Clinical Function EQuIP6 Standard Tables. Final. 1

Standard 1.
1: Consumers / patients are provided with safe, high quality care throughout the care delivery process.
Criterion 1.1.1: Assessment ensures current and ongoing needs of the consumer / patient are identified.
This is a mandatory criterion
LA - Awareness SA - Implementation MA - Evaluation EA - Distinction OA - Leadership
a) Guidelines to direct the a) Assessments are conducted and a) The assessment process is a) The organisation shows a) The organisation demonstrates
assessment of the physical, documented as soon as evaluated, and improvements distinction in consumer / it is a leader in systems for
spiritual, cultural, psychological practicable. are made as required. patient assessment and consumer / patient assessment
and social needs of consumers / planning for transfer of care / and planning for transfer of
patients are readily available to b) Consumers / patients are b) Processes for identifying, discharge. care / discharge.
staff. involved in the assessment assessing and managing
process. vulnerable consumers /
b) Guidelines are available on the patients and groups are
specific needs of vulnerable c) A support person / carer is evaluated, and improvements
consumers / patients and involved in assessment are made as required.
population groups. whenever practicable.
c) Planning for transfer of care /
c) There are processes to identify, d) Planning for transfer of care / discharge is evaluated to ensure
assess and manage vulnerable discharge commences at that it:
consumers / patients and assessment, is multidisciplinary (i) routinely occurs
population groups. when necessary, and (ii) is multidisciplinary when
coordinated. required
d) There are processes for the (iii) includes referral to
assessment of a consumer / specialty services when
patient’s need for health required
education. (iv) meets consumer / patient
and carer needs.
e) Referral systems to other
relevant health service d) Referral systems are evaluated,
providers are in place. and improvements are made as
required.
The Australian Council on Healthcare Standards. EQuIP6 standards, criteria and elements© December 2015.
Standard 1.1: Consumers / patients are provided with safe, high quality care throughout the care delivery process.
Criterion 1.1.2: Care is planned and delivered in collaboration with the consumer / patient and, when relevant, the carer to achieve the best possible outcomes.
a) Guidelines for care planning and a) Care planning and delivery are a) Compliance with guidelines and a) The organisation shows a) The organisation demonstrates
delivery are based on current based on the assessment of practices for care planning and distinction in care planning and it is a leader in care planning
professional standards and consumer / patient needs, in delivery is monitored and delivery. and delivery practices.
evidence-based practice, and partnership with the consumer evaluated, and improvements
are readily available to staff. / patient and their carer. are made as required.
b) Care planning addresses the b) Care is coordinated, planned b) The care planning and delivery
diverse physical, spiritual, and delivered by skilled and process is evaluated, and
cultural, medical, psychological trained health professionals improvements are made as
and social needs of consumers / within a multidisciplinary team required.
patients. with an identified team leader.
c) Multidisciplinary team
c) Care planning addresses the c) Care planning, decisions, processes for care delivery are
specific needs of vulnerable actions and changes are evaluated, and improvements
consumers / patients and documented in the consumer / are made as required.
population groups. patient health record, and are
regularly reassessed. d) The regular reassessment of the
d) Consumers / patients are consumer / patient is evaluated,
informed of factors impacting d) The consumer / patient is and improvements are made as
on their health and a plan for regularly informed about their required.
promoting their individual health status, and provided
wellbeing is discussed. with information that allows
them to understand their care,
e) Care is provided in response to care delivery options, and
consumer / patient needs in a changes to their care plan.
timely manner and in
accordance with relevant policy
/ guidelines.
f) Care planning and delivery

reflect the requirements of the
consumer / patient’s advance
care directive where applicable.
Criterion 1.1.3: Consumers / patients are informed of the consent process, and they understand and provide consent for their health care.
a) Policy / guidelines addressing a) Consent is obtained for a) The consent process is a) The organisation shows a) The organisation demonstrates
consent are consistent with investigations, treatments or evaluated, and improvements distinction in its management of it is a leader in consent systems.
relevant legislation, standards, procedures and any associated are made as required. the consent process.
guidelines and/or codes of costs, and for the
practice, and are readily communication of consumer / b) Compliance with the consent
available to staff. patient information, in process is monitored and
accordance with the evaluated, and strategies for
b) Health professionals are organisation’s policy / improvement are identified and
educated about the consent guidelines. implemented as required.
policy / guidelines and how to
obtain informed consent. b) There is a process to manage:
(i) when consent cannot be
c) Consumers / patients and given at the appropriate
carers are provided with time
information on recommended (ii) when the consumer /
investigations, treatment or patient does not have the
procedures, the risks involved capacity to provide consent
and the costs, in appropriate (iii) provision of consent by
formats / languages. someone other than the
consumer / patient
(iv) the limits of consent.
c) Details of the information

