Ach067 Equip National Day Procedures Completeweb

EQuIPNational
Day Procedure Centres Standards

Safety. Quality. Performance.
EQuIPNational Standards
Published by the Australian Council on Healthcare Standards (ACHS)
Copies available from the ACHS Publications Service
Phone: + 61 2 9281 9955
Fax: + 61 2 9211 9633
Copyright © The Australian Council on Healthcare Standards (ACHS)
This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may be reproduced
by any process without prior written permission from The Australian Council on Healthcare Standards. Requests
and enquiries concerning reproduction and rights should be addressed to the Chief Executive, The Australian
Council on Healthcare Standards, 5 Macarthur Street, Ultimo NSW 2007 Australia
Recommended citation: The Australian Council on Healthcare Standards (ACHS) EQuIPNational Day Procedure
Centres Standards and Guidelines. Sydney Australia; ACHS; 2012.
EQuIPNational Day Procedure Centres Standards and Guidelines
First Published 2012
ISBN 13: 978-1-921806-41-4 (paperback)
ISBN 13: 978-1-921806-42-1 (web)
EQuIPNational Day Procedure Centres Standards
Contents
Foreword2
Introduction4
About the Australian Council on Healthcare Standards 6
What is Accreditation? 7
Layout of the EQuIPNational Day Procedure Centres Standards 7
Ratings8
Standards:
Standard 11: Service and Care Delivery 9
Standard 12: Workforce Planning and Management 14
Standard 13: Information Management 17
Standard 14: Organisational Systems 21
Standard 15: Systems for Safety 24
Guidelines:
Acknowledgements161
EQuIPNational Day Procedure Centres Standards and Guidelines 1

Foreword
The Australian Council on Healthcare Standards (ACHS) has been at the forefront of
healthcare accreditation in Australia for almost 40 years and continues this tradition
with the latest evolution in its healthcare standards.
On behalf of the Board and Council I am very proud of the achievement that the new EQuIPNational program
represents. ACHS has created an innovative product to meet the expectations of the healthcare system.
With the introduction of the compulsory National Safety and Quality Health Service (NSQHS) Standards
by the Australian Commission on Safety and Quality in Health Care (ACSQHC), ACHS offers a program
for quality and safety that extends beyond the ACSQHC’s focus and encompasses all major components
of a healthcare provider’s organisational activities.
This new program, EQuIPNational Day Procedure Centres, continues the strong legacy of the Evaluation
and Quality Improvement Program (EQuIP) with the addition of a further five standards derived from
EQuIP5 Day Procedure Centres. They complement the Commission’s ten standards, and offer a
comprehensive performance assessment program.
Following wide consultation throughout the industry to review the veracity of ACHS’s knowledge, careful
consideration has been given to the selection of the new standards, as well as the range of criteria and
actions they incorporate. Importantly, their format has been aligned to that adopted by the ACSQHC to
facilitate the use of these standards by member organisations.
The new EQuIPNational Day Procedure Centres program is impressive. It distinguishes itself as a robust
program that will appeal to day procedure centres participating in accreditation programs and who wish
to cover specific areas not addressed in the NSQHS Standards, including: Service and Care Delivery,
Workforce Planning and Management, Information Management, Organisational Systems and Systems
for Safety.
By adopting a wider range of standards, day procedure centres will have the opportunity to grow and
expand their capabilities and maintain contemporary performance strategies directed at assuring safety
and quality in the delivery of services. EQuIPNational Day Procedure Centres ensures our members have
the opportunity to remain as leaders in patient quality and safety, and continuous improvement.
ACHS’s ongoing influence and authority on the national quality and health services agenda continues
with the release of EQuIPNational Day Procedure Centres. On behalf of the Board and the Council of ACHS,
I commend to you the new EQuIPNational Day Procedure Centres program.
Adjunct Associate Professor Karen Linegar FCNA

President, ACHS
November 2012
2 EQuIPNational Day Procedure Centres Standards and Guidelines

