / patients, carers and
care and served by the organisation the community
for a private hospital, the community will consist t the level of individual care, with the consumer /
a
of their visiting medical officers (VMOs) and the patient and, where appropriate, his or her carer(s) being
consumers / patients who use their services. actively involved in the planning and delivery of care.
While a healthcare organisation, especially one servicing
an extensive community, is not expected to be aware Some avenues of participation are:
of every individual group within that community, it is
unsolicited feedback (complaints, praise)
nevertheless essential that it have a good understanding
of those likely to require or have an interest in its services. solicited feedback (surveys)
Thorough consumer / patient data collection and the use individual care planning (decision making in care,
of internal surveys are essential. Organisations should consumer / patient-centred planning)
also enter into partnerships with various community
roup care planning (education sessions, consumer /
g
and advocacy associations, and make use of their
patient and carer support groups)
accumulated knowledge bases.
onsultation (focus / interest groups, public meetings,
c
discussion papers for reaction)
Prompt points artnerships (quality improvement committees,
p
ow does the organisation demonstrate
H advocacy groups, community advisory committees,
its commitment to consumer / patient, carer consumer and carer committees, research committees)
and community participation in health care?
decision making (policy forums, governance structures).
ow does the organisation ensure that it has
H
identified the various groups that make up the For effective consumer / patient participation,
community it services? organisations should:
sk their community what opportunities and avenues
a
to participation it wants
involve specific groups and the broader community in
their decision-making process
perate within an atmosphere of respect
o ave a straightforward application process, while any
h
and openness resources subsequently required for participation, for
example, transport for someone with a disability, or
ather consumer / patient feedback and data on an
g
catering for any special dietary requirements, should
ongoing basis.
be allocated
ake the recruitment notice and any other relevant
m
Prompt points information, such as an application form, available via
the organisation’s normal channels for dissemination
ow does the organisation decide what
H
of consumer information, as well as via broader
participation strategies to implement?
means such as advertising.
y what means does the organisation solicit
B
feedback and suggestions from the community?
oes the organisation have consumers on any
D
Prompt points
of its committees? On which committees? How n how many different committees within
O
did those consumers become members of the organisation do consumers participate?
the committees? How many of these are advisory, and how many
decision-making?
ith what special interest or professional groups
W
has the organisation entered into partnership? ow does the organisation recruit consumers?
H
How does it encourage participation by
y what means does the organisation gather
B
people from diverse backgrounds and with
feedback on its consumer participation program?
diverse needs?
How does it respond to this feedback?
hat are some of the organisation’s positive
W
outcomes from consumer participation? Providing information and education
To whom did the organisation disseminate to consumers / patients, staff and
information of these outcomes?
the community
Training and education programs for staff and
Providing opportunities for consumer / management are critical, in order to highlight the
patient and community participation importance of consumer participation, the benefits to
the community and the organisation alike and ways to
Some forms of consumer participation are quite informal, involve the community.
such as completion of surveys and involvement in focus
groups. Others are more formal, such as membership One of the ways that management can demonstrate its
on committees or Boards. However participation occurs, commitment to consumer / patient, carer and community
the requirements should be addressed within the participation is through the provision of resources, facilities
organisation’s policy / guidelines. and varied opportunities for such training.
To assist consumers on formal committees, the When inviting consumers to participate at a governance
organisation should: level, the organisation should consider:
lready have a description of the committee's role, its

a that they may be less knowledgeable about the formal
terms of reference, and its intended contribution to the operation of committees, the terminology used by
broader functioning of the organisation health professionals and how the feedback from
the committee is integrated into decision-making
raft a recruitment notice, somewhat like a position
d processes within the organisation
description, outlining the consumer’s role on the
committee and any desirable attributes / experiences, roviding guidelines that clearly delineate the role of
p
and including such details as the frequency and length consumers on a particular committee and any other
of meetings information necessary to facilitate their involvement,
such as a glossary of terms likely to be used within
ncourage applicants from diverse backgrounds
e the committee
and/or with diverse needs
March 2016 179

Criterion 1.6.1 Suggested reading

Consumers / patients, carers and the Rural and Regional Health and Aged Care Services Division.
community participate in the planning, Doing it with us not for us: Strategic direction 2010–13.
Available from: https://www2.health.vic.gov.au/about/
delivery and evaluation of the health service. publications/researchandreports/Doing%20it%20with%20
(continued) us%20not%20for%20us%20Strategic%20direction%202010-13
roviding training as appropriate to inform and
p
Health Issues Centre. Improving Health Services Through
support consumer representatives and to make their Consumer Participation: A Resource Guide for Organisations.
participation as meaningful as possible Available from: http://www.healthissuescentre.org.au/images/
training for staff members directly involved with uploads/resources/Improving-health-services-through-cp-
resources-guide-for-orgs.pdf Viewed 29 February 2016.
consumer participation, in such aspects of the process
as consumer / patient-centred communication skills, Cancer Australia. Consumer participation guide. Available
shared decision making, implementation of participation from: http://canceraustralia.gov.au/publications-and-resources/
strategies and mentoring. cancer-australia-publications/consumer-participation-guide
SA Health. Consumer and Community
Prompt points Participation Policy Directive. Available from:
https://www.rah.sa.gov.au/cac/downloads/
hat skills does the organisation require
W ConsumerandCommunityParticipationPolicydirective
from its consumers? What training does the 2009.pdf Viewed 22 February 2016.
organisation provide for consumers prior to their
South Western Sydney Local Health District. Consumer and
taking up a committee role?
Community Participation Framework. Available from: https://
hat training and education is provided for
W www.swslhd.nsw.gov.au/ccp/pdf/CP_Framework.pdf Viewed
staff involved in consumer / patient, carer and 22 February 2016.
community participation? National Health and Medical Research Council (NHMRC). A
Model Framework for Consumer and Community Participation
in Health and Medical Research. Available from: https://www.
nhmrc.gov.au/_files_nhmrc/publications/attachments/r33.pdf
The following evidence may help to Viewed 22 February 2016.
address criterion 1.6.1 Austin Health. Consumer and Community Participation.
Available from: http://www.austin.org.au/page?ID=135
Inclusion of a consumer participation program in Viewed 22 February 2016.
the organisation’s strategic plan
Regional and Rural Health and Aged Care Services. How
Policies enabling and governing to develop a community participation plan. Available
consumer participation from: https://www2.health.vic.gov.au/about/publications/
policiesandguidelines/How%20to%20develop%20a%20
Evidence of consumer participation community%20participation%20plan
on committees Viewed 22 February 2016.
Terms of reference for the relevant committees, Victorian Department of Health. Community advisory committee
and minutes of their meetings guidelines. Available from: https://www2.health.vic.gov.
au/getfile/?sc_itemid=%7B7D8E9161-5714-450A-ABE0-
Evidence of consumer and staff 3DC6974280DE%7D&title=Community%20advisory%20
training / education committee%20guidelines Viewed 22 February, 2016.
Evidence of feedback / news of positive Health Issues Centre. Getting Started: Involving consumers on
outcomes / quality improvements from consumer committees. Available from: http://healthissuescentre.org.au/
participation, e.g. websites, newsletters images/uploads/resources/Involving-consumers-on-health-
service-committees.pdf Viewed 22 February 2016.
Feedback from selected consumer
representatives on their role and achievements
Department of Health & Human Services, Victoria. Participation
and communication. Available from: https://www2.health.vic.
gov.au/about/participation-and-communication Viewed 22
March 2016.
Health Consumers Queensland. Your voice in health. Strategic
plan 2008 - 2010. Available from: https://www.health.qld.gov.au/
hcq/publications/hcq_toolkit_may11.pdf Viewed 22 March 2016.
Flinders University / South Australian Community Health
Research Unit. Community Participation Evaluation Tool.
Available from: http://som.flinders.edu.au/FUSA/SACHRU/
Toolkit/PDF/1.pdf Viewed 22 March 2016.
National Health and Medical Research Council. Resource
Pack for Consumer and Community Participation in Health
and Medical Research. Available from: http://www.nhmrc.gov.
au/_files_nhmrc/file/publications/synopses/r34.pdf Viewed 22
March 2016.
Queensland Government / Queensland Health. Consumer
and Community Participation Toolkit. For Queensland Health
staff. Available from: http://www.healthissuescentre.org.au/
documents/items/2008/08/226706-upload-00001.pdf Viewed
22 March 2016.
March 2016 181