provided to the consumer /
patient in the process of
obtaining informed consent is
documented in the health
record.
Criterion 1.1.4: The organisation implements effective systems for the management of medical emergencies, including the identification and care of deteriorating
consumers / patients.
a) Policy / guidelines addressing a) There is governance / a) The organisation-wide medical a) The organisation shows a) The organisation demonstrates
the management of medical committee oversight of medical emergency management distinction in its management of it is a leader in medical
emergencies are consistent emergency responses. system is evaluated, and medical emergencies. emergency preparedness and
with relevant standards, improvements are made as management systems.
guidelines and/or codes of b) Medical emergency required.
practice, and are readily
available staff. management plans are
developed, reviewed and tested b) The system to identify and
b) Regular observations are in consultation with relevant manage deteriorating
recorded for each consumer / staff. consumers / patients is
patient on standardised evaluated, and improvements
observation charts. c) Equipment and resuscitation are made as required.
trolleys are standardised
c) There is a system to identify throughout the organisation. c) Records of emergency calls are
and manage clinical maintained and responses are
deterioration in consumers / d) Rostering ensures that medical evaluated, and improvements
patients.
emergency respondents are are made as required.
d) There are processes to escalate available to meet organisational
the care of a deteriorating needs. d) There are demonstrated links
consumer / patient when between identification of
necessary. e) Relevant health professionals deteriorating consumers /
are trained in appropriate first patients and escalation of care.
e) Medical emergency response response techniques.
plans and instructions are e) Staff training and competence
prominently displayed f) Relevant health professionals in managing medical
throughout the organisation. are trained in advanced clinical emergencies are evaluated, and
f) Health professionals are life support. improvements are made as
educated and trained at required.
orientation and annually in the
correct response to medical f) Outcomes of the evaluation of
emergencies. the organisation’s responses to
medical emergencies are
g) Health professionals and other reported to the governing body.
relevant staff are trained in
basic life support and records of
the training are maintained.
Criterion 1.1.5: Processes for clinical handover, transfer of care and discharge address the needs of the consumer / patient for ongoing care.
a) Policy / guidelines addressing a) There is an effective, a) The processes for clinical a) The organisation shows a) The organisation demonstrates
clinical handover, transfer of organisation-wide system for handover, transfer of care and distinction in its management of it is a leader in processes for
care and discharge are readily clinical handover within the discharge are evaluated, and clinical handover, transfer of clinical handover, transfer of
available to staff. organisation, which ensures improvements are made as care and discharge. care and discharge.
that all necessary information required.
b) Results of investigations follow about the consumer / patient is
the consumer / patient through communicated. b) The system for providing
the referral system. discharge and referral
b) Processes for transfer of care information to consumers /
c) Arrangements with other health and discharge ensure continuity patients and external health
service providers and the carer of care and timely notification service providers is evaluated,
are made with consumer / between referrers and health and improvements are made as
patient consent and input, and service providers. required.
confirmed prior to transfer of
care or discharge. c) There is evidence to c) The system for follow-up of at-
demonstrate that external risk consumers / patients is
d) Discharge information is health service providers receive evaluated, and improvements
recorded in the consumer / timely notification about are made as required.
patient health record. consumers / patients
discharged to their care.
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.
Criterion 1.1.6: Systems for ongoing care of the consumer / patient are coordinated and effective.
a) There are formal processes for a) Care coordination and/or case a) The ongoing care process is a) The organisation shows a) The organisation demonstrates
timely coordination of ongoing management is available for evaluated with consumer / distinction in the management it is a leader in systems for
care by multiple health service appropriate consumers / patient involvement, and of ongoing care. ongoing care.
providers. patients and their carers. improvements are made as
required.
b) There are systems for b) Strategies are developed to
screening, prioritisation and reduce acute presentations and b) The strategies developed to
readmission of at-risk avoidable admissions of reduce acute presentations and
consumers / patients, and those consumers / patients with avoidable admissions are
with chronic conditions. chronic conditions. evaluated, and improvements
are made as required.
c) Information on relevant c) Processes are in place to ensure
external health service effective management of c) The screening, prioritisation and
providers is available to staff. consumers / patients with readmission of at-risk
chronic conditions who develop consumers / patients are
d) Written and verbal information an unrelated health issue evaluated, and improvements
is provided to consumers / and/or deteriorate. are made as required.
patients about their chronic
condition. d) Education is available for d) The information and education
consumers / patients with provided for consumers /
chronic conditions and their patients requiring ongoing care
carers on how to manage the and their carers are evaluated,
condition. and improvements are made as
required.
Criterion 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.
a) Policy / guidelines addressing a) Processes ensure that advance a) Compliance with policy, a) The organisation shows a) The organisation demonstrates
the management of consumer / care directives are followed procedures and guidelines distinction in its management of it is a leader in systems for end-
patient end-of-life care are where appropriate. addressing end-of-life-care, end-of-life care. of-life care.
consistent with relevant including cultural sensitivity and
legislation, standards, b) When clinically indicated, staff education, is monitored
guidelines and/or codes of consumers / patients are and evaluated, and
practice, and advance care referred to palliative care, pain improvements made as
directives, and are readily management services and/or required.
available to staff. other support services.
b) Compliance with advance care
b) Processes for the management c) Processes are in place for the directives is evaluated, and
of death and related issues management of a sudden or improvements are made as
address diverse spiritual, unexpected death. required.
cultural, and social beliefs.
d) There is a support system to c) Clinical review committees,
c) Policy / guidelines direct the
recognition and recording of assist family, carers, patients including morbidity / mortality
advance care directives. and staff affected by a death and case review, evaluate the
and related issues. appropriateness of referrals to
d) The organisation has access to palliative care, pain
palliative care, pain e) There are processes to support management services, and/or
management and/or other staff, consumers / patients and other support services, and
support services. carers involved in organ and improvements are made as
tissue donation. required.
e) Relevant health professionals
are educated in end-of-life care f) Relevant health professionals d) Processes surrounding dying
processes, including related are trained in organ and tissue and death are evaluated, and
ethical considerations. donation processes. improvements are made as
required.
f) The organisation has processes
to 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.
Criterion 1.1.8: The health record ensures comprehensive and accurate information is collaboratively gathered, recorded and used in care delivery.
a) Policy / guidelines addressing a) There is a system to monitor a) Health records are evaluated to a) The organisation shows a) The organisation demonstrates
health record documentation compliance with health record ensure that they meet medico- distinction in its management it is a leader in systems to
are consistent with relevant creation and documentation legal requirements, professional and use of health record collect, record and use
legislation, standards, policies. documentation standards, content. consumer / patient health
guidelines and/or codes of guidelines and/or codes of information.
practice, and are readily b) Health professionals use the practice, and improvements are
available to staff. health record to document and made as required.
communicate all aspects of care