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Introduction
The National Safety and Quality Health
Service (NSQHS) Standards are a critical
component of the Australian Health Services
Safety and Quality Accreditation Scheme EQuIPNational Day
and were endorsed by the Australian Procedure Centres removes
Health Ministers in September 2011. duplication of content
Assessment against the NSQHS Standards between EQuIP5 Day
for accreditation is mandatory for hospitals Procedure Centres and
and day procedure services nationally from
the NSQHS Standards and
1 January 2013.
is designed to provide a
In response to the implementation of the seamless, organisation-
NSQHS Standards, ACHS has developed wide quality improvement
a program that allows day procedure framework. EQuIPNational
centre member organisations to retain the Day Procedure Centres
organisation-wide evaluation and quality Standards presents existing
improvement program that is EQuIP. EQuIP content, reformatted
to align with the NSQHS
ACHS accreditation programs are based
Standards format. It includes
on partnerships and consultations with
key stakeholders and participants in the the ten NSQHS Standards:
healthcare industry, so that the standards
and accreditation services reflect their
needs and encourage ownership of the
programs. EQuIPNational Day Procedure
Centres has been developed with input
from member organisations and other
relevant stakeholders via a process of EQuIPNational Day Procedure
field review and extensive consultation. Centres provides a further
five Standards that focus
on the performance of
non-clinical systems as
part of a comprehensive
organisation‑wide assessment:

1. Governance for Safety and Quality in Health Service Organisations
2. Partnering with Consumers
3. Preventing and Controlling Healthcare Associated Infections
4. Medication Safety
5. Patient Identification and Procedure Matching
6. Clinical Handover
7. Blood and Blood Products
8. Preventing and Managing Pressure Injuries
9. Recognising and Responding to Clinical Deterioration in Acute Health Care
10. Preventing Falls and Harm from Falls
11. Service and Care Delivery
12. Workforce Planning and Management
13. Information Management
14. Operational Systems
15. Systems for Safety

About the Australian Council on Healthcare Standards

The Australian Council on Healthcare Standards Effective leadership – demonstrates responsibility
(ACHS) is an independent, not-for-profit organisation and commitment to excellence in care provision,
dedicated to improving the quality of health care in quality improvement and performance by:
Australia through the continual review of performance, • providing direction for the organisation /
assessment and accreditation. ACHS was established health service
in 1974 and is the leading independent authority
• pursuing the ongoing development of strategies,
on the measurement and implementation of quality
systems and methods for achieving excellence
improvement systems for Australian healthcare
organisations. ACHS offers accreditation services, • inspiring and motivating the workforce and
standards development, clinical indicators and encouraging employees to contribute, develop
education services. and learn
• considering proposals that are innovative
The ACHS vision is to improve the quality and safety and creative.
of health care. Its mission is to be the leading provider
of products and services for accreditation that Continuous improvement – management and staff
support performance excellence in safety and quality demonstrate how they continually strive to improve the
programs for a broad range of health service providers quality of care. Continuous improvement assists the
and consumers. organisation / health service through:
• looking for ways to improve as an essential part of
The ACHS Council is comprised of individuals who
everyday practice
represent peak industry bodies in health, professional
colleges and associations, governments and healthcare • consistently achieving and maintaining quality care
consumers. ACHS is governed by a Board of Directors that meets consumer / patient needs
elected by and from Council members. The ACHS Board • monitoring outcomes in consumer / patient care and
is supported by a corporate management structure that seeking opportunities to improve both the care and
oversees standards development and the evaluation of its results.
health services against those standards by surveyors
who have professional experience within relevant Evidence of outcomes – organisations depend on the
healthcare service sectors. measurement and analysis of performance. Indicators of
good care processes or, wherever possible, outcomes
The principles upon which all ACHS programs are of care, demonstrate a commitment to maintaining
developed reflect the characteristics displayed by an quality and striving for ongoing improvement by:
improving organisation. These principles can be applied • providing critical data and information about key
to all aspects of service within an organisation. processes, outputs and results
A consumer focus – care provision is demonstrated by: • reflecting those factors that lead to improved health
and/or quality of life for consumers / patients or to
• understanding the needs and expectations of
better operational performance.
present and potential consumers / patients
• ensuring consumers / patients are the priority Striving for best practice – the organisation compares
• evaluating the service from the consumer / its performance with, or learns from, others and
patient perspective. applies best-practice principles. Organisations might
demonstrate their efforts through:
• discovering new techniques and technologies, and
using them to achieve world-class performance
• learning from others to increase the efficiency
and effectiveness of processes
• improving consumer / patient satisfaction
and outcomes.