Implementation
Criterion 1.6.2 a) Policy / guidelines / charters a) Staff and volunteers are provided
addressing consumer / patient with orientation and ongoing
Consumers / patients are informed of
rights and responsibilities are education about their role with
their rights and responsibilities.
consistent with relevant legislation, respect to:
standards, guidelines and/or
(i) c
onsumer / patient rights and
codes of practice, and are readily
responsbilities
available to staff.
(ii) h
ow to maintain privacy and
b) Policy / guidelines addressing
confidentiality while interacting
the management of personal and
with consumers / patients
health-related information are
consistent with relevant privacy (iii) m
aintaining confidentiality of
legislation, and are readily available consumer / patient personal
to staff. and health-related information.
c) Staff and volunteers sign b) T
he organisation provides
confidentiality agreements consumers / patients and carers
on appointment. with a copy of the rights and
responsibilities document.
d) Information about consumer /
patient rights and responsibilities c) Staff discuss rights and
is readily available to consumers / responsibilities with the consumer /
patients, staff and the community in patient and, when practicable,
appropriate formats / languages. their carer.
e) The organisation provides d) Feedback is sought from
information on how consumers / consumers / patients, carers and
patients and, when practicable, the community regarding the
carers can access advocacy and organisation’s management of
support services. rights and responsibilities.
f) The procedure for consumer /
patient access to their health
records is documented and
communicated to consumers /
patients and carers.
Overview carers involved in a given episode of care, in particular

the rights governing communication, participation and
This criterion is designed to assist healthcare
the right to comment upon any aspect of the healthcare
organisations in meeting their responsibilities to inform
experience. This awareness should be demonstrated
consumers / patients of both their rights and their
throughout the organisation’s policies and procedures.
responsibilities, in order to achieve the best possible
health outcomes.
While the focus of this criterion is upon the rights and
responsibilities of the consumer / patient, organisations
must be aware that in most instances these rights and
responsibilities will extend to family members and/or
a) T
he system to inform consumers / a) The organisation shows distinction a) The organisation demonstrates it
patients of their rights and in its recognition of and support is a leader in processes to ensure
responsibilities is evaluated, and for consumer / patient rights that consumer / patient rights and
improvements to documents and and responsibilities. responsibilities are respected
practices are made as required. and supported.
b) C
onsumer / patient privacy and
confidentiality are monitored,
breaches are analysed, action is
taken according to policy, and
as required.
c) Feedback from consumers /
patients, carers and the
community informs the
organisation’s evaluation of its
management of rights
and responsibilities.
Relationships of 1.6.2 with other criteria 1.1.8 and 2.3.1). Failure of the organisation to meet its
obligations with respect to consumer / patient rights
Among the rights of the consumer / patient are the
may lead to incidents (Criterion 2.1.3) and complaints
right to collaborate in the planning and delivery of care
(Criterion 2.1.4).
(Criterion 1.1.2), to give informed consent to that care
(Criterion 1.1.3) and, when required, to have information
provided to them in different formats (e.g. in Braille
or verbally) or in a language other than that spoken
within the organisation, in printed form or via a trained
interpreter (Criterion 1.6.3). Every consumer / patient
has the right to access his or her health record (Criteria
March 2016 183

Criterion 1.6.2 The organisation should:

Consumers / patients are informed of their rovide a copy of the relevant Charter, or
p
rights and responsibilities. (continued) develop and implement their own rights and
responsibilities document
This criterion requires healthcare raw upon the provisions of its Charter of Rights
d
organisations to: where applicable
ave a rights and responsibilities document that is
H e guided by national and/or jurisdictional
b
provided to consumers / patients and carers. standards and guidelines such as Privacy Acts or
aintain the privacy and confidentiality of consumers /
M other Standards
patients’ health information and their personal privacy. e guided by information provided by advocacy
b
Inform consumers / patients about how to access agencies, which are relevant to the community served
their health information. by the organisation
rovide education / training to consumers / patients,

P involve consumers / patients and families if developing
health professionals and other staff about upholding its own document
rights and responsibilities. e aware of, and make provision for, those
b
circumstances under which the rights of the consumer /
Providing a consumer / patient rights and patient are transferred to a family member or carer
responsibilities Charter or other document e aware of circumstances under which the rights
b
A Charter or other document about consumer / patient of the consumer / patient and/or their carer(s) are
healthcare rights and responsibilities should be provided superseded by the requirements of legislation, including
to all consumers / patients and carers. Charters usually under various provisions of Mental Health Acts.
summarise the basic rights that consumers / patients
are entitled to receive when accessing health services,
and outline the responsibilities of the consumer / Prompt points
patient while receiving health care. The aim of a oes the organisation have its own Charter
D
Charter is to provide a framework for the creation of of Rights, or has it implemented a jurisdictional
a genuine partnership between consumers / patients Charter of Healthcare Rights? If it has its own
and healthcare providers, in order to achieve the best Charter, how has it ensured that it aligns with all
possible health outcomes. aspects of the jurisdictional Charter?
Having a Charter or document on consumer / patient ow is the Charter of Healthcare Rights
H
healthcare rights and responsibilities is applicable to all referenced in the organisation’s policies and
health settings. procedures, and its management of complaints?
Charters or rights and responsibilities documents should hat other policies / guidelines, if any, have
W
summarise the basic rights that consumers / patients been drawn upon in the organisation’s drafting
and carers are entitled to receive when accessing of its rights and responsibilities documentation?
healthcare services.
Many jurisdictions have a Charter of Healthcare Rights
or similar statement. Organisations should adopt this Maintaining the privacy and confidentiality
Charter where it is made available, or develop and of consumers / patients’ health and
implement their own Charter to outline the rights and personal information
responsibilities of their consumers / patients.
The consumer / patient’s right to privacy, and to have
personal disclosures and medical information handled
with strict confidentiality, is fundamental to health care
and one of the basic rights mandated in most Charters
of Healthcare Rights. There is an expectation within
communities that personal health information will be
treated with the utmost care, and this duty to maintain Maintaining personal privacy
confidentiality is underpinned by legal and professional
In addition to ensuring privacy and confidentiality of
standards. All staff, including volunteers, who work
documented consumer / patient health information,
within the health system, are in a position of trust, where
organisations should ensure that when:
they may gain access to personal health information that
is confidential. information is exchanged verbally, whether between
the consumer / patient and a health professional, or
Organisations must have a privacy and confidentiality
from one health professional to another, privacy and
policy / guideline in place that:
confidentiality are considered
eets the demands of all relevant legislation, codes of
m
transporting consumers / patients to and from other
professional ethics, and accepted standards
areas, such as bathrooms, consumer / patient
is available to all health professionals, other staff, modesty is maintained and staff ensure they are
volunteers and contractors covered appropriately
requires all staff and volunteers to sign a confidentiality in casual conversations between staff members or
agreement, where appropriate as part of their to other consumers / patients, any details that are
employment contract verbalised would not lead anyone to assume that they
s pecifies under what circumstances personal may know the identity of the subject
information will be shared, by whom and with whom aking telephone calls, there is an area where privacy
m
rovides information about consumer / patient access
p and confidentiality can be maintained.
to his or her health records.
The right of the consumer / patient to access his or Prompt points
her own health record is guaranteed under most
Charters of Healthcare Rights, as well as relevant ow are breaches of privacy and
H
privacy legislation. confidentiality managed?
The organisation must develop a process by which ow does the organisation ensure privacy and
H
the consumer / patient can obtain this access, and confidentiality during handover? What about if
the details of this process should be documented and handover occurs at the bedside?
made available to the consumer / patient in a range of hat advice is given to staff regarding
W
formats and languages, and via the use of an interpreter maintaining consumer / patient modesty?
if necessary. Are staff encouraged to monitor consumer /
patient modesty?
Prompt points
hat legislation / standards / codes has
W Providing information and education /
the organisation drawn upon in drafting and training to consumers / patients, health
implementing its policy / guidelines for matters professionals and other staff
of privacy and confidentiality?
The organisation must provide documentation to inform
ow are staff made aware of the terms of the
H consumers / patients of their rights and responsibilities,
privacy and confidentiality policy / guidelines? and give consumers / patients all assistance required to
When are staff confidentiality agreements signed? understand them.
ow would a consumer / patient obtain
H Organisations developing or implementing a rights and
access to his or her health record? How is this responsibilities document should ensure:
information provided to the consumer / patient?
the language is clear and translated copies are
available as relevant to the community
March 2016 185

Criterion 1.6.2 It is of particular importance that those staff members

Consumers / patients are informed of their whose duties centre about the provision of information
and support to consumers / patients, such as social
rights and responsibilities. (continued) workers and consumer / patient liaison officers, are
aware not only of the rights accorded to consumers /
there is encouragement within the document for the
patients by a Charter of Rights, but of how its scope can
consumer / patient to ask questions
assist them in the performance of their duties.
the availability of translators and that consumers /
patients know how to access them
there be no sense that the consumer / patient is being
Prompt points
‘lectured’ and no hint that these responsibilities in any here is the organisation’s Charter of
W
way form a barrier to access to health care Rights displayed within the organisation?
Into how many different languages has it
tone of positive engagement, and encouragement
a
been translated?
of consumers / patients to see that in exercising their
rights and meeting their responsibilities, they are hen does the organisation provide consumers /
W
entering into an active partnership with the goal of patients with information about their rights
better health outcomes and responsibilities? In what form(s) is this
the provision of information via documentation and
direct explanation, and that it is noted in the ow does the organisation ensure that its staff
H
consumer / patient’s health record are able to answer questions about and discuss
the provisions of its Charter of Rights?
the consumer / patient’s understanding of the
information, as determined during discussion, or ow does the organisation inform its
H
via survey. community of the rights and responsibilities of
the consumer / patient?
A copy of the organisation’s Charter of Rights should be:
rom whom does the organisation seek
F
isplayed at reception, in waiting areas, in consulting
d
feedback about its provision of information
rooms and wards
about consumer / patient rights and
included in any information packs sent to elective responsibilities? How is this feedback
consumers / patients prior to admission documented? How is it used?
rovided on attendance or admission to
p
the organisation
Consumer / patient advocacy
iven to anyone receiving domiciliary care on the
g
first visit It is the right of the consumer / patient to access
advocacy services if required or desired, and this should
displayed upon the organisation’s website be clearly stated within the organisation’s rights and
istributed via existing partnerships with community
d responsibilities documentation; separate information
and advocacy groups pamphlets should also be provided.
s upplied to related health facilities such as nursing To ensure access to consumer / patient advocacy,
homes and hostels. organisations should:
There are various ways in which the organisation can ssist consumers / patients to access such support
a
educate and train its staff in the practical implementation services by advising that these services are available if
of its Charter of Rights: needed. Organisations are not themselves required to
provide advocacy services
copy of the organisation’s Charter should be
a
included in the employment package for new staff rovide information on local advocacy services and
p
how to contact them by telephone or via the internet,
s essions on the implications and content of such with the process facilitated by interpreters if necessary
a Charter should be included in orientation and
‘refresher’ education courses for all staff.
regularly evaluate the means by which they provide Suggested reading
information about advocacy services and consumer / World Health Organization. Patients' rights. Available from:
patient satisfaction with the process http://www.who.int/genomics/public/patientrights/en/ Viewed
s eek feedback from consumers / patients, their family 22 March 2016.
members and/or carers on the information provided. Australian Commission on Safety and Quality in Health Care.
Australian Charter of Healthcare Rights. Available from: http://
www.safetyandquality.gov.au/national-priorities/charter-of-
Prompt points healthcare-rights/ Viewed 22 March 2016.
ow does the organisation make

H Office of the Australian Information Commissioner. Australian
Privacy Principles. Available from: https://www.oaic.gov.au/
consumers / patients aware of the availability
privacy-law/privacy-act/australian-privacy-principles Viewed
of advocacy services? 22 March 2016.
hat changes, if any, have been made to
W The Department of Health, Australian Government.
the provision of information about advocacy Private Patients' Hospital Charter. Available from: http://
services as a result of consumer feedback? www.health.gov.au/internet/main/publishing.nsf/Content/
ED482F77EC304A2DCA257BF0001D4C3F/$File/PPHC%20
English%20Final%201.3.2011.pdf Viewed 22 March 2016.
Department of Health & Human Services, Victoria. Statement
The following evidence may help of rights and responsibilities for the Home and Community
to address criterion 1.6.2 Care program. Available from: https://www2.health.vic.gov.
au/ageing-and-aged-care/home-and-community-care/hacc-
Consumer / patient rights and responsibilities quality-and-service-development/quality/hacc-statement-of-
document / pamphlet, in a range of rights-and-responsibilities Viewed 22 March 2016.
appropriate languages
Staff education and training programs
on the provisions of the Charter and
their implementation
Documented process for access to health
records by consumers / patients
Evidence of dissemination of information on
consumer / patient rights and responsibilities
outside the organisation
Documented improvements made to the
systems for disseminating information on
consumer / patient rights and responsibilities
March 2016 187

Implementation
Criterion 1.6.3 a) Policy / guidelines are consistent a) Food, services, care and
with relevant legislation, standards, consideration for spiritual / cultural
The organisation meets the needs
guidelines and/or codes of needs are provided in a manner
of consumers / patients and carers
practice, and ensure that the that is appropriate to consumers /
with diverse needs and from diverse
organisation meets the needs of patients with diverse needs and/or
backgrounds.
consumers / patients and carers from diverse backgrounds.
from diverse backgrounds.
b) Translated information is
b) The organisation collects developed appropriate to
demographic data to identify the diverse needs and/or
the diverse needs and diverse diverse backgrounds of
backgrounds of the community consumers / patients.
it serves, to ensure appropriate
c) Trained interpreters are available
planning and delivery of care
and consumers / patients,
and services.
carers and staff are informed
c) The organisation enters into of the availability.
partnerships with relevant local
d) Staff are provided with the
and community-based bodies, in
opportunity for training to enhance
order to support the delivery of
their skills in the planning and
care and services to those with
delivery of appropriate services to
diverse needs and/or from
with diverse needs and/or from
d) Staff are educated about and diverse backgrounds.
have access to information and
e) Feedback is sought from
resources regarding consumers /
consumers / patients, carers and
patients and carers with
the wider community regarding
the organisation’s provision of
care and services to those with

A healthcare organisation's community is comprised of The organisation’s responsibility to provide care and
many diverse groups, whose needs must be met during services to those consumers / patients with diverse
the delivery of health care. This criterion outlines how needs, and from diverse backgrounds, must be
an organisation can fulfil its obligation to provide for the met in terms of both its physical environment and
diversity of the community it serves. its communication. Consumers / patients and, in
some cases, their carers must be able to access
the organisation, and to locate the required services
(Criterion 3.2.2). They must understand their rights and
responsibilities (Criterion 1.6.2), understand and give
informed consent to their treatment (Criterion 1.1.3)
and, where appropriate, participate in the planning and
delivery of their care (Criterion 1.1.2). The organisation,
a) T
he organisation evaluates a) The organisation shows distinction a) The organisation demonstrates
whether the diverse needs of in its provision of services for those it is a leader in service delivery,
consumers / patients and their with diverse needs and/or from consultation and participation
carers are met, and strategies diverse backgrounds. strategies that meet the
for improvement are implemented requirements of consumers /
as required. patients and carers with
diverse needs and from
b) D
ata on utilisation of health
services by people with diverse
needs and/or from diverse
backgrounds are collected and
maintained to monitor access,
which is improved as required.
c) The organisation evaluates its
partnerships with relevant local
and community-based bodies,
and improvements are made as
required to support the delivery
of care and services to meet the
diverse needs of consumers /
patients and their carers.
d) Feedback from consumers /
patients, carers and community
informs the organisation’s
evaluation of the care and
services provided to those
with diverse needs and/or from
in turn, must understand the community that it is This criterion requires healthcare
servicing, and supply all necessary information about its organisations to:
services (Criterion 1.2.1).
Create and maintain a culturally competent workplace.
Identify the diverse needs and diverse backgrounds of
the community they serve.
eet the needs of consumers / patients from
M
eet the needs of consumers / patients with
M
diverse needs.
Provide information, education and training for staff.
March 2016 189

Criterion 1.6.3 s trive for the creation of a culturally competent

The organisation meets the needs of working environment
consumers / patients and carers with diverse implement processes and practices that foster
needs and from diverse backgrounds. inclusiveness and establish the progression of learning
(continued) about diversity and differences and their impact on
the way services are delivered, received, accessed
and promoted.
Creating and maintaining a culturally
competent workplace Identifying the needs of consumers /
Equal opportunity and freedom from discrimination patients from diverse backgrounds
on the basis of age, race, religion, gender, sexual
orientation and disability are basic human rights. Within Frequent international travel has become common for
the healthcare system, this translates to an obligation people in the industrialised regions of the world. There is
to create an environment where recognition of diversity a constant stream of people travelling to other countries
is embedded within the culture of the organisation and on business trips and as tourists, sometimes settling in
where all consumers / patients, whatever their individual those countries as expatriates, even if just for a short
circumstances, receive equality of care. time. In addition immigrants and refugees will add to
the mix of cultural diversity in many countries. This
Diversity is a broad concept that refers to the various movement of people has implications for individual and
qualities that define the individual and exist across society population health.
as a whole. It includes characteristics or factors such as:
The prevalence of diseases often differs between
age cultures, with respect to exposure to disease, migration
race trajectories, living conditions and genetic predispositions.
Language and cultural differences, along with lack of
ethnicity familiarity with preventive care and fear and distrust
language of a new healthcare system, can impair access to
appropriate healthcare services; certain barriers can
gender
exist that may interfere with the provision of health care
sexual orientation to the members of these communities.
religion To identify the needs of consumers / patients from
diverse backgrounds, organisations should understand
beliefs
the barriers that may exist. These include:
family
ifferent culturally-based concepts of health and
d
social structure illness which may affect the understanding of
ability, including disability treatment and the impact of compliance
socioeconomic level lack of familiarity with the local health system, which
a
may be very different from health services in the
educational attainment country of origin
personality lack of understanding of consumer / patient rights
a
marital and parental status and responsibilities
general life and work experience lack of proficiency in the common language of the
a
country / organisation, which impacts on the ability to
status within the general community.
access and communicate with healthcare providers
Organisations should: lack of confidence, which may hinder effective
a
participation in healthcare planning and evaluation
recognise that each person is a unique and complex
being, which is integral to understanding and
responding effectively to healthcare needs at an
individual, family or community level
language and cultural barriers, which may prevent v aluing families, carers and volunteers for the
the understanding required for informed consent to contribution they make towards meeting the support
medical / surgical procedures, and which have serious needs of children and adults with diverse needs
medico-legal implications
eveloping more effective strategies to respond to
d
s erious ongoing physical and mental health issues the increasing demand for diverse needs care within
as a result of a history that includes past trauma, the community
including torture, refugee experiences and/or
eveloping community partnerships in order to create
d
confinement to prisons or camps.
opportunities for education of people with diverse
needs, and providing training for staff working with
Meeting the needs of consumers / patients people who have diverse needs
with diverse needs
orking in partnership with community groups in rural /
w
Organisations should plan to accommodate for the full regional / urban areas (as applicable) to improve
spectrum of diverse needs. This may mean: accessibility for, and encourage the inclusion of,
s little as providing a nutritionally-balanced vegetarian
a people with diverse needs within those communities
meal for a vegetarian consumer / patient and as much v aluing spiritual, cultural and community
as facilitating the particular rituals that are associated supports already in place whilst identifying further
with birth or death in certain cultures support opportunities.
recognising the role played by health beliefs, not only Those individuals whose personal condition or situation
health practices. Other specific cultural considerations makes it difficult for them fully to participate in their own
that may impact upon the successful provision of health care are said to have special needs. The personal
services are the management of personal hygiene condition or situation may be:
issues, and the availability of appropriate spiritual care
poor literacy
roviding access to an interpreter service for people
p
with limited language proficiency and for the hearing- affected by trauma
impaired. The use of interpreters in health care should affected by medication / drugs
be considered in all situations where communication
age (either very young or very old / frail)
is essential.
a disability.
Some of the key areas that organisations should
address when providing for people with diverse needs There are many different types of disability. A disability
and their families / carers include: can be caused by a genetic condition, an illness or an
accident, and may mean that the individual in question
improving access to all aspects of the organisation’s
has special needs. Disability may include:
support structure (physical environment,
communication, interpreter services, education, direct intellectual disability
care services, follow-up)
physical disability
ot relying upon family members or other non-
n
sensory disability
professional individuals to facilitate communication
with consumers / patients with a limited proficiency in acquired brain injury
language or a hearing impairment
neurological impairment
nabling support to be provided early, and responding
e
mental illness
to people’s individual needs as well as to the needs of
their families / carers ual disability / co-morbidity (i.e. one of the above and
d
a psychiatric disability), also known as dual diagnosis;
nsuring that care and services enable and empower
e
this often refers to a person with a mental illness and a
people with diverse needs, so that they can
drug or alcohol addiction
participate in, and be comfortable with, their own
health care and make informed choices
March 2016 191

Criterion 1.6.3 Providing information, education

The organisation meets the needs of and training
consumers / patients and carers with diverse Apart from providing a formal interpretation service,
needs and from diverse backgrounds. the organisation should encourage, and provide the
(continued) resources and time for, staff to undergo further training
in order to enhance their ability to provide care for a
disabilities that are unrelated to ageing diverse consumer / patient base. Furthermore, the
organisation may wish to consider the recruitment of
any combination of the above.
bilingual staff, which should also be done with reference
Alternative modes of communication may need to be to the community demographic, with the goal of
sought for those with vision, speech, language, hearing facilitating effective and responsive care.
and cognitive impairments. Care should be taken to
Various options exist for providing culturally and
focus on the consumer / patient’s overall health, and not
linguistically diverse consumers / patients with the
just on factors relating to their disability.
required information, such as fact sheets in a variety
of languages, including for the hearing-impaired; the
languages into which the text is translated should reflect
Prompt points the demographic served by the organisation.
ow does the organisation identify the
H
different groups (other cultural and linguistic
groups and/or diverse needs) for which it needs The following evidence may help to
to provide targeted services? address criterion 1.6.3
ow are other cultural and linguistic groups and
H Policy that fulfils legislative requirements
diverse needs consumers / patients involved in Staff training programs
the decision making process?
Pre-admission information
ow many different language groups are
H
serviced by the organisation’s interpreter Disability and multicultural signage
service? How did the organisation determine to Availability of information in appropriate
provide support in these languages? languages, and for the sight- and
ow often does the organisation reassess the
H hearing-impaired
demographic of the community that it serves? Evidence of access and use of interpreter
How is this carried out? services by consumers / patients
ow does the organisation determine whether
H Evaluation of interpreter services
the services it provides for its other cultural and
linguistic groups and diverse needs consumers / Evaluation of demographic information
patients are appropriate? Evidence of community partnerships
ith what community groups does the
W
organisation interact in order to best meet the
needs of its other cultural and linguistic groups
and diverse needs consumers / patients?
ow does the organisation foster a greater
H
cultural awareness and better provision of
services for culturally and linguistically diverse
consumers / patients by its staff?
ow does the organisation facilitate
H
communication with special needs
consumers / patients?
Suggested reading
Australian Institute of Health and Welfare / Australian
Institute of Family Studies / Australian Government. Cultural
competency in the delivery of health services for Indigenous
people. Available from: http://www.aihw.gov.au/uploadedFiles/
ClosingTheGap/Content/Our_publications/2015/ctgc-ip13.pdf
The Quarterly, The Royal Australasian College of Medical
Administrators. Cultural Competence for Medical Administrators
in Australia and New Zealand: Position Paper. Available from:
http://racma.edu.au/index.php?option=com_docman&task=doc_
download&gid=1515 Viewed 22 March 2016.
Queensland Health. Five cross cultural capabilities for
clinical staff. Available from: https://www.health.qld.gov.au/
multicultural/health_workers/CCC-clinical.pdf Viewed 22
March 2016.
The Benevolent Society. Supporting older people
from culturally and linguistically diverse backgrounds.
Available from: http://www.benevolent.org.au/~/
media/807D20FDC1E308806DB3B065E642FA6E.ashx
Multicultural Mental Health Australia. Cultural awareness tool:
Understanding cultural diversity in mental health. Available
from: http://www.mhima.org.au/pdfs/Cultural_aware_tool.pdf
Ethnic Disability Advocacy Centre (EDAC). National disability
strategy: focusing on CaLD people with disabilities. Perth
WA; EDAC; 2008. Available from: http://www.edac.org.au/
pubattach/08decnds.pdf Viewed 22 February, 2016.
National Health and Medical Research Council (NHMRC).
Cultural Competency in health: A guide for policy, partnerships
and participation. Available from: https://www.nhmrc.gov.au/
guidelines-publications/hp19-hp26 Viewed 22 February 2016.
Panayiota Romios, Tony McBride, Jackie Mansourian.
Consumer participation and culturally and linguistically diverse
communities: a discussion paper. Available from: http://
www.healthissuescentre.org.au/images/uploads/resources/
Consumer-participation-and-CALD-communities-discussion-
paper.pdf Viewed 22 February 2016.
NSW Health. Policy Directive: Interpreters - standard procedures
for working with health care interpreters. Available from: http://
www0.health.nsw.gov.au/policies/pd/2006/pdf/PD2006_053.
pdf Viewed 22 February 2016.
National Ethnic Disability Alliance (NEDA). This Is My Home
- Belonging, Disability and Diversity. Available from: http://
www.culturaldiversity.net.au/research/research-documents/
doc_view/52-microsoft-word-this-is-my-home-august-2009-
final.html Viewed 22 February 2016.
March 2016 193

SECTION 6 Glossary
Definitions in this glossary are for use in the context of the ACHS EQuIP6 standards, criteria, elements
and guidelines.
access the various pathways and processes via which the consumer / patient may enter the health
system and obtain required services
accessibility the ability of consumers / patients or potential consumers / patients to obtain required or
available services when needed within an appropriate time
accountability responsibility and requirement to answer for tasks or activities. This responsibility may not be
delegated and should be transparent
accreditation a public recognition by a healthcare accreditation body of the achievement of accreditation
standards by a healthcare organisation, demonstrated through an independent external peer
assessment of that organisation’s level of performance in relation to the standards
advance care instructions that consent to, or refuse, specified medical treatments. It becomes effective in
plan / directive situations where the consumer / patient is no longer able to make their own treatment decisions
Advanced in the context of EQuIP6:
Completion in
an opportunity for an organisation to promptly address outstanding issues to achieve an
60 days survey
acceptable level of performance within 60 days from an EQuIP survey date.
(AC60)
may be offered to an organisation in up to four criteria in order to address:
high priority recommendations (HPRs), and/or
an SA rating in mandatory criteria, and/or
an SA rating in non mandatory criteria
admission the point in the care journey at which an organisation acknowledges a consumer / patient as
a client, and accepts responsibility for his or her care; in some contexts, the term ‘registration’
may be used rather than admission. The point at which admission is considered to have
occurred, and the processes by which it happens, varies considerably according to the nature
of an organisation.
in the first instance, admission refers to the administrative process by which an individual’s
details are entered into the organisation’s systems so that the care journey may begin.
However, it is important to recognise that, depending upon the nature and sector of the
organisation, admission does not necessarily require the provision of accommodation, or
access to a specific facility
adverse event an incident that results in harm to a consumer / patient, where harm includes disease, injury,
suffering, disability and death
adverse reaction unexpected harm arising from a justified treatment
agreement a mutual arrangement describing the scope for cooperative ventures between parties and
documenting relevant responsibilities
analysis breakdown of the essential features into simple elements, such as a summary, outline or
identification of the essence of an issue
antimicrobial a chemical substance that inhibits or destroys bacteria, fungi or parasites. These include
antibiotics, antivirals and disinfectants
appropriate a service that is consistent with a consumer / patient’s expressed requirements and is
provided in accordance with current best practice
in the context of EQuIP6: is suitable, or fitting, to do
appropriateness doing what is necessary, and not doing what is not necessary. Occurs when consumers /
patients receive appropriate and necessary care, interventions and services in the most
appropriate setting
artificial nutritional parenteral and/or enteral nutrition therapy
support
(parenteral nutrition: intravenous administration of nutrients into a central or peripheral vein;
enteral nutrition: feeding provided through the gastrointestinal tract via a tube, catheter, or
stoma that delivers nutrients distal to the oral cavity)
as required as an action becomes necessary
assessment a process by which the characteristics and needs of consumers / patients, groups or
situations are evaluated or determined so that they can be addressed. Assessment forms the
basis of a plan for services or action. While assessment may be known by different names
and occurs in a broad variety of contexts, such as triage in an emergency department,
comprehensive assessment by an Aged Care Assessment Service, or screening and intake
by a community health or outreach service, the process remains consistent and as defined
above
at-risk consumer / a consumer / patient characterised by high risk or susceptibility (as to disease) or event e.g.
patient falls
benchmarking the continuous measurement of a process, product, or service compared to those of the
toughest competitor, to those considered industry leaders, or to similar activities in the
organisation in order to find and implement ways to improve it. One of the foundations of
both total quality management and continuous quality improvement. Internal benchmarking
occurs when similar processes within the same organisation are compared. Competitive
benchmarking occurs when an organisation’s processes are compared with best practices
within the industry. Functional benchmarking refers to benchmarking a similar function or
process, such as scheduling, in another industry
blood homologous and autologous whole blood
blood component fresh blood components including red cells, platelets, fresh frozen plasma, cryoprecipitate and
cryodepleted plasma
blood products plasma derivatives and recombinant products
business plan the current action plan for achieving organisation goals
by-laws rules, regulations or legislation adopted by the organisation for the regulation of both its
internal and external affairs
March 2016 195

SECTION 6 Glossary
care plan the documentation of items agreed to in a care planning process. This should include:
the date of development
participants in the development of care plan
consumer / patient-stated and agreed issues or problems
consumer / patient-stated and agreed goals
agreed actions and the name of the person or service responsible for each action
timeframe for attaining goals and actions
planned review date
consumer / patient acknowledgement of the care plan (signed or verbal)
actual review date
carers / support people who provide unpaid care and support to family members and friends who have a
persons disability, mental illness, chronic condition, terminal illness or who are frail. Carers include
parents and guardians caring for children
change the process of managing the effective implementation of organisational strategies, ensuring
management that permanent changes in goals, behaviours, relationships, processes and systems are
achieved to the organisation’s advantage
clinical audit a systematic independent examination and review to determine whether actual activities and
results comply with planned arrangements
clinical the process of translating data on diseases, conditions, injuries and interventions from a
classification consumer / patient record into a coded format using a relevant classification system
clinical the system by which the governing body, managers and health professionals share responsibility
governance and are held accountable for consumer / patient care, minimising risks to consumers / patients
and for continuously monitoring and improving the quality of clinical care
clinical handover the transfer of professional responsibility and accountability for some or all aspects of care
for a consumer / patient, or group of consumers / patients, to another person or professional
group on a temporary or permanent basis.
clinical indicator a measure of the clinical management and/or outcome of care that should screen, flag or
draw attention to a specific clinical issue. Clinical indicators identify the rate of occurrence of
an event and are used to assess, compare and determine the potential to improve care
clinical pathway sometimes called a care map, a consumer / patient management tool that organises,
sequences and times the major consumer / patient care activities and interventions of the
entire interdisciplinary team for a consumer / patient with a particular diagnosis or procedure
code of practice a published document that sets out commonly agreed sets of guidelines and informs all
parties of responsibilities and expectations under the code. Codes of practice can be:
v oluntary agreements where a group of companies or an industry sector agree to abide by
a particular code
uasi-regulation where the code may be developed by industry in cooperation
q
with government
o-regulation where the code describes required performance or behaviour or specifies
c
acceptable means of meeting broader performance-based obligations and there are
penalties for non-compliance with the code
community a group of people who share a common interest or background (e.g. cultural, social, political,
economic, health), which may also be, but is not necessarily, geographic
competence a guarantee that an individual’s knowledge and skills are appropriate to the service provided
and an assurance that the knowledge and skill levels are regularly evaluated
complaint expression of a problem, an issue, or dissatisfaction with services that may be verbal or
in writing
conditional survey in the context of EQuIP6:
an additional survey that is undertaken one year following an Organisation-Wide Survey or a
Periodic Review during which issues have been identified as needing to be addressed rapidly.
A recommendation for a Conditional Survey is made for issues for which a 60 day framework
is too short to achieve the level of change required, and provides the organisation with an
opportunity to address issues that require some time and resources in order to achieve an
acceptable level.
a Conditional Survey may be offered to an organisation in up to two criteria in order
to address:
High Priority Recommendations (HPRs), and/or
a SA rating in mandatory criteria
in addition, a Conditional Survey may be offered to an organisation in order to address:
LA/SA ratings in between six and 11 non-mandatory criteria
confidentiality guaranteed limits on the use and distribution of information collected from individuals
or organisations
consent, in the absence of a completed consent form, an acknowledgement of consent in the health
acknowledgement record, signed by the consumer / patient and the treating health professional, stating that the
of proposed treatment, the benefits and risks and any costs involved have been explained to the
consumer / patient
consent, informed a process of communication between a consumer / patient and their health professional that
results in the consumer / patient’s authorisation or agreement to undergo a specific medical
intervention. This communication should ensure the consumer / patient has an understanding
of all the available options and the expected outcomes such as the success rates and/or side
effects for each option
March 2016 197

SECTION 6 Glossary
consumer / a person, however titled, who makes either direct or indirect use of health services; that is,
patient a current or potential user of the health system, and/or their carer(s). This encompasses
consumers / patients receiving health care from a health professional, those with specific
health needs, or who may at some time have them, and those who have a general interest
in the health system and health funding. Many consumers / patients also have an indirect
influence upon the health system in the capacity of taxpayers
consumer / patient the process of involving consumers / patients and the community meaningfully in decision
participation making about their own health care, health service planning, policy development, setting
priorities and quality issues in the delivery of services
continuity of care the ability to provide uninterrupted, coordinated care or services across programs,
practitioners, organisations and levels over time
contract a mutual agreement between two or more competent parties that creates a legally
supportable obligation to do or not do something specified
coordinate to bring together in a common, ordered and harmonious action or effort
corporate the processes by which the organisation is directed, controlled and held to account. It
governance encompasses the systems, processes and arrangements by which authority, accountability,
stewardship, leadership, direction and control are exercised in an organisation. It influences
how objectives are set and achieved, how risk is monitored and assessed and how
performance is optimised
credentialing the formal process used to verify the qualifications, experience, professional standing and
other relevant professional attributes of health professionals for the purpose of forming a view
about their competence, performance and professional suitability to provide safe, high quality
health care and services within specific organisational environments
credentials documentation that an individual’s knowledge, skills, competence and qualifications comply
with specific requirements
criteria specific steps to be taken or activities to be done, to reach a decision or a standard
cultural the processes and practices implemented by an organisation that foster inclusiveness and
competence establish the progression of learning about diversity and differences, and their impact on
the way services are delivered, received, accessed and promoted. In the context of health
care, cultural competence focuses on the capacity of the organisation to improve health and
wellbeing for the individual and the community by integrating culture into the delivery of health
services
culture, the prevailing pattern of beliefs, attitudes, values and behaviours within an organisation
organisational
current an approach that has been shown to produce superior results, selected by a systematic
best-practice process, and judged as exemplary, or demonstrated as successful. It is then adapted to fit a
particular organisation
data unorganised facts from which information can be generated
data collection a store of data captured in an organised way for a specific defined purpose
data integrity accuracy, consistency and completeness of data
data security protection of data from intentional or unintentional destruction, modification or disclosure
defining the scope the process that follows on from the credentialing of health professionals which involves
of clinical practice delineating the extent of, and limits to, an individual’s clinical practice within a particular
organisation based on that individual’s credentials, competence, performance and
professional suitability, and the needs and the capability of the organisation to support the
individual’s scope of clinical practice
delegation the devolution of authority appropriate to individual roles and responsibilities within an
organisation for the operation of clinical and non-clinical services. A formal delegation system
ensures that clear lines of accountability exist, particularly where temporary delegations are
enacted
deteriorating a consumer / patient with worsening of pre-existing symptoms or the onset of an acute
consumer / condition. Applies to any consumers / patients receiving medical, surgical, maternity or
patient mental health care and is determined by observing and documenting changes in their clinical
circumstances. This includes both the absolute change in physiological measurements and
abnormal observations, as well as the rate of change over time for an individual
disaster recovery a set of pre-determined procedures that provides for substitute operations and a quick return
to normal after any disruption
discharge the release of a consumer / patient from care or movement of a consumer / patient from one
healthcare organisation to another
diverse the breadth of social, economic and cultural factors that influence an individual consumer /
background patient’s experience and perspective. This encompasses culturally and/or linguistically diverse
backgrounds
diverse needs the range of consumer / patient needs that may be found within the community that an
organisation serves, and which may form a barrier to health care if not addressed by the
organisation in meeting its duty of care. Such needs may be cultural, physical, linguistic,
economic or health-status related
document control a planned system for controlling the release, change and use of important documents within
system an organisation, particularly policies and procedures. The system requires each document
to have a unique identification, to show dates of issue, updates and authorisation. Issue
of documents in the organisation is controlled and all copies of all documents are readily
traceable and obtainable
education systematic instruction and learning activities to develop or bring about change in knowledge,
attitudes, values or skills
effective producing the desired result
effectiveness care, intervention or action that is relevant to the consumer / patient’s needs and based on
established standards. This care, intervention or action achieves the desired outcome
efficiency achieving desired results with the most cost-effective use of resources
electronic records a record on electronic storage media that is produced, communicated, maintained
and/or accessed by means of electronic equipment. An Electronic Health Record (EHR) is
a repository of information regarding the health status of a consumer / patient, in computer
processable form
March 2016 199

SECTION 6 Glossary
elements in the context of EQuIP6:

identify what should be in place to achieve the criterion at a certain rating level: a description
of what is required to achieve the criterion. These provide prompts for improvement and
best practice
employee a proven strategy for assisting staff members and their families with personal and work-
assistance related problems, difficulties and concerns which they may experience from time to time and
program can affect work performance
end-of-life care a quality management approach that evaluates the individual holistic needs of a consumer /
patient, their families and carers, and coordinates appropriate care. It recognises the
interdependent physical, social, emotional, cultural and spiritual aspects of care and includes
the combination of broad health and community services that care for a person at the end of
their life
entry a process by which a consumer / patient comes into a healthcare organisation to
receive services
environmental development that meets the needs of the present without compromising the ability of future
sustainability generations to meet their own needs. The ability to maintain the balance between non-living
organisms and resources, such as water, timber and solar energy, and living organisms such
as humans, animals and plants
error unintentionally being wrong in conduct or judgement. Errors may occur by doing the wrong
thing (commission) or by failing to do the right thing (omission)
ethics acknowledged set of principles which guide professional and moral conduct
evaluation assessment of the degree of success in meeting the goals and expected results (outcomes)
of the organisation, services, program or consumers / patients
evidence data and information used to make decisions. Evidence can be derived from research,
experimental learning, indicator data, and evaluations. Evidence is used in a systematic way
to evaluate options and make decisions
evidence based the use of systematically reviewed, appraised clinical research findings to aid the delivery of
optimum clinical care to consumers / patients; the transfer of knowledge from research into
healthcare practice
feedback a communication from a consumer / patient relaying how delivered products, services and
messages compare with consumer / patient expectations
flexible work working arrangements that assist staff members to meet personal responsibilities, such as
practices caring for a child or other family member. These may include:
changes in hours of work
changes in patterns of work
changes in location of work
follow-up processes and actions taken after a service has been completed
formalised documented processes and actions taken after a service has been completed
follow-up
governance the set of relationships and responsibilities established by a healthcare organisation between
its executive, workforce and stakeholders (including consumers). It incorporates the
processes, customs, policy directives, laws, and conventions affecting the way a healthcare
organisation is directed, administered or controlled. Governance arrangements specify the
mechanisms for monitoring performance
governing body a body that carries legal accountability and/or scope of organisational responsibility for the
services provided, such as an individual owner or a group of senior managers, a governing
body of directors, a board, a group of senior managers and/or a chief executive appointed by
a government agency
guidelines principles guiding or directing action. Clinical practice guidelines are systematically developed
statements to assist practitioner and consumer / patient decisions about appropriate health
care for specific circumstances. Guidelines in the EQuIP6 Guide provide essential information
for the achievement of the EQuIP6 standards
healthcare- infections acquired in healthcare facilities (nosocomial infections) and infections that occur as
associated a result of healthcare interventions (iatrogenic infections), and which may manifest after people
infections leave the healthcare facility
healthcare a team or individuals who, in cooperation with the consumer / patient, assume responsibility
provider for all aspects of an episode care in response to the diagnosis and needs of the
consumer / patient
health priority identified areas which contribute significantly to the burden of illness and injury, which have
areas potential for health gains and reduction in the burden of disease
health a trained healthcare provider, whether registered or non-registered, who spends the majority
professional of their time providing direct clinical care. The term encompasses medical practitioners,
nurses, dentists, paramedics and allied healthcare providers such as physiotherapists,
occupational therapists, speech pathologists, dietitians, radiographers, social workers,
psychologists, pharmacists and all others in active clinical practice, but excludes those in
training and junior practitioners who must work under supervision
health record collated data and reports describing a consumer / patient's episode of care and/or services
received from the organisation
health workforce the workforce that provides health care to consumers / patients; ranging from workers with
no formal qualifications providing support services in home-based settings through to highly
qualified specialists working in technology intensive super-acute hospital settings
high priority in the context of EQuIP6:
recommendation
a recommendation where there is an area of high risk identified by the surveying team when:
(HPR)
consumer / patient care is compromised, and/or
the safety of consumers / patients and/or staff is jeopardised.
the HPR is a trigger for the organisation to address the issue either at an AC60 or at a
Conditional Survey
home-ward outlier a consumer / patient who is being treated in an area of the organisation that normally treats
a different casemix, e.g. a consumer / patient with a medical condition such as diabetes who
may be admitted to a surgical ward due to a lack of available medical beds
iatrogenic arising from or associated with health care rather than an underlying disease or injury
March 2016 201

SECTION 6 Glossary
ICD - 10 - AM a system of codes, from a set of defined categories, which are used to categorise activity in
a consistent and systemised way: the International Classification of Diseases, 10th Revision,
Australian modification
incident an event or circumstance which could have or did lead to unintended and/or unnecessary
harm to a person, and/or complaint, loss or damage
include(s) a list that provides examples and is not limiting
indicator performance measurement tool, screen or flag that is used as a guide to monitor, evaluate,
and improve the quality of services. Indicators relate to structure, process and outcomes
infection control a documented plan that outlines the structure of an infection control program, its overall aims
management plan and objectives, associated quality management activities, program evaluation criteria and time
frames for review. The document should address the governance of infection control
and identify:
who is at risk and from what
the hazards involved
the procedures for minimising risk, and
ppropriate measures for infection control, based on standard precautions and when
a
required, additional precautions
information the process of planning, organising, analysing and controlling data and information. The
management management of information applies to both computer-based and manual systems
information the right of a person to control the use and disclosure of information that reveals their identity,
privacy health information or health status
information a system that provides access to information using hardware, software, supplies, policies,
system procedures and people
information mechanical and electronic devices designed for the collection, storage, manipulation,
technology (IT) presentation and dissemination of information
integrated an additional approach that aims to strengthen and streamline healthcare organisation
governance governance arrangements by focusing on quality as the driver of change and placing clinical
governance at the heart of governance arrangements. Considered a key building block of
good governance in health care
intervention any act performed to prevent harming of a consumer / patient or to improve the mental,
emotional or physical function of a consumer / patient
IT security a tangible set of physical and logical mechanisms which can be used to protect information
held in hard copy, computer systems and information and telecommunication infrastructure,
from unauthorised access
IT system a group of interacting, interrelated or interdependent elements forming or regarded as forming
a collective entity
leadership the ability to provide direction and cope with change. It involves establishing a vision,
developing strategies for producing the changes needed to implement the vision, aligning
people and motivating and inspiring people to overcome obstacles
legibility quality of writing, print or images that makes them easily readable / understood
legislation the body of laws made by Parliament. These consist of: Acts of Parliament; and Regulations,
Ordinances, Rules which are also called ‘subordinate’ or ‘delegated’ legislation
magnet hospital a term coined in the United States from research that sought to understand why certain
hospitals were able to attract and retain staff
management setting targets or goals for the future through planning and budgeting, establishing processes
for achieving those targets and allocating resources to accomplish those plans. Ensuring that
plans are achieved by organising, staffing, controlling and problem-solving
mandatory in the context of EQuIP6:
criterion
one where it is considered that without marked achievement (evaluation), the quality of care or
the safety of people within the organisation could be at risk
malnutrition a state of nutrition in which a deficiency or excess (or imbalance) of energy, protein, and
other nutrients causes measurable adverse effects on tissue / body form (shape, size and
composition) and function and clinical outcome
manual task a task comprised wholly or partly by any activity requiring a person to use any part of their
musculoskeletal system in performing their work. Manual tasks can include:
lifting, lowering, pushing, pulling, carrying or otherwise moving, holding or restraining any
person, animal or item
repetitive actions
sustained work postures
exposure to vibration
medication error any preventable event that may cause or lead to inappropriate medication use or consumer /
patient harm while the medication is in the control of the healthcare professional or
consumer / patient
medication the processes of dispensing, prescribing, storing, administering and monitoring the effects
management of medication
medico-legal requirements of or relating to both medicine and law
requirements
mission a broad written statement in which an organisation states what it does and why it exists. The
mission sets apart one organisation from another
monitor to check, supervise, observe critically, measure or record the progress of an activity, action or
system on a regular basis in order to identify change and/or track change
morbidity a diseased state or symptom or the incidence of disease: the rate of sickness in a specified
community or group
mortality the number of deaths in a given time or place or the proportion of deaths in a
given population
multidisciplinary care or a service given with input from more than one discipline or profession
National Chronic the overarching framework of national direction for improving chronic disease prevention
Disease Strategy and care across Australia. A nationally agreed agenda to encourage coordinated action
in response to the growing impact of chronic disease on the health of Australians and the
healthcare system
March 2016 203

SECTION 6 Glossary
near miss an incident that did not cause harm, but had the potential to do so
needs physical, mental, emotional, social or spiritual requirement for wellbeing. Needs may or may
not be perceived or expressed by those in need. They must be distinguished from demands,
which are expressed desires, not necessarily needs
non-clinical information that is not direct, personal consumer / patient information
information
non-surgical wounds that may arise following admission to a health service and only whilst the consumer /
wounds patient is in hospital. This encompasses pressure ulcers, or ulcers that may develop by other
means; skin tears, caused by friction and/or tearing; skin infections, etc. This does not include
wounds that would be the purpose of the admission, such as burns, wounds related to
cancers, radiation injuries, gravel rash, etc., as these would be covered under normal treatment
nutritional care interventions, monitoring, and evaluation designed to facilitate appropriate nutrient intake
based upon the integration of information from the nutrition assessment
nutrition a comprehensive approach to gathering pertinent data in order to define nutritional status and
assessment identify nutrition-related problems. The assessment often includes consumer / patient history,
medical diagnosis and treatment plan, nutrition and medication histories, nutrition related
physical examination including anthropometry, nutritional biochemistry, psychological, social,
and environmental aspects
nutrition screening the process of identifying consumers / patients with characteristics commonly associated with
nutrition problems who may require comprehensive nutrition assessment and may benefit
from nutrition intervention
objective a target that must be reached if the organisation is to achieve its goals. It is the translation of
the goals into specific, concrete terms against which results can be measured
ongoing care the active and supportive management of care for people with chronic or complex conditions
as well as the process that follows an admission to a healthcare organisation
open disclosure the open discussion of incidents that resulted in harm to a consumer / patient while receiving
health care. The criteria of open disclosure are an expression of regret and a factual
explanation of what happened, the potential consequences and the steps being taken to
manage the event and prevent recurrence
operational plan a short-term plan that details how aspects of a strategic plan will be accomplished
organisation all sites / locations under the governance of, and accountable to, the governing body / owner(s)
orientation a formal process of informing and training staff on entry into a position or organisation,
covering the policies, processes and procedures applicable to that healthcare organisation
outcome results that may or may not have been intended that occur as a result of a service
or intervention
palliative care plan a written statement developed for a consumer / patient who is suffering from a life limiting
illness, with little or no prospect of a cure, and for whom the primary treatment goal is quality
of life, which states the nursing and other interventions to be undertaken, the health outcomes
to be achieved and the review of care which will occur at regular intervals
pathway a multidisciplinary plan of care that commences before or on admission and finishes
at discharge
patient master permanent listing or register of health information held by an organisation on consumers /
index patients who have received or are scheduled to receive services
personal information or an opinion (including information or an opinion forming part of a database),
information whether true or not, and whether recorded in a material form or not, about an individual
whose identity is apparent, or can reasonably be ascertained, from the information or opinion
policy written statement(s) which acts as a guideline and reflects the position and values of the
organisation on a given subject. All procedures and protocols should be linked to a
policy statement
pressure ulcer a localised injury to the skin and/or underlying tissue, usually over a bony prominence and
caused by unrelieved pressure, friction or shear. Pressure ulcers occur most commonly on the
sacrum and heel but can develop anywhere on the body
prevention and a systematic approach adopted by all sections of an organisation to ensure appropriate
management identification and actions for consumers / patients at risk of an illness or condition
procedure a set of documented instructions conveying the approved and recommended steps for a
particular act or sequence of acts
process a series of actions, changes / functions that bring about an end or a result
psycho-social pertaining to a combination of psychological and social factors
quality activities activities which measure performance, identify opportunities for improvement in the delivery of
care and services, and include actions and follow-up
quality framework an overarching approach to quality improvement that promotes integration of risk
management with quality improvement strategies and informs decision making and planning
quality ongoing response to quality assessment data about a service in ways that improve the
improvement processes by which services are provided to consumers / patients
quality use of the judicious, appropriate, safe and effective use of medicines
medicines
records field of management responsible for the efficient and systematic control of the creation,
management receipt, maintenance, use and disposition of records
record storage the function of storing records for future retrieval and use
recruitment and process used to attract, choose and appoint qualified staff
selection
referral the process of directing or redirecting a consumer / patient to an appropriate specialist or
agency for definitive treatment
relevant when something is connected with a matter; when there is a logical connection
research an active, diligent and systematic process of inquiry in order to discover, interpret or revise
facts, events, behaviours, or theories, or to make practical applications with the help of such
facts, laws or theories
March 2016 205

SECTION 6 Glossary
risk the effect of uncertainty on objectives which may be positive and/or negative. Objectives can
have different aspects, such as financial, health and safety, and environmental goals and can
apply at different levels, such as strategic, organisation-wide, project, product and process.
Risk is often expressed in terms of a combination of the consequences of an event and the
associated likelihood of occurrence
risk management coordinated activities to direct and control an organisation with regard to risk, such as
activities that identify, control and minimise threats to the ongoing efficiency, effectiveness and
success of its operations to deliver desired outcomes
risk management a set of components that provide the foundations and organisational arrangements for
framework designing, implementing, monitoring, reviewing and continually improving risk management
throughout the organisation. The framework should be embedded within the organisation’s
overall strategic and operational policies and practices
root cause a systematic process whereby the factors which contributed to an incident are identified
analysis
sample blood collected from a consumer / patient for purposes of blood or blood product /
component transfusion / infusion
sampling the collection of a sample from a consumer / patient
scope of clinical delineating the extent of an individual health professional’s clinical practice within a
practice particular organisation, based on the individual’s credentials, competence, performance and
professional suitability, and the needs and the capability of the organisation to support the
medical practitioner’s scope of clinical practice. This occurs after the process of credentialing
sentinel event an unexpected occurrence involving death or serious physical or psychological injury, or
the risk thereof. Serious injury specifically includes loss of limb or function. The phrase
“or the risk thereof” includes any process variation for which a recurrence would carry a
significant chance of a serious adverse outcome. Such events signal the need for immediate
investigation and response
services products of the organisation delivered to consumers / patients; units of the organisation that
deliver products to consumers / patients
skill mix the mix of posts, grades or occupations within an organisation. It may also refer to the
combinations of activities or skills needed for each job within the organisation
specialty ward an area of an organisation that normally treats consumers / patients with a specific casemix,
area for example, an orthopaedic ward, a paediatric ward, a maternity ward, etc
staff term which includes employed, visiting, sessional, contracted or volunteer personnel
staff development the process by which staff gain new skills or extend existing skills or qualifications
stakeholders individuals, organisations or groups that have an interest or share in services
standard a desired and achievable level of performance against which actual performance is measured
statutory any requirement laid down by an act of parliament
requirement
strategic plan a formalised plan that establishes an organisation’s overall objectives and that seeks to
position the organisation in terms of its environment
strategy a long-term plan of action designed to achieve a particular objective
surveillance the ongoing, systematic collection, analysis and interpretation of health-related data essential
to the planning, implementation and evaluation of public health practice, closely integrated
with the timely dissemination of these data to those responsible for prevention and control
survey in the context of EQuIP6:
external peer review which measures the performance of the organisation against an agreed
set of standards
system the resources, policies, processes and procedures that are organised, integrated, regulated
and administered to accomplish an objective
tracking creating, capturing and maintaining information about the movement and use of records
training the delivery of specialised education to develop practical skills related to the professional
development needs of the individual and organisation and which may be incorporated into
professional development programs
unique identifier universal number or code that uniquely identifies a person or other discrete entity
validate to make sound, ratify, confirm, substantiate or to give legal force to. Validity deals with the
relationship of the data obtained to the purpose for which it was collected, or measures what
it seeks to measure
values principles and beliefs that guide an organisation and may involve social or ethical issues
vision description of what the organisation would like to be
waiting list a register which contains essential details about consumers / patients who have been
assessed as needing elective care
when required required at the time
where required required in certain circumstances
March 2016 207

March 2016 209
Safety
Quality
Performance
Enquiries regarding EQuIP6, other ACHS accreditation

programs and program education and support should
be directed to:
The Australian Council on
Healthcare Standards (ACHS)
5 Macarthur Street
Ultimo NSW 2007
Australia
+61 2 9281 9955 achs@achs.org.au
+61 2 9211 9633 www.achs.org.au

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The ACHS EQuIP6 GUIDE

On behalf of the Board of Directors, it is my pleasure

Mr John Smith, PSM

Section 1 The Standards (Corporate Function) 319

ACHS and Accreditation 7 Section 8

1.1 The Australian Council on 1.2 What is accreditation?

Table 1. EQuIP6 Standards

2.2 The EQuIP criterion ratings 2.3 Mandatory criteria

Little Some Marked Extensive Outstanding

Awareness Implementation Evaluation Distinction Leadership

Table 3 may assist organisations to apply for

Achieving EA CALCULATE: the magnitude of the benefit - increased

2.6 The EQuIP accreditation cycle

3.1 Terminology and definitions  ealth professional: any professionally qualified

1 Australian Indigenous HealthInfoNet. Overview of Australian Indigenous health status 2013.

Criterion 1.1.1 a) Guidelines to direct the assessment a) Assessments are conducted

Overview Relationships of 1.1.1 with other criteria

Criterion 1.1.1 Reassessment should occur at regular intervals, and

 e timely; policy should direct what is considered

Criterion 1.1.1 Planning for transfer of care / discharge

Overview Relationships of 1.1.2 with other criteria

Criterion 1.1.2 Effective planning, delivery and coordination of care may

The care plan or clinical pathway may include:

 hen are case conferences used to coordinate

Criterion 1.1.2 Consumers / patients may require education to

identifying options available, evidence of their efficacy

Criterion 1.1.3 a) Policy / guidelines addressing a) Consent is obtained for

Overview  onsent for collection of health information, and to

Relationships of 1.1.3 with other criteria This criterion requires healthcare

Criterion 1.1.3 s ituations where procedures, care and treatment

Criterion 1.1.3  here information may affect employment

3. Can the person make a judgment based on

Criterion 1.1.4 a) Policy / guidelines addressing a) There is governance / committee

Overview Relationships of 1.1.4 with other criteria

the deteriorating consumer / patient may be regarded as Record consumer / patient

Criterion 1.1.4 Identify and manage clinical deterioration

Criterion 1.1.4 Staff training in first aid, basic life support

 olicy / guidelines on management of

Criterion 1.1.5 a) Policy / guidelines addressing a) There is an effective, organisation-

Overview Relationships of 1.1.5 with other criteria

• diagnoses and current condition of the between services or levels of care

The key issues to be considered in the transfer of care

Criterion 1.1.5 Consumer / patient test results

Specific elements to be discussed with the consumer /

Overview Relationships of 1.1.6 with other criteria

This criterion requires healthcare Care coordination and/or case

Criterion 1.1.6 Screening, prioritisation and readmission of

Criterion 1.1.7  ow decisions are to be made regarding the

 hat policy is in place regarding organ

 hat processes does the organisation use to

Criterion 1.1.8 a) Policy / guidelines addressing a) There is a system to monitor

Overview Relationships of 1.1.8 with other criteria

Criterion 1.1.8 Good policies and systems are important, but it is

s ystems to support the allocation and maintenance of

 rocesses for tracking provision of care where

 ny alterations to handwritten notes are attributed to

1.2 Access Standard

Overview Relationships of 1.2.1 with other criteria

Criterion 1.2.1  ow the organisation will handle health information,

Providing information about relevant The following evidence may help to

 e known to staff, including where and how to access

Overview Relationships of 1.2.2 with other criteria

This criterion requires healthcare Inclusion / exclusion criteria and systems to

Criterion 1.2.2 their duty of care to, at a minimum, provide advice

1.1 The Australian Council on 1.2 What is accreditation?

3.1 Terminology and definitions ealth professional: any professionally qualified

1 Australian Indigenous HealthInfoNet. Overview of Australian Indigenous health status 2013.

Criterion 1.1.1 a) Guidelines to direct the assessment a) Assessments are conducted

e timely; policy should direct what is considered

hen are case conferences used to coordinate

identifying options available, evidence of their efficacy

Criterion 1.1.3 a) Policy / guidelines addressing a) Consent is obtained for

Overview onsent for collection of health information, and to

Criterion 1.1.3 s ituations where procedures, care and treatment

Criterion 1.1.3 here information may affect employment

3. Can the person make a judgment based on

Criterion 1.1.4 a) Policy / guidelines addressing a) There is governance / committee

olicy / guidelines on management of

Criterion 1.1.5 a) Policy / guidelines addressing a) There is an effective, organisation-

• diagnoses and current condition of the between services or levels of care

Criterion 1.1.7 ow decisions are to be made regarding the

hat policy is in place regarding organ

hat processes does the organisation use to

Criterion 1.1.8 a) Policy / guidelines addressing a) There is a system to monitor

s ystems to support the allocation and maintenance of

rocesses for tracking provision of care where

ny alterations to handwritten notes are attributed to

Criterion 1.2.1 ow the organisation will handle health information,

e known to staff, including where and how to access

Criterion 1.2.2 their duty of care to, at a minimum, provide advice

Criterion 1.3.1 a) Clinical guidelines are used to a) Service planning includes an

Criterion 1.3.1 hat backup is available if required, such as intensive

veruse, when a health service is provided even

ake use of data that would indicate either overuse

Criterion 1.4.1 a) Documented processes a) The organisation supports health

Collection of clinical indicator data

Criterion 1.5.1 a) Policy / guidelines for medication a) A multidisciplinary body oversees

anage medication risks, support error reporting and

rovide access to information and education about

Criterion 1.5.2 a) Policy / guidelines addressing infection a) T

Criterion 1.5.2 anage infection control in the general organisational

• respiratory etiquette onitor and audit compliance with policy and

• decontamination of the physical environment, include reporting to jurisdictional authorities according

• sterilisation e managed as described in policy and procedures,

construction and renovation Cleaning / sterilisation of equipment and plant should:

Criterion 1.5.2 here linen cleaning is carried out onsite, provide

Prompt points Staff immunisation records

ow does the organisation ensure that

Criterion 1.5.3 a) Policy / guidelines addressing a) Multidisciplinary wound prevention

Criterion 1.5.3 e repeated as necessary during the episode of

• appropriate referral to medical, nursing and allied Wound management should:

Criterion 1.5.3 assist consumers / patients and carers to:

Criterion 1.5.4 a) Policy / guidelines addressing falls a) A

Criterion 1.5.4 ave processes to identify, eliminate and mitigate

Criterion 1.5.4 • condition of feet and footwear

Minutes of meetings of committees / bodies