b) Every consumer / patient has a delivery in accordance with the b) Health records are evaluated to
health record with a recognised organisation’s policy / ensure that the clinical content
unique identifier. guidelines. supports safe, high quality care,
and improvements are made as
c) Health professionals are c) Health records are monitored required.
provided with orientation and for completeness and legibility,
ongoing education in the including: c) Evaluation of the completeness
organisation’s processes for (i) the readability of written and legibility of the health
health record creation and and printed material record is addressed through the
documentation. (ii) the use of black or blue ink use of audits, and
(iii) for clarity of scans / improvements are made as
d) Authorised internal and photocopies required.
external health professionals (iv) the use of approved
have access to information abbreviations only d) Timeliness of inclusion of
about the consumer / patient in (v) that no blank areas are left. reports and information from
accordance with relevant reviews, tests and other clinical
privacy legislation. d) Results of reviews and clinical investigations into the health
consultations are made record is evaluated, and
e) Consumers / patients are available to health professionals improvements are made as
provided with information on at the point of consumer / required.
how to access their health patient care.
records.
Standard 1.2: Consumers / patients and communities have access to health services and care appropriate to their needs.
Criterion 1.2.1: The community has information on health services appropriate to its needs.
a) The organisation has defined a) Services are designed to meet a) The organisation evaluates the a) The organisation shows a) The organisation demonstrates
the community that it serves. the needs of the identified information supplied to the distinction in the provision of it is a leader in providing
community. community about the services it health service information to its information on health services
b) The organisation develops or provides, and improvements community. appropriate to the community’s
sources information about the b) Consumers / patients are are made as required. needs.
specific services it provides and provided with information
supplies this information to the about the specific service(s) b) The organisation evaluates
community. they are using. processes for dissemination of
information on its services, and
c) Health professionals within the c) An internal service directory improvements are made as
organisation have information listing operational and contact required.
on relevant external services. details of external health
service providers is maintained c) Maintenance of the external
d) Relevant external health service and made available to relevant health service providers’
providers are supplied with staff. directory is evaluated, and
information on the health improvements are made as
service and are informed of d) There is collaboration between required.
referral and entry processes. the organisation, consumers /
patients, carers and external d) The organisation evaluates its
health service providers to collaboration with consumers /
develop information about patients, carers and external
referral and entry processes. health service providers, and
improvements are made as
required.
Standard 1.2: Consumers / patients and communities have access to health services and care appropriate to their needs.
Criterion 1.2.2: Access and admission / entry to the system of care are prioritised according to healthcare needs.
a) Policy / guidelines addressing a) The organisation’s system for a) The system for prioritisation of a) The organisation shows a) The organisation demonstrates
the prioritisation of admission / prioritising care meets the care is evaluated, and distinction in prioritisation and it is a leader in admission /
entry to the health service are needs of the consumer / improvements are made as processes for admission / entry entry processes and systems for
consistent with relevant patient. required. and access to care. prioritising access according to
legislation, standards, healthcare needs.
guidelines and/or codes of b) The organisation has a system b) Admission / entry processes are
practice, and are readily to manage its waiting times / evaluated, and improvements
available to staff. wait lists. are made as required.
b) The organisation has clear c) There are policy / guidelines to c) The organisation’s inclusion /
inclusion and/or exclusion manage the referral of exclusion criteria, and the
criteria for admission to the consumers / patients who do referral of those not meeting
service. not meet the inclusion criteria. the inclusion criteria, are
evaluated, and improvements
c) Admission / entry processes d) There are processes that ensure are made as required.
meet consumer / patient needs continuity of care between
and minimise duplication. referrers and health service
providers.
d) Information in referral
documents received on
admission of the consumer /
patient is utilised.
Standard 1.3: Appropriate care and services are provided to consumers / patients.
Criterion 1.3.1: Appropriate health care and services are delivered in the most appropriate setting.
a) Clinical guidelines are used to a) Service planning includes an a) The appropriateness of care, a) The organisation shows a) The organisation demonstrates
direct appropriate care delivery. evaluation of the services and interventions is distinction in its provision of it is a leader in providing
appropriateness of the services evaluated by health appropriate care. appropriate care and services in
b) Policy / guidelines addressing to be provided. professionals and management, the appropriate setting.
how the organisation assesses and consumers as practicable,
the appropriateness of care and b) The organisation has a strategy and improvements are made as
interventions are readily to ensure the appropriateness required.
available to staff. of care and interventions.
b) The appropriateness of the
c) Policy / guidelines addressing c) The organisation collects a suite settings for care delivery is
how the organisation assesses of key indicators relating to evaluated, and improvements
the appropriateness of the appropriateness of care and are made as required.
setting in which care is interventions.
delivered are readily available c) Processes for managing
to staff. d) Consumers / patients and consumers / patients
carers participate in decisions accommodated outside the
d) There are processes to manage about the appropriate setting specialty area are evaluated,
and minimise risk to consumers for care delivery. and improvements are made as
/ patients accommodated required.
outside the specialty area. e) Relevant health professionals
are educated about the d) The organisation’s use of
e) Policy / guidelines address the appropriate use of restraint. restraint is evaluated, and
organisation’s use of restraint, improvements are made as
including: required.
(i) physical restraint
(ii) chemical restraint
(iii) seclusion and/or locked
doors.
Standard 1.4: The organisation provides care and services that achieve effective outcomes.
Criterion 1.4.1: Outcomes of clinical care, including individual care episodes and the overall effectiveness of care, are evaluated by healthcare providers.
a) Documented processes guide a) The organisation supports a) The results of organisation-wide a) The organisation shows a) The organisation demonstrates
health professionals in health professionals in the clinical audits are reviewed by distinction in care evaluation it is a leader in the evaluation of
implementing evidence-based implementation of evidence- relevant health professional and the overall effectiveness of consumer / patient outcomes
clinical practice. based care. groups and used to support the its care. and the overall effectiveness of
evaluation and improvement of care.
b) Guidelines addressing how the b) Care process mapping is health care.
organisation assesses the documented and undertaken by
overall effectiveness of care and a multidisciplinary team where b) The organisation evaluates the
interventions are readily applicable. effectiveness of care and
available to staff. interventions, including through
c) The organisation collects key the use of key indicators, and
c) Guidelines addressing how the indicators relating to improvements are made as
organisation assesses the effectiveness of care and required.
effectiveness of individual care interventions.
episodes are readily available to c) Individual consumer / patient
staff. d) Individual consumer / patient outcomes are evaluated, and
outcomes are assessed against: improvements to care
d) Consumers / patients and (i) the agreed care plan processes are made as
carers are informed of how to (ii) evidence-based guidelines. required.
give feedback on the care
provided. e) Prior to discharge, health d) Feedback from consumers /
professionals discuss the patients and carers informs the
outcomes of care with the organisation’s evaluation of the
consumer / patient and their effectiveness of its care and
carer, and this is documented. services.
f) Feedback is sought from

consumers / patients and carers
regarding the delivery of care
and services.
Standard 1.5: The organisation provides safe care and services.
Criterion 1.5.1: Medication management systems support the safe and effective use of medicines.
a) Policy / guidelines for a) A multidisciplinary body a) The organisation-wide a) The organisation shows a) The organisation demonstrates
medication management are oversees the organisation-wide medication management distinction in its management of it is a leader in medication
consistent with relevant medication management system is evaluated, and medications. management systems and
legislation, standards, system. improvements are made as processes.
guidelines, and/or codes of required.
practice, and are readily b) A standardised system for
available to staff. medication management, b) Medication documentation is
including the safe use of high- evaluated, and improvements
b) Health professionals have risk medications, is are made as required.
access to published guidelines implemented throughout the
for medication management. organisation. c) Processes for timely medication
review and reconciliation are
c) A standardised list of approved c) Medication review and evaluated, and improvements
abbreviations for medications is reconciliation occurs as soon as are made as required.
used throughout the practicable following admission
organisation. of the consumer / patient. d) The system for distribution,
storage and disposal of
d) Medication documentation is in d) Procedures are implemented to medications is evaluated, and
an appropriate and reduce the risk and severity of improvements are made as
standardised format medication incidents. required.
throughout the organisation.
e) The organisation supports e) Medication incidents, near
e) Medications, including health professionals, consumers misses and adverse drug
temperature-sensitive / patients and carers in the reactions are analysed and
medications, are distributed, identification and reporting of trended, and further strategies
stored and disposed of securely medication incidents, near to reduce medication incidents
and safely in accordance to misses and adverse drug are implemented.
manufacturer’s instructions, reactions.
legislation and organisational f) Education and training in
guidelines. f) Health professionals are trained medication management are
in medication management evaluated in consultation with
f) Consumer / patient current practices relevant to their role relevant staff, and
medications are documented as and responsibilities. improvements are made as
soon as practicable following required.
admission, and prior to transfer g) Education is available for
of care / discharge. consumers / patients and their g) The information and education
carers about prescribed provided for consumers /
Criterion 1.5.1: Medication management systems support the safe and effective use of medicines.
g) Health professionals are medications, to encourage patients and carers is evaluated,
provided with orientation and ongoing safe use of medications and improvements are made as
ongoing education on and compliance after discharge. required.
medication management,
including safe practice, risk h) Outcomes of evaluation of the
reduction and correct medication management
documentation. system, including incident
management, are reported to
h) Written and verbal information the governing body.
is provided to consumers /
patients about their
medications.
Criterion 1.5.2: The infection control system supports safe practice and ensures a safe environment for consumers / patients and healthcare workers.
a) Policy / guidelines addressing a) The infection control system, a) Compliance with the infection a) The organisation shows a) The organisation demonstrates
infection control are consistent including the infection control control policy / guidelines is distinction in its management of it is a leader in infection
with relevant legislation, plan, is managed and monitored and evaluated, and infection prevention and prevention and control systems.
standards, guidelines and/or monitored by a improvements are made as control.
codes of practice, and are multidisciplinary infection required.
readily available to staff. control committee and/or
team. b) The infection control system,
b) The infection control plan including all aspects of the
includes: b) Infection prevention strategies infection control plan, is
(i) hand hygiene and aseptic are integrated into all stages of evaluated, and improvements
technique healthcare planning, including are made as required.
(ii) antimicrobial stewardship health facility planning,
and appropriate use of construction and c) Maintenance and monitoring of
antibiotics refurbishment. environmental factors relevant
(iii) notifiable diseases to infection control are
(iv) outbreak management c) There is a planned and evaluated, and improvements
(v) transmission precautions documented schedule of are made as required.
and occupational exposure regular maintenance and/or
prevention and monitoring of the d) The organisation collects a suite
management environmental factors of infection control indicators
(vi) sterilisation and associated with infection and evaluates the results, and
reprocessing of control. improvements are made as
instruments and devices. required.
d) There are documented risk
c) The infection control plan reduction and containment e) Education and training in
addresses environmental measures for identified infection prevention and
factors, including: infections. control are evaluated in
(i) cleaning services consultation with relevant staff,
(ii) food safety and kitchen e) Health professionals and other and improvements are made as
cleaning staff are trained in infection required.
(iii) linen handling and laundry prevention and control
services strategies relevant to their role f) The effectiveness of
(iv) relevant equipment and and responsibilities. communication of infection
plant. risks, control strategies and
f) Infection risks, control safety requirements to
d) The infection control plan is strategies and safety consumers / patients, carers,
approved, supported and requirements are visitors, students and external
Criterion 1.5.2: The infection control system supports safe practice and ensures a safe environment for consumers / patients and healthcare workers.
properly resourced by the communicated to consumers / service providers is evaluated,
governing body and/or its patients and carers. and improvements are made as
delegated authority. required.
e) There is an effective g) Outcomes of the evaluation of

surveillance system to monitor the organisation’s infection
and report healthcare- control system are reported to
associated infections. the governing body.
f) Health professionals are

supplied with equipment and
an environment that enables
them to comply with the
infection control policy /
guidelines.
g) Health professionals and other

staff are provided with
orientation and ongoing
education about infection risks
and their responsibilities in
preventing infection.
h) External service providers,

students and visitors are
advised of the organisation’s
infection safety requirements.
Criterion 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.
a) Policy / guidelines addressing a) Multidisciplinary wound a) The system for skin integrity a) The organisation shows a) The organisation demonstrates
the preservation of skin prevention and management preservation and wound distinction in the preservation it is a leader in the preservation
integrity, and the management programs are implemented and management is evaluated, and of skin integrity and wound of skin integrity and wound
of pressure ulcers and other adapted to local needs and improvements are made as prevention and management. prevention and management
wounds, are readily available to healthcare settings. required. programs.
staff.
b) Risk assessment processes b) The incidence of skin integrity
b) Strategies for the prevention of occur: breaks, including pressure ulcer
pressure ulcers and (i) on admission rates where applicable, is
preservation of skin integrity (ii) at transitions of care analysed and trended, and
are evidence-based. (iii) following changes in health improvements are made to
status wound prevention and
c) Processes for the management (iv) prior to commencement of management strategies as
of wounds include high-risk procedures. required.
consideration of, and strategies
for, managing pain. c) Wound documentation systems c) Education and training in the
that support continuity of care preservation of skin integrity,
d) Health professionals are and assessment of progress wound prevention and
provided with orientation and towards goals are management, and the use of
ongoing education on the implemented. evidence-based processes /
preservation of skin integrity tools are evaluated, and
and wound prevention and d) Health professionals are trained improvements are made as
management. in the correct use of evidence- required.
based risk assessment
e) Written and verbal information processes / tools to assess skin
is provided to consumers / integrity.
patients and carers about
recognising potential risks to e) Consumers / patients and
skin integrity or to wounds, carers are advised how they can
including wound infections. alert relevant staff to any
changes in skin integrity or to
wounds, including wound
infections.
Criterion 1.5.4: The incidence of falls and fall injuries is minimised through a falls management program.
a) Policy / guidelines addressing a) Appropriate evidence-based a) The system for falls prevention a) The organisation shows a) The organisation demonstrates
falls prevention / minimisation, multidisciplinary falls reduction / minimisation is evaluated, and distinction in its management of it is a leader in falls prevention,
including where applicable the strategies are implemented improvements are made as falls and fall injury prevention. minimisation and management
minimal use of restraint, are according to identified risk required. systems.
readily available to staff. factors.
b) Individual falls prevention and
b) Healthcare providers use an b) Consumers / patients and, management plans are
evidence-based risk assessment where practicable, carers are reviewed, their effectiveness is
process / tool to assess involved in the development of evaluated, and improvements
consumers / patients for risk of an individualised falls are made as required.
falls: prevention / management plan
(i) on admission which addresses risk factors c) Falls and fall injury data are
(ii) following a change of risk identified during assessment. analysed and trended, and
factor / clinical status improvements are made to falls
(iii) after a fall c) Relevant health professionals prevention strategies as
and the level of risk is conveyed are trained in falls injury risk required.
to the consumer / patient, carer assessment, prevention and
and clinical team. management, and the use of d) Education and training in falls
falls prevention equipment. prevention / minimisation and
c) Health professionals and other falls injury management are
relevant staff are provided with d) The organisation supports staff, evaluated, and improvements
orientation and ongoing consumers / patients and carers are made as required.
education in falls prevention / in the identification and
minimisation. reporting of falls incidents and e) The information, education and
near misses. training provided to consumers
d) Written and verbal information / patients and carers on falls
is provided to consumers / e) Falls and fall injury prevention prevention and management is
patients and carers on falls equipment is available for evaluated, and improvements
prevention. consumers / patients following are made as required.
appropriate education and
training for use.
f) Falls risk is considered as part of

discharge planning for at-risk
consumers / patients.
Criterion 1.5.5: The system to manage samples and blood and blood products, sample collection and consumer / patient blood administration ensures safe and
appropriate practice.
a) Policy / guidelines addressing a) The sample and blood and blood a) The sample and blood and a) The organisation shows a) The organisation demonstrates
blood management are product management system blood product management distinction in its management it is a leader in management of
consistent with relevant ensures: system is evaluated, and of samples and blood and samples and blood and blood
legislation, standards, (i) verification of consumer/ improvements are made as blood products. products, and consumer /
guidelines and/or codes of patient identification at the required. patient blood administration
practice, and include: time of sample collection systems.
(i) consumer / patient (ii) timely and safe collection b) The system for transportation
identification at the time and labelling of samples and storage of samples and
of sample collection (iii) documented indication and blood and blood products is
(ii) completion of the request prescription for blood and evaluated, and improvements
form, safe collection, blood products are made as required.
identification and labelling (iv) the consumer / patient and
of the consumer/patient carer are informed of the c) The blood and blood products
sample risks, benefits and inventory register is evaluated,
(iii) prescription and appropriateness of the blood and improvements are made
documentation of blood and blood product for their as required.
and blood product therapy clinical situation, and
(iv) obtaining and consent for administration is d) The appropriateness of
documenting informed obtained transfusion decisions is
consent (v) timely availability of blood evaluated, and improvements
(v) managing consumers / and blood products are made as required.
patients who refuse (vi) verification of correct
administration of blood or consumer / patient and e) Sample and blood and blood
blood products blood or blood product, and product errors, near misses
(vi) the timely availability and safe administration of blood and adverse events are
safe administration of and blood products. analysed and trended, and
blood and blood products further strategies to reduce
(vii) monitoring and review of b) The system for the safe sample and blood and blood
the appropriateness of transportation and storage of product incidents are
blood and blood product samples and blood and blood implemented.
therapy products includes:
(viii) consumer / patient blood (i) a blood and blood products f) Education and training in safe
management including inventory register sample and blood and blood
blood conservation (ii) allocated responsibilities for product management are
strategies and alternatives responding to storage alarms evaluated in consultation with
to blood or blood product and taking corrective action relevant staff, and
therapy (iii) documentation improvements are made as
(ix) reporting and accompanying samples and required.
Criterion 1.5.5: The system to manage samples and blood and blood products, sample collection and consumer / patient blood administration ensures safe and
appropriate practice.
management of adverse blood and blood products
effects of blood and blood (iv) labels being checked each g) Outcomes of the evaluation of
product therapy. time the blood or blood the blood management
product is handled system, including incident
b) Policy / guidelines addressing (v) policy for monitoring blood management, are reported to
storage conditions and and blood product usage and the governing body.
transportation of samples and wastage.
blood and blood products
include: c) Relevant health professionals are
(i) validating, monitoring and provided with orientation and
recording of temperature ongoing education on procedures
for all blood fridges for safe sample and blood and
(ii) maintenance standards blood product management,
for all blood fridges including:
(iii) the response to blood (i) consumer / patient
fridge alarms identification and sample
(iv) delivery, placement and collection
removal of blood and (ii) storage and transportation of
blood products from any samples and blood and blood
blood fridge / controlled products
storage / pneumatic tubes (iii) blood and blood product
/ other transportation therapy prescription and safe
systems administration.
(v) monitoring of blood and
blood product usage and d) The organisation supports health
wastage professionals, consumers /
(vi) a documented audit trail. patients and carers in the
identification and reporting of
blood-related incidents, near
misses and adverse reactions.
Criterion 1.5.6: The organisation ensures that the correct consumer / patient receives the correct procedure on the correct site.
a) Policy / guidelines addressing a) The system to ensure correct a) Compliance with policy / a) The organisation shows a) The organisation demonstrates
correct consumer / patient identification of consumers / guidelines on correct consumer distinction in its management of it is a leader in correct
identification, correct patients, correct procedure and / patient identification, correct correct consumer / patient, consumer / patient
procedure and correct site prior correct site in any medical procedure and correct site is correct procedure and correct identification, correct
to any clinical intervention are intervention includes: monitored and evaluated, and site processes. procedure and correct site
consistent with relevant improvements are made as
legislation, standards, (i) verification of consumer / required. systems.
guidelines and/or codes of patient information
practice. (ii) matching the information b) Compliance with the
against documentation organisation’s correct consumer
b) Policy / guidelines addressing (iii) marking the correct site / / patient, correct procedure and
the management of side for intervention correct site system is monitored
instruments, accountable items (iv) taking time out for team and evaluated, and
and other items used for verification prior to the improvements are made to
surgery or procedures are intervention related education programs as
consistent with relevant (v) post-procedure required.
legislation, standards, confirmation, counting and
guidelines and/or codes of c) Compliance with the
practice. documentation organisation’s policy /
and mitigates the associated guidelines on the management
c) The organisation has risks. of instruments, accountable
documented systems for items and other items used for
standardisation of consumer / b) The organisation supports staff, surgery or procedures is
patient identification. consumers / patients and carers monitored and evaluated, and
in the identification and improvements are made as
d) Health professionals and other reporting of incidents and near required.
relevant staff are provided with misses involving correct
orientation and ongoing d) Incidents involving incorrect
consumer / patient, correct consumer / patient, procedure
education in correct consumer/ procedure and correct site
patient identification, correct or site are analysed and
identification. trended, and further strategies
procedure and correct site
policy / guidelines and to reduce incidents are
processes. implemented.
e) Outcomes of the evaluation of
e) Written and verbal information the system for ensuring correct
is provided to consumers / consumer / patient
patients and carers about identification, correct
correct consumer / patient, procedure and correct site,
correct procedure and correct including incident management,
site processes. are reported to the governing
body.
Criterion 1.5.7: The organisation ensures that the nutritional needs of consumers / patients are met.
a) Policy / guidelines addressing a) A multidisciplinary team oversees a) Compliance with policy / a) The organisation shows a) The organisation demonstrates
the delivery of nutritional care the organisation’s nutrition guidelines for the delivery of distinction in its management it is a leader in strategies to
are consistent with relevant management strategy to ensure nutritional care is monitored of consumer / patient ensure that the nutritional
legislation, standards, that the provision of food and fluid and evaluated, and nutrition. needs of consumers / patients
guidelines and/or codes of to consumers / patients is improvements are made as are met.
practice. consistent with good nutritional required.
care.
b) The organisation has a strategic b) The nutritional care of
and coordinated approach to b) The nutrition policy / guidelines consumers / patients is
delivering consumer / patient- are adapted to local needs and evaluated, and improvements
centred nutritional risk implemented across the are made as required.
screening and care for those organisation.
with malnutrition. c) Education on nutritional care
c) Relevant health professionals use and malnutrition is evaluated,
c) Food, fluid and nutritional care a validated nutrition risk screening and improvements are made
is considered as part of an tool to assess consumers / as required.
intervention and medical patients:
treatment plan. (i) on admission d) Incidents contributing to
(ii) weekly thereafter deterioration in consumer /
d) Health professionals and other (iii) following a change of health patient nutritional status are
relevant staff are provided with status. analysed and trended, and
orientation and ongoing improvements are made to the
education about their roles and d) Strategies to deliver food and nutritional policy / guidelines
responsibilities in delivering fluids to consumers / patients as required.
nutritional care and preventing requiring physical assistance are
malnutrition. implemented, according to the e) Outcomes of the evaluation of
consumer / patient requirements. the system for delivering
e) Nutritional care is incorporated nutritional care and preventing
into the consumer / patient e) Referrals to nutrition-related malnutrition, including incident
care plan, in collaboration with services occur in a timely manner. management, are reported to
the consumer / patient and, the governing body.
when practicable, their carer. f) The organisation supports staff,
consumers / patients and carers in
the identification and reporting of
nutrition-related incidents and
near misses.
Standard 1.6: The governing body is committed to consumer / patient participation.
Criterion 1.6.1: Consumers / patients, carers and the community participate in the planning, delivery and evaluation of the health service.
a) Policy / guidelines addressing a) Consumers / patients and, a) The consumer / patient, carer a) The organisation shows a) The organisation demonstrates
consumer / patient, carer and when relevant, carers are and community participation distinction in consumer / it is a leader in consumer /
community participation are involved in policy / guideline program is evaluated with patient and carer participation. patient, carer and community
readily available to staff. development and health consumer / patient and carer participation in the planning,
services planning. involvement, and delivery and evaluation of the
b) The organisation has identified improvements are made as health service.
its community and main b) Consumers and consumer required.
consumer groups. groups are consulted about
effective ways of participating b) The organisation’s facilitation of
c) Consumer participation is with the organisation and consumer participation,
representative of the partnerships are established. including committee
community that the membership, is evaluated, and
organisation serves. c) Relevant staff are trained in improvements are made as
how to implement and evaluate required.
d) The organisation identifies ways consumer / patient, carer and
of encouraging consumer community group participation c) Education and training of staff
participation in the planning, strategies. in consumer / patient, carer and
delivery and evaluation of care community group participation
and services, and implements d) Consumers / patients, carers and the involvement of staff in
relevant training. and other stakeholders are participation strategies is
provided with relevant evaluated, and improvements
e) Relevant staff are educated in information to enable them to are made as required.
how consumers / patients and fully participate in the activities
carers can participate in the of committees. d) Outcomes of consumer /
planning, delivery and patient, carer and community
evaluation of the health service. involvement in the evaluation
of the health service are
f) The governing body communicated to the governing
demonstrates its commitment body.
to consumer / patient, carer
and community participation.
Criterion 1.6.2: Consumers / patients are informed of their rights and responsibilities.
a) Policy / guidelines / charters a) Staff and volunteers are a) The system to inform a) The organisation shows a) The organisation demonstrates
addressing consumer / patient provided with orientation and consumers / patients of their distinction in its recognition of it is a leader in processes to
rights and responsibilities are ongoing education about their rights and responsibilities is and support for consumer / ensure that consumer / patient
consistent with relevant role with respect to: evaluated, and improvements patient rights and rights and responsibilities are
legislation, standards, (i) consumer / patient rights to documents and practices are responsibilities. respected and supported.
guidelines and/or codes of and responsbilities made as required.
practice, and are readily (ii) how to maintain privacy
available to staff. and confidentiality while b) Consumer / patient privacy and
interacting with consumers confidentiality are monitored,
b) Policy / guidelines addressing / patients breaches are analysed, action is
the management of personal (iii) maintaining confidentiality taken according to policy, and
and health-related information of consumer / patient improvements are made as
are consistent with relevant personal and health-related required.
privacy legislation, and are information.
readily available to staff. c) Feedback from consumers /
b) The organisation provides patients, carers and the
c) Staff and volunteers sign consumers / patients and carers community informs the
confidentiality agreements on with a copy of the rights and organisation’s evaluation of its
appointment. responsibilities document. management of rights and
responsibilities.
d) Information about consumer / c) Staff discuss rights and
patient rights and responsibilities with the
responsibilities is readily consumer / patient and, when
available to consumers / practicable, their carer.
patients, staff and the
community in appropriate
formats / languages. d) Feedback is sought from
consumers / patients, carers
e) The organisation provides and the community regarding
information on how consumers the organisation’s management
/ patients and, when of rights and responsibilities.
practicable, carers can access
advocacy and support services.
f) The procedure for consumer /

patient access to their health
records is documented and
communicated to consumers /
patients and carers.
Criterion 1.6.3: The organisation meets the needs of consumers / patients and carers with diverse needs and from diverse backgrounds.
a) Policy / guidelines are a) Food, services, care and a) The organisation evaluates a) The organisation shows a) The organisation demonstrates
consistent with relevant consideration for spiritual / whether the diverse needs of distinction in its provision of it is a leader in service delivery,
legislation, standards, cultural needs are provided in a consumers / patients and their services for those with diverse consultation and participation
guidelines and/or codes of manner that is appropriate to carers are met, and strategies needs and/or from diverse strategies that meet the
practice, and ensure that the consumers / patients with for improvement are backgrounds. requirements of consumers /
organisation meets the needs of diverse needs and/or from implemented as required. patients and carers with diverse
consumers / patients and carers diverse backgrounds. needs and from diverse
from diverse backgrounds. b) Data on utilisation of health backgrounds.
b) Translated information is services by people with diverse
b) The organisation collects developed appropriate to the needs and/or from diverse
demographic data to identify diverse needs and/or diverse backgrounds are collected and
the diverse needs and diverse backgrounds of consumers / maintained to monitor access,
backgrounds of the community patients. which is improved as required.
it serves, to ensure appropriate
planning and delivery of care c) Trained interpreters are c) The organisation evaluates its
and services. available and consumers / partnerships with relevant local
patients, carers and staff are and community-based bodies,
c) The organisation enters into informed of the availability. and improvements are made as
partnerships with relevant local required to support the delivery
and community-based bodies, d) Staff are provided with the of care and services to meet the
in order to support the delivery opportunity for training to diverse needs of consumers /
of care and services to those enhance their skills in the patients and their carers.
with diverse needs and/or from planning and delivery of
diverse backgrounds. appropriate services to d) Feedback from consumers /
consumers / patients and carers patients, carers and community
d) Staff are educated about and with diverse needs and/or from informs the organisation’s
have access to information and diverse backgrounds. evaluation of the care and
resources regarding consumers services provided to those with
/ patients and carers with e) Feedback is sought from diverse needs and/or from
diverse needs and/or from consumers / patients, carers diverse backgrounds.
diverse backgrounds. and the wider community
regarding the organisation’s
provision of care and services to
those with diverse needs
and/or from diverse
backgrounds.

Clinical Function EQuIP6 Standard Tables. Final. 1

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Standard 1.

f) Care planning and delivery

c) Details of the information

e) Formalised follow-up occurs for

g) Where appropriate, the

f) Feedback is sought from

e) There is an effective g) Outcomes of the evaluation of

f) Health professionals are

g) Health professionals and other

h) External service providers,

f) Falls risk is considered as part of

f) The procedure for consumer /

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