Standard 2.

1: The governing body leads the organisation in its commitment to improving performance and ensures
the effective management of corporate and clinical risks.
Criterion 2.1.1: The organisation’s continuous quality improvement system demonstrates its commitment to improving the outcomes of care and service delivery.
This is a mandatory criterion
LA - Awareness
a) Policy / guidelines addressing
continuous quality
improvement are consistent
with relevant legislation,
standards, guidelines and/or
codes of practice, support the
organisation’s vision, values and
strategic direction, and are
readily available to staff.
b) An integrated, organisation-
wide quality improvement
framework is developed,
documented and implemented.
c) Health professionals and other
staff are provided with
orientation and ongoing
education about the
organisation-wide quality
improvement framework and
their responsibilities for quality
improvement.
d) The governing body
demonstrates its commitment
to continuous quality
improvement.
SA - Implementation
a) Quality improvement is planned
and continuous, and responsive
to the risk management system
and the strategic plan.
b) Annual planning includes
identification of key quality
improvement objectives both
organisation-wide and at the
unit / department level.
c) The organisation supports
health professionals and other
staff in identifying and
responding to opportunities to
improve the quality of care and
service delivery.
d) Leaders in quality improvement
are identified and developed
across the organisation to drive
ongoing improvement.
MA - Evaluation EA - Distinction OA - Leadership
a) The effectiveness of the quality a) The organisation shows a) The organisation demonstrates
improvement framework and distinction in continuous quality it is a leader in continuous
its component activities is improvement. quality improvement.
evaluated, and improvements
are made as required.
b) Qualitative and quantitative
data are collected, analysed and
used to plan and drive
improvement.
c) Improvement strategies are
evaluated, communicated, and
where appropriate
implemented across the
organisation to ensure safe
practice and a safe
environment.
d) Health professionals, other staff
and relevant stakeholders
including consumers are
involved in the evaluation of
the quality improvement
system.
e) Outcomes of quality and safety
initiatives are reported to staff,
consumers, the community, and
the governing body.

The Australian Council on Healthcare Standards. EQuIP6 standards, criteria and elements© December 2015.
Standard 2.1: The governing body leads the organisation in its commitment to improving performance and ensures
the effective management of corporate and clinical risks.
Criterion 2.1.2: The integrated organisation-wide risk management framework ensures that corporate and clinical risks are identified, minimised and managed.
This is a mandatory criterion
LA - Awareness
a) Policy / guidelines addressing
corporate and clinical risk are
consistent with relevant
legislation, standards,
guidelines and/or codes of
practice, identify specific
strategies for managing risk,
and are readily available to
staff.
b) An integrated, organisation-
wide risk management
framework addressing
corporate and clinical risk is
developed, documented and
implemented.
c) Health professionals and other
staff are provided with
orientation and ongoing
education about the risk
management framework and
their responsibilities for
identifying and managing risk.
d) The governing body
demonstrates its commitment
to managing risk within the
organisation.
The Australian Council on Healthcare Standards. EQuIP6 standards, criteria and elements© December 2015.
SA - Implementation MA - Evaluation EA - Distinction OA - Leadership
a) There is integration between a) The corporate and clinical risk a) The organisation shows a) The organisation demonstrates
quality improvement, risk management framework is distinction in risk management. it is a leader in corporate and
management and strategic evaluated, and improvements clinical risk management.
planning. are made as required.
b) Annual planning includes the b) Risk mitigation strategies are
identification of key evaluated, and improvements
organisational risks, and are made as required.
controls to mitigate risk.
c) Health professionals, managers
c) A risk management approach is and other staff use data from
used when considering and risk management processes to
developing new and modified plan and implement
services. improvements to care and
services.
d) Risk identification and risk
analysis are undertaken using d) Outcomes of risk analysis and
qualitative and quantitative management are reported to
data and strategies are the governing body.
developed and implemented to
mitigate risk.
e) The organisation supports
health professionals and other
staff in identifying and
responding to opportunities to
mitigate risk.
f) There are processes to ensure
that timely action is taken to
mitigate risks identified by
health professionals, other
staff, consumers / patients,
carers and other visitors.
Standard 2.1: The governing body leads the organisation in its commitment to improving performance and ensures
the effective management of corporate and clinical risks.
Criterion 2.1.3: Healthcare incidents are managed to ensure improvements to the systems of care.
This is a mandatory criterion
LA - Awareness
a) Policy / guidelines addressing
incident management and open
disclosure are consistent with
relevant legislation, standards,
guidelines and/or codes of
practice, and are readily
available to staff.
b) Consumers / patients are
provided with information
about incident management
processes, including open
disclosure and how to access
advocacy support.
c) Health professionals and other
staff are provided with
orientation and ongoing
education about incident
management, their
responsibilities in incident
reporting, and open disclosure.
d) The organisation supports and
promotes the principles of open
disclosure.
The Australian Council on Healthcare Standards. EQuIP6 standards, criteria and elements© December 2015.
SA - Implementation MA - Evaluation EA - Distinction OA - Leadership
a) There is an integrated incident a) The incident management a) The organisation shows a) The organisation demonstrates
management system, which system is evaluated in distinction in incident it is a leader in incident
includes: consultation with health management. management systems and
(i) documented delineation of professionals, other staff and processes.
responsibilities relevant stakeholders including
(ii) documented lines of
communication consumers, and improvements
(iii) identification, risk rating and are made as required.
review of incidents, including
near misses b) Incidents are trended, risks are
(iv) in-depth investigation of identified, and improvements
serious incidents / sentinel are made as required.
events, including Root Cause
Analysis where necessary c) The support provided for
(v) appropriate corrective action consumers / patients, carers
(vi) support for consumers / and staff involved in incidents is
patients, carers and staff
involved in incidents evaluated, and improvements
(vii) dissemination of outcomes are made as required.
of investigations and action
taken. d) Outcomes of incidents and the
organisation’s response are
b) There are processes to guide reported to the governing body.
the immediate response to an
incident.
c) The principles of open
disclosure are evident in the
system to manage incidents.
d) Relevant health professionals,
managers and staff are trained
in incident management and
open disclosure.
e) The organisation supports the
identification and reporting of
near misses by staff, consumers
/ patients and carers.
Standard 2.1: The governing body leads the organisation in its commitment to improving performance and ensures
the effective management of corporate and clinical risks.
Criterion 2.1.4: Healthcare feedback, including complaints, is managed to ensure improvements to the systems of care.
LA - Awareness
a) Policy / guidelines addressing
feedback and complaints
management are consistent
with relevant legislation,
standards, guidelines and/or
codes of practice, and are
readily available to staff.
b) The organisation has a process
for receiving and managing
complaints, including assessing
the severity of a complaint,
which is communicated to staff.
c) Consumers / patients and
carers are informed of the
process for giving feedback or
making a complaint, including
the process for escalating
complaints and how to access
advocacy services.
d) Health professionals and other
staff are provided with
orientation and ongoing
education regarding:
(i) complaints management
(ii) consumer / patient and
carer feedback
(iii) the use of feedback and
complaints to drive
improvement.
SA - Implementation
a) There is a system for the
management of complaints,
which includes:
(i) registration of the complaint
(ii) review, including formal
review of serious complaints
(iii) response in a timely manner
(iv) support and/or advocacy for
consumers / patients, carers
and staff involved in
complaints
(v) communication of outcomes
to the complainant and
others involved.
b) Relevant staff are trained in
methods of conflict and
complaint resolution.
c) There is a system to implement
the recommendations from the
review of feedback and
complaints.
d) Feedback is sought from
consumers / patients and carers
regarding the organisation’s
management of complaints.
e) Feedback received about care
and services is made available
to staff, consumers / patients
and management.
MA - Evaluation EA - Distinction OA - Leadership
a) The complaints management a) The organisation shows a) The organisation demonstrates
system is evaluated with distinction in the management it is a leader in the management
consumer / patient and carer of feedback and complaints. of feedback and complaints.
participation, and
improvements are made as
required.
b) Complaints are trended, risks
are identified, and
improvements are made as
required.
c) The support and access to
advocacy provided for
consumers / patients, carers
and staff involved in complaints
are evaluated, and
improvements are made as
required.
d) Outcomes of feedback and
complaints management are
reported to the governing body.

The Australian Council on Healthcare Standards. EQuIP6 standards, criteria and elements© December 2015.
Standard 2.2: Human resources management supports quality health care, a competent workforce and a
satisfying working environment for staff.
Criterion 2.2.1: Workforce planning supports the organisation’s current and future ability to deliver safe, high quality care and services.
LA - Awareness SA - Implementation MA - Evaluation EA - Distinction OA - Leadership
a) Policy / guidelines / tools a) The workforce strategic plan is a) The workforce policy, plan, a) The organisation shows a) The organisation demonstrates
addressing workforce planning clearly linked to the goals and strategic direction are distinction in workforce it is a leader in planning for
and management are readily organisation’s strategic evaluated, and improvements planning. current and future workforce
available to staff. direction and goals. are made as required. requirements.

b) The organisation’s workforce b) Workforce management b) Unit / department workforce

planning ensures the skill mix of
clinical and support staff, and
reflects current and future
needs of consumers / patients
and staff.
c) Strategies are in place to ensure
safe, high quality treatment and
care if prescribed levels of skill
mix of clinical and support staff
are not available.
d) Policy / guidelines addressing
safe working hours support the
management of shift work and
fatigue, and are readily
available to staff.
functions and responsibilities
are clearly identified and
documented.
c) There are contingency plans to
manage long- and short-term
workforce shortages, including
unplanned shortages.
d) Fatigue prevention and
management strategies are
implemented.
plans are evaluated, and
improvements are made as
required.
c) Strategies for fatigue
prevention and management
are evaluated, and
improvements are made as
required.

The Australian Council on Healthcare Standards. EQuIP6 standards, criteria and elements© December 2015.
Standard 2.2: Human resources management supports quality health care, a competent workforce and a
satisfying working environment for staff.
Criterion 2.2.2: The recruitment, selection and appointment system ensures that the skill mix and competence of staff, and mix of volunteers, meets the needs of the
organisation.
LA - Awareness
a) Policy / guidelines addressing
recruitment, selection and
appointment are consistent
with relevant legislation,
standards, guidelines and/or
codes of practice, and are
readily available to staff.
b) Recruitment, selection and
appointment processes ensure
that staff and volunteers have
the necessary licences,
registration, qualifications, skills
and experience to fill their
defined roles.
The Australian Council on Healthcare Standards. EQuIP6 standards, criteria and elements© December 2015.
SA - Implementation
a) The recruitment, selection and
appointment system ensures
that the number and skill mix of
staff is commensurate with
organisational need and the
provision of safe, high quality
care.
b) The recruitment, selection and
appointment system responds
to changing service
requirements.
c) All units / departments comply
with the organisation’s
recruitment, selection and
appointment processes.
d) The volunteer recruitment
system supports an adequate
number and mix of volunteers
to provide appropriate services.
e) There is a system and program
for the orientation and
integration of all staff and
volunteers.
MA - Evaluation EA - Distinction OA - Leadership
a) The effectiveness of the a) The organisation shows a) The organisation demonstrates
recruitment, selection, and distinction in recruitment, it is a leader in recruitment,
appointment system in selection, appointment, selection, appointment,
maintaining necessary staffing orientation and integration of orientation and integration
and volunteer levels is staff and volunteers. systems.
evaluated, and improvements
are made as required.
b) Performance measures are
used to evaluate the
recruitment, selection and
appointment system, and
improvements are made as
required.
c) The orientation and integration
system is regularly evaluated,
and improvements are made as
required.
Standard 2.2: Human resources management supports quality health care, a competent workforce and a
satisfying working environment for staff.
Criterion 2.2.3: The performance management system ensures the competence of staff and volunteers.
LA - Awareness
a) Accurate and complete
personnel records, including
qualifications and completed
mandatory and non-mandatory
training, are maintained and
kept confidential.
b) Health professionals, other staff
and volunteers are provided
with a written description
outlining their position or
volunteer role, responsibilities
and accountabilities.
c) Staff comply with published
codes of professional practice
relevant to their professional
role, and the organisation’s
Code of Conduct.
d) There is a process to identify
mandatory training for health
professionals, other staff and,
where appropriate, volunteers.
e) There is an organisation-wide
process for the performance
review of all staff, including
volunteers.
f) Policy / guidelines address the
process for managing a
complaint or concern about a
health professional, including
ensuring the immediate safety
of consumers / patients.
g) Policy / guidelines address the
The Australian Council on Healthcare Standards. EQuIP6 standards, criteria and elements© December 2015.
SA - Implementation
a) The performance management
and review system ensures
that:
(i) health professionals, other
staff and volunteers are
competent and
accountable for their work
(ii) there is active participation
of both the manager and
the individual in
performance review
(iii) areas for improvement and
additional education needs
are identified
(iv) opportunities for
professional development
are identified.
b) There are processes to ensure
effective management of staff
and volunteers at unit /
department level.
c) There is a process to ensure
that professional and other
licensed staff provide verified
documentary evidence to
demonstrate their continuing
registration with the relevant
regulatory body.
d) Position descriptions including
accountabilities and
responsibilities are regularly
reviewed.
MA - Evaluation EA - Distinction OA - Leadership
a) The performance management a) The organisation shows a) The organisation demonstrates
and review system is regularly distinction in performance it is a leader in performance
evaluated with staff management. management systems.
participation, and
improvements are made as
required.
b) Evaluation is undertaken to
ensure that staff, including
contracted staff and, when
appropriate, volunteers have
participated in performance
review, and improvements are
made as required.
c) The performance review
process is evaluated to ensure
that it addresses the
competency and accountability
of staff and volunteers, and
improvements are made as
required.
d) The management of staff and
volunteers at unit / department
level is evaluated, and
improvements are made as
required.
e) The process for managing a
complaint or concern about a
health professional, including
the steps taken to ensure the
immediate safety of consumers
/ patients, is evaluated, and
improvements are made as
required.
f) The process for managing a
Standard 2.2: Human resources management supports quality health care, a competent workforce and a
satisfying working environment for staff.
Criterion 2.2.3: The performance management system ensures the competence of staff and volunteers.
LA - Awareness SA - Implementation MA - Evaluation EA - Distinction OA - Leadership
process for managing a complaint or concern about
complaint or concern about non-clinical staff, including
non-clinical staff, including contractors and volunteers, is
contractors and volunteers. evaluated, and improvements
are made as required.

The Australian Council on Healthcare Standards. EQuIP6 standards, criteria and elements© December 2015.
Standard 2.2: Human resources management supports quality health care, a competent workforce and a
satisfying working environment for staff.
Criterion 2.2.4: The learning and development system ensures the skill and competence of staff and volunteers.
LA - Awareness
a) There is a planned and
documented learning and
development program that
addresses organisational and
staff needs.
b) Staff and volunteers are
consulted about their learning
and development needs.
c) The organisation provides
mandatory training in
accordance with legislative and
policy requirements.
d) The organisation provides
adequate resources for learning
and development.
e) Staff and volunteers and, where
relevant, students are provided
with appropriate supervision by
experienced, trained and
qualified staff.
f) There is a system to record and
check staff completion of
professional development
requirements.
SA - Implementation
a) There is an evidence-based
learning and development
system available to staff,
including volunteers, that:
(i) identifies the needs of
both the organisation and
staff
(ii) ensures staff remain
competent to perform
their work
(iii) meets new and changing
staff needs in a timely
manner
(iv) responds to changes in the
organisation’s
environment.
b) The organisation ensures that
education and training are
delivered by appropriately
qualified individuals and/or to
an appropriate standard.
c) Where relevant, the
organisation ensures that
student requirements for
training are met.
d) Staff meet their requirements
for self-directed professional
development.
MA - Evaluation EA - Distinction OA - Leadership
a) The learning and development a) The organisation shows a) The organisation demonstrates
system is regularly evaluated distinction in staff and it is a leader in learning and
with staff participation to volunteer learning and development systems.
ensure that it meets development.
organisational and staff needs,
and improvements are made as
required.
b) The education and training
delivered by the organisation
are evaluated, and
improvements are made as
required.
c) The supervision of staff,
volunteers and students is
evaluated, and improvements
are made as required.
d) The system to record and check
completion of mandatory
training and professional
development is evaluated, and
improvements are made as
required.

The Australian Council on Healthcare Standards. EQuIP6 standards, criteria and elements© December 2015.
Standard 2.2: Human resources management supports quality health care, a competent workforce and a
satisfying working environment for staff.
Criterion 2.2.5: Support systems promote staff wellbeing and a positive work environment.
LA - Awareness SA - Implementation MA - Evaluation EA - Distinction OA - Leadership
a) The workplace rights and a) The organisation supports a) Performance measures are a) The organisation shows a) The organisation demonstrates
responsibilities of management flexible work practices. used regularly to assess staff distinction in staff support it is a leader in systems to
and staff are clearly defined, access to assistance programs systems. promote staff wellbeing and a
communicated and respected. b) There is a system that and to evaluate the staff positive working environment.
motivates staff and identifies support services, and
b) Staff know about, and can the value of staff through improvements are made as
access, support systems that appropriate acknowledgement. required.
promote staff wellbeing and a
positive work environment. c) Managers facilitate staff access b) Staff are involved in the
to support services and evaluation of support systems,
c) Staff are consulted about workplace relations. and improvements are made as
workplace support services and required.
workplace relations. d) Management and staff work
cooperatively and, where c) The management and
d) There is a process for appropriate, in consultation resolution of workplace issues,
identifying and managing staff with relevant external bodies to including grievances, is
or volunteer behaviour that is achieve effective workplace evaluated, and improvements
inappropriate or creates risk. relations. are made as required.

e) Information about grievance e) There is a transparent system to

processes is readily available to identify, manage and resolve
management and staff. workplace issues, which
includes a consultation process.

The Australian Council on Healthcare Standards. EQuIP6 standards, criteria and elements© December 2015.
Standard 2.3: Information management systems enable the organisation’s goals to be met.
Criterion 2.3.1: Health records management systems support the collection of information and meet consumer / patient and organisational needs.
LA - Awareness
a) Policy / guidelines addressing
health records management are
consistent with relevant
legislation, standards,
guidelines and/or codes of
practice, and are readily
available to staff.
b) Organisation-wide policy /
guidelines describe the
allocation of a unique identifier
for each consumer / patient.
c) A central index of identifiers is
maintained.
d) Where multiple records for the
consumer / patient exist they
are cross-referenced.
e) Clinical classification is
undertaken for all inpatient
admissions in accordance with
relevant legislation, standards,
guidelines and/or codes of
practice.
f) Guidelines describing how
consumers / patients can access
their health records are readily
available and staff are advised
of their responsibility to
facilitate the process.
The Australian Council on Healthcare Standards. EQuIP6 standards, criteria and elements© December 2015.
SA - Implementation
a) There is a health records
management system that ensures:
(i) the secure, safe and
systematic storage of data and
records
(ii) the allocation and
maintenance of the unique
identifier
(iii) timely and accurate retrieval
and transport of records
stored on or off-site
(iv) consumer / patient privacy
when information is
communicated
(v) retention and destruction
according to all relevant
legislation, standards, guidelines
and/or codes of practice.
b) All components of the health
record are accounted for at a
central point, and are monitored.
c) The health record is linked to
other health information systems
using the unique identifier.
d) Relevant staff are trained in health
record keeping and records
management.
e) Coding and reporting time-frames
meet internal and external
requirements.
f) Health professionals participate in
the analysis of data including
clinical classification information.
g) Requests by consumers / patients
MA - Evaluation EA - Distinction OA - Leadership
a) The health records management a) The organisation shows a) The organisation
system is evaluated, and distinction in health records demonstrates it is a leader in
improvements are made as management. health records management
required. systems.
b) Compliance with health record
keeping and records
management is monitored and
evaluated, and improvements
are made to training programs
as required.
c) Checks for consumers / patients
with multiple identifiers are
regularly made on the central
index, and improvements / links
are made as required.
d) The tracking and monitoring of
health records is evaluated, and
improvements are made as
required.
e) Coding and reporting processes
are evaluated, and
improvements are made as
required.
f) Compliance with policy and
timeliness of response to
consumer / patient requests for
health record access are
monitored, and improvements
are made as required.
Standard 2.3: Information management systems enable the organisation’s goals to be met.
Criterion 2.3.1: Health records management systems support the collection of information and meet consumer / patient and organisational needs.
LA - Awareness SA - Implementation MA - Evaluation EA - Distinction OA - Leadership
for access to health records are
met within a set period in
accordance with relevant
legislation, standards, guidelines
and/or codes of practice.

The Australian Council on Healthcare Standards. EQuIP6 standards, criteria and elements© December 2015.
Standard 2.3: Information management systems enable the organisation’s goals to be met.
Criterion 2.3.2: Corporate records management systems support the collection of information and meet organisational needs.
LA - Awareness SA - Implementation MA - Evaluation EA - Distinction OA - Leadership
a) Policy / guidelines for corporate a) There is a corporate records a) The corporate records a) The organisation shows a) The organisation demonstrates
records management are management system that management system is distinction in corporate records it is a leader in corporate
consistent with relevant ensures: evaluated, and improvements management. records management systems.
legislation, standards, (i) the secure, safe and are made as required.
guidelines and/or codes of systematic storage of data
practice, and are readily and records b) Compliance with corporate
available to staff. (ii) timely and accurate record keeping and records
retrieval and transport of management is monitored and
b) Policy / guidelines define the records stored on or off- evaluated, and improvements
governance and accountability site are made to training programs
for corporate records (iii) appropriate retention and as required.
management. destruction of records
according to all relevant c) Corporate records creation and
c) Policy / guidelines specify the legislation, standards, tracking is evaluated, and
requirements for standardised guidelines and/or codes of improvements are made as
record creation and tracking. practice. required.

b) The security of corporate

records is assured through
restricted access.

c) Corporate records created by

the organisation are supported
by appropriate record systems.

d) Relevant staff are trained in

corporate record keeping and
records management.

The Australian Council on Healthcare Standards. EQuIP6 standards, criteria and elements© December 2015.
Standard 2.3: Information management systems enable the organisation’s goals to be met.
Criterion 2.3.3: Data and information are collected, stored and used for strategic, operational and service improvement purposes.
LA - Awareness
a) Policy / guidelines addressing
the collection, validation,
protection, storage and use of
data and information comply
with professional and statutory
requirements, and are readily
available to staff.
b) Data are available for:
(i) research
(ii) development
(iii) improvement activities
(iv) education
(v) corporate and clinical
decision making.
c) Adequate resources are
provided for the collection,
analysis and use of data.
d) The organisation contributes to
external databases and
registers.
e) There are systems to provide
information to authorised
stakeholders that are consistent
with relevant privacy
legislation.
f) The needs of staff for reference
and resource materials are
identified, analysed and
prioritised.
The Australian Council on Healthcare Standards. EQuIP6 standards, criteria and elements© December 2015.
SA - Implementation
a) An implemented information
management plan identifies the
needs of the organisation at all
levels.
b) A system is implemented for
the validation and protection of
data and information.
c) Data storage and retrieval are
facilitated through effective
classification and indexing.
d) Responsibility and
accountability for action on
data and information are clearly
delineated.
e) Databases are linked to provide
access within and across units
and departments.
f) Staff are informed of the data
collected that are relevant to
their position and have access
to training on data and
information management.
g) Reference and resource
materials are available for use
by staff.
h) Liaison with external bodies
improves the quality of
information supplied and
received.
MA - Evaluation EA - Distinction OA - Leadership
a) Systems used for the validation a) The organisation shows a) The organisation demonstrates
and protection of data and distinction in the collection, it is a leader in systems for the
information are evaluated, and storage and use of data and collection, use and storage of
improvements are made as information. data and information.
required.
b) Monitoring and analysis of
clinical and non-clinical data
and information occur to
ensure:
(i) accuracy, integrity and
completeness of data
(ii) timeliness of information
and reports
(iii) the needs of the
organisation are met
and improvements are made as
required.
c) Data use and reporting
processes are evaluated, and
improvements are made as
required.
d) The organisation reviews results
from external databases and
registers and improves care and
services as indicated.
e) Reference management and
resource material systems are
evaluated, and improvements
are made as required.
Standard 2.3: Information management systems enable the organisation’s goals to be met.
Criterion 2.3.4: The organisation has an integrated approach to the planning, use and management of information and communication technology (ICT).
LA - Awareness
a) There is effective governance of
ICT that is supported by policy
and procedure.
b) Licences are purchased as
required.
c) There is a system to manage
the use of mobile devices used
in the course of healthcare
delivery.
d) There is a system of ICT
operational support.
e) There is a documented plan for
managing ICT risks and crises.
f) Staff are trained in the correct
use of ICT relevant to the
organisation and their roles.
g) Staff are provided with
orientation and ongoing
education in the appropriate
use of personal mobile devices
in healthcare delivery.
h) The organisation ensures that
staff education and training in
ICT is adequately resourced.
The Australian Council on Healthcare Standards. EQuIP6 standards, criteria and elements© December 2015.
SA - Implementation
a) The organisation’s ICT planning
addresses current and future
ICT needs.
b) Strategies for:
(i) backup
(ii) security
(iii) protection of privacy
(iv) virus detection
are implemented and used.
c) There is a planned system for
preventive maintenance of ICT.
d) A strategy and plan for disaster
recovery / business continuity is
implemented and tested.
e) The integrated ICT system
supports the collection,
aggregation and analysis of
data.
f) Relevant staff have access to
decision support software
and/or tools and are trained in
their use.
MA - Evaluation EA - Distinction OA - Leadership
a) The ICT system is evaluated, a) The organisation shows a) The organisation demonstrates
and improvements are made as distinction in the planning, use it is a leader in the planning, use
required. and management of ICT. and management of ICT.
b) Compliance with ICT policy and
procedures is monitored and
evaluated, and improvements
are made as required.
c) The security and protection of
the ICT system are evaluated,
and improvements are made as
required.
d) The preventive maintenance
and repair system for ICT is
regularly evaluated, and
improvements are made as
required.
e) The risk and crisis management
system for ICT is regularly
evaluated, and improvements
are made as required.
f) Staff education and training in
the use of ICT are evaluated,
and improvements are made as
required.
Standard 2.4: The organisation promotes the health of the population.
Criterion 2.4.1: The organisation conducts health promotion and consumers / patients, carers, staff and the community are educated about better health and
wellbeing.
LA - Awareness
a) Policy / guidelines addressing
health promotion are consistent
with government / authority
priorities and relevant
education programs, and are
readily available to staff.
b) Staff and other key
stakeholders are informed of
population health principles
and participate in evidence-
based health promotion
strategies.
c) The organisation is aware of
current and emerging health
priority areas.
d) The organisation understands
its statutory requirements for
reporting on public health
matters.
e) Training and resources are
available for staff to support the
development of evidence-based
health promotion and
education for consumers /
patients, carers and the
community.
SA - Implementation
a) The organisation optimises the
delivery of health promotion
and interventions to consumers
/ patients and carers.
b) Opportunistic health promotion
strategies are undertaken in
partnership with consumers /
patients, carers, staff and the
community.
c) Health surveillance data
appropriate to the organisation
are collected.
d) Where appropriate, the
organisation provides health
education to consumers /
patients, carers, staff and the
community via its healthcare
and community collaborations.
MA - Evaluation EA - Distinction OA - Leadership
a) The outcomes of health a) The organisation shows a) The organisation demonstrates
promotion are evaluated for distinction in health promotion it is a leader in health
their effectiveness in improving and education. promotion and education.
the health and wellbeing of
consumers / patients, staff,
carers and the community, and
improvements are made as
required.
b) Performance measures are
developed, and quantitative or
qualitative data collected, to
evaluate the effectiveness /
outcomes of health promotion
strategies implemented by the
organisation.
c) The organisation evaluates the
effectiveness of its
collaborations in supporting its
health education programs, and
improvements are made as
required.

f) The organisation works in

collaboration with relevant
healthcare and community
bodies to utilise resources
effectively and support health
promotion activities.

The Australian Council on Healthcare Standards. EQuIP6 standards, criteria and elements© December 2015.
Standard 2.5 The organisation encourages and adequately governs the conduct of research to improve the
safety and quality of health care within organisations.
Criterion 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.
LA - Awareness SA - Implementation MA - Evaluation EA - Distinction OA - Leadership
a) The organisation fosters and a) The organisation’s research a) The system for ensuring a) The organisation shows a) The organisation demonstrates
encourages clinical and health program and/or its involvement effective research governance is distinction in research that it is a leader in research
services research aimed at in clinical trials are managed so evaluated, and improvements governance. governance and the
improving outcomes for as to ensure the safety and are made as required. management of associated risk.
consumers / patients. wellbeing of relevant
consumers / patients. b) The organisation’s research
b) Policy / guidelines addressing program and/or its involvement
research governance are b) The respective responsibilities in clinical trials are evaluated
consistent with relevant of all parties involved in with respect to the safety and
legislation, guidelines, research are identified and wellbeing of relevant
standards, statements and/or documented. consumers / patients, and
codes of conduct. results are reported to the
c) Research ethics approval governing body.
c) Policy / guidelines define which processes are transparent and
research requires ethics consistent with relevant c) The organisation’s:
approval and under what guidelines and scientific review (i) research-related reporting
conditions ethics approval will standards. (ii) internal ethics processes
apply. (iii) management of clinical
d) Where relevant, the trials, where relevant,
d) Research policy / guidelines are organisation’s research ethics including any specimens or
readily available to staff and committee is adequately medications
consumers. resourced. are evaluated, and
improvements are made as
e) Formal agreements with e) The organisation’s research required.
collaborating and funding ethics oversight processes are
agencies are in place. clearly defined. d) Research outcomes are
reported to the governing body,
f) The governing body f) Consumers and researchers and made readily available to
demonstrates its responsibility work in partnership with the staff and consumers.
for the governance of research. organisation to make decisions
about research priorities, policy
and practices.

The Australian Council on Healthcare Standards. EQuIP6 standards, criteria and elements© December 2015.