What is Accreditation? Layout of the
Accreditation is public recognition by a healthcare Equipnational Day Procedure
accreditation body of the achievement of accreditation
standards by a healthcare organisation, demonstrated
Centres Standards
through an independent external peer assessment of
Each Standard contains:
that organisation’s level of performance in relation to
the standards. • the Standard, which outlines the intended actions
and strategies to be achieved
Accreditation systems are considered to comprise • a statement of intent, which describes the intended
five key elements: outcome for the Standard
1. A governance or stewardship function • a statement on the context in which the Standard

must be applied
2. A standards-setting process
• a list of key criteria; each criterion has a series
3. A process of external evaluation of compliance
of items and actions that are required in order to
against those standards
meet the Standard.
4. A remediation or improvement process
following the review The mandatory actions within the five EQuIPNational
5. Promotion of continuous quality improvement Day Procedure Centre‑specific Standards are indicated
by italicised text. For the significance of the mandatory
The EQuIPNational Day Procedure Centres program actions, see Book 2: EQuIPNational Day Procedure
is presented as two books with content as follows: Centres Accreditation Program (available on the
ACHS website).
1. E
QuIPNational Day Procedure Centres
Standards and Guidelines:
• Standard 11 Guidelines
2. E
QuIPNational Day Procedure Centres
Accreditation Program
This is Book 1: EQuIPNational Day Procedure

Centres Standards and Guidelines.

EQuIPNational Day Procedure
Standard 11: Service and CareCentres
DeliveryStandards
Ratings
In line with the Australian Commission on Safety and There are two mechanisms for agreeing Not Applicable
Quality in Health Care’s (ACSQHC) recommendations for Standards / criteria / actions. The ACSQHC publishes
the NSQHS Standards, assessment of EQuIPNational a list of Standards / criteria / actions which may not be
Day Procedure Centres Standards will be against a three applicable in certain healthcare settings, including day
point rating scale: procedure centres. A list of designated Not Applicable
actions is shown in the Day Procedure Services
Not Met – the actions required have not been achieved. Accreditation Workbook, available on the ACSQHC’s
website: www.safetyandquality.gov.au. Any additional
Satisfactorily Met – the actions required have
actions beyond the published list can be applied for
been achieved.
through the ACHS Customer Services Managers and
Met with Merit – in addition to achieving the actions will be reviewed by an internal ACHS Committee. ACHS
required, measures of good quality and a higher level reports the amalgamated results of any additional
of achievement are evident. This would mean a culture Standards / criteria / actions agreed as Not Applicable
of safety, evaluation and improvement is evident to the ACSQHC on a quarterly basis.
throughout the organisation in relation to the action or
An organisation will need to formally discuss and agree
Standard under review.
with its Customer Services Manager any criteria or
This rating system will be used at the level of individual actions that are not applicable to the organisation prior
actions in each Standard and can also be applied to to an onsite survey being undertaken. All EQuIPNational
the overall Standard. Day Procedure Centres criteria will be considered
applicable to all organisations, except where it has
There are a number of Standards, criteria and/or been formally agreed that they are not applicable. It is
items and actions that may not be applicable to some accepted that in some organisations there may be some
organisations. Criteria may be described as ‘Not criteria which are only partially relevant, but in these
Applicable’ when the topic of the criterion would cases the criteria will still be applicable for ACHS onsite
never occur or would never have the potential to survey purposes.
occur in the organisation.

Standard 11
Standard 11: Service and Care Delivery
Service and Care Delivery

Safe, appropriate and effective care of consumers / patients depends upon comprehensive
systems of service delivery. Standard 11 addresses the progression of engagement with the
health service by consumers / patients, through to how services are delivered.
The intention of this Standard is to: Criteria to achieve the Service and Care Delivery
Standard:
Ensure that the community the day procedure centre
serves has access to high quality healthcare services 1. Information and Admission Services
that are appropriate, effective and meet their needs.
The organisation provides information on available
Consumer / patient and clinician needs should
health services to facilitate admission.
be considered from entry / admission to the day
procedure centre, through to discharge or transfer.
2. Consumer / Patient Consent
Context Consumers / patients are informed of the consent
process, and they understand and provide consent
The day procedure centre should define its community for their health care.
and/or regular users of its services, in order to
understand the specific requirements and/or cultural
influences of that community. The community will not 3. Appropriate and Effective Care
necessarily be defined by geography, and will include Health care and services are evaluated to ensure that
the external service providers who refer consumers / they are appropriate and effective.
patients. Care delivery processes should consider the
needs of the consumer / patient to ensure that care is
4. Diverse Needs and Diverse Backgrounds
delivered in the most appropriate and effective way.
The organisation meets the needs of consumers /
patients and carers with diverse needs and from
diverse backgrounds.
5. Assessment, Planning and Delivery

of Care
Assessment, planning and delivery of care ensure that
current and ongoing needs of the consumer / patient
are identified and met.
6. Discharge / Transfer of Care

Systems for discharge and transfer support ongoing
care of the consumer / patient.
EQuIPNational Day Procedure Centres Standards and Guidelines – Standard 11 9

Information and Admission to Services
The organisation provides information on available health services to facilitate admission.
This criterion will be achieved by: Actions required:
11.1 Informing consumers / patients 11.1.1 There is evidence of evaluation and improvement of the
and the community about services quality of information provided to consumers / patients and referring
accessible through the organisation. clinicians about:
• services provided by the organisation
• access to support services, including advocacy.
11.1.2 The organisation’s processes for disseminating information

on healthcare services are evaluated, and improved as required.
11.2 Informing healthcare providers 11.2.1 Healthcare providers within the organisation have information
both internal and external about on relevant external services.
health services available.
11.2.2 Relevant external service providers are provided with information
on the health service and are informed of referral and entry processes.
11.3 Meeting the needs of 11.3.1 The organisation evaluates and improves its system for
consumers / patients and the admission / entry, which includes:
community for admission / entry. • clear inclusion and/or exclusion criteria
• minimisation of duplication
• utilisation of information in referral documents from other service
providers received on admission of the consumer / patient.
Consumer / Patient Consent
Consumers / patients are informed of the consent process, and they understand and provide consent for
their health care.
11.4 Demonstrating that the consent 11.4.1 The organisation has implemented policies and procedures
process is managed through systems that address:
of governance which are consistent • how consent is obtained
with organisational, jurisdictional and
• situations where implied consent is acceptable
legislative requirements.
• situations where consent is unable to be given
• when consent is not required
• the limits of consent.
11.4.2 The consent system is evaluated and improved as required.
10 EQuIPNational Day Procedure Centres Standards and Guidelines – Standard 11

Standard 11
Appropriate and Effective Care
Health care and services are evaluated to ensure that they are appropriate and effective.
11.5 Implementing systems to ensure 11.5.1 The organisation ensures appropriate and effective care through:
that consumers / patients receive • processes used to assess the appropriateness of care
appropriate and effective care and
• an evaluation of the appropriateness of services provided
services in the appropriate setting.
• the involvement of clinicians, managers and consumers / patients
in the evaluation of care and services.
11.5.2 Policies / guidelines are implemented that address the

appropriateness of the setting in which care is provided.
Diverse Needs and Diverse Backgrounds
The organisation meets the needs of consumers / patients and carers with diverse needs and from
11.6 Establishing the needs of the 11.6.1 The organisation obtains demographic data to:
community in order to meet legislative • identify the diverse needs and diverse backgrounds of
requirements, inform the delivery of consumers / patients and carers
services and assess whether those
• monitor and improve access to appropriate services
needs are met.
• improve cultural competence, awareness and safety.
11.7 Ensuring that diverse 11.7.1 Policies and procedures that consider cultural and spiritual needs
populations are provided with care are implemented to ensure that care, services and food are provided in
and services that meet their needs. a manner that is appropriate to consumers / patients with diverse needs
and from diverse backgrounds.
11.7.2 Mechanisms are implemented to improve the delivery of care to

diverse populations, where relevant, through:
• demonstrated partnerships with local and national organisations
• providing staff with opportunities for training.

Assessment, Planning and Delivery of Care
Assessment, planning and delivery of care ensure that current and ongoing needs of the consumer / patient
11.8 Ensuring assessment is 11.8.1 Guidelines are available and accessible by staff to assess
comprehensive and based upon physical, spiritual, cultural, psychological and social needs.
current professional standards
11.8.2 Guidelines are available and accessible by staff on the specific
and evidence-based practice.
health needs of self-identified Aboriginal and Torres Strait Islander
consumers / patients.
11.9 Meeting the needs of 11.9.1 The assessment process is evaluated to ensure that it includes:
consumers / patients through • timely assessment with consumer / patient and, where appropriate,
a timely, comprehensive carer participation
assessment process.
• regular assessment of the consumer / patient need for pain
/ symptom management
• provision of information to the consumer / patient on their
health status.
11.9.2 Results of pre-admission investigations follow the

consumer / patient through the referral system.
11.10 Planning and delivering 11.10.1 Planning and delivery of care are evaluated to ensure that it is:
care based upon assessment • effective
of consumer / patient needs.
• comprehensive
• multidisciplinary
• informed by assessment
• documented in the health record
• carried out with consumer / patient consent and, where
appropriate, carer participation.
11.11 Ensuring that the 11.11.1 Planning for discharge / transfer of care is evaluated to
assessment process includes ensure that it:
planning for discharge and use • commences at assessment
of the referral system.
• is coordinated
• consistently occurs
• is multidisciplinary where appropriate
• meets consumer / patient and carer needs.

Standard 11
Discharge / Transfer of Care
Systems for discharge and transfer support ongoing care of the consumer / patient.
11.12 Ensuring that appropriate 11.12.1 Discharge / transfer information is discussed with the consumer
clinical information is made available / patient and a written discharge summary and/or discharge instructions
in a timely manner to external are provided.
healthcare providers and consumers
11.12.2 Arrangements with other service providers and, where
/ patients to facilitate ongoing care.
appropriate, the carer are made with consumer / patient consent
and input, and confirmed prior to discharge / transfer of care.
11.13 Implementing a system that 11.13.1 Formalised follow up occurs for identified at-risk
facilitates follow up of identified consumers / patients.
at‑risk consumers / patients.
11.14 Implementing policy and 11.14.1 Policy and procedures for the management of an unexpected
procedures that address mortality death consistent with jurisdictional legislation, policy and common law
management. are available, and staff receive relevant education.

Standard 12: Workforce Planning and Management

Workforce planning is a continuous process of matching workforce requirements to the
organisation’s objectives, and anticipating the human resource implications when undertaking
particular operational or strategic activities. Workforce management is the policies, practices
and systems that influence employees’ behaviours, attitudes and performance.1
The intention of this Standard is to: Criteria to achieve the Workforce Planning and
Management Standard:
Ensure that the organisation recruits and manages its
workforce in a manner that supports the delivery of safe,
high quality health care. Workforce planning needs to
1. Workforce Planning
consider the changing environmental and social factors Workforce planning supports the organisation’s
which will impact on the availability and needs of the current and future ability to address needs.
workforce, to ensure that the day procedure centre’s
current and future workforce needs will be met. 2. Recruitment and Ongoing Clinician
Appointment Processes
Context The recruitment, selection and appointment system
Recruitment policies and procedures should aim to ensures that the skill mix and competence of staff
assemble the right skill mix of staff to undertake the meets the needs of the organisation.
activities of the day procedure centre. Human resources
management systems should be in place to promote 3. Continuing Employment and
an environment and culture that strive toward building
effective staff relationships through participatory
Development
management, effective leadership and sound The continuing employment and development system
professional practice. ensures the competence of staff.
Workplace policies and procedures need to

communicate the minimum performance level expected
4. Employee Support and Workplace
by defining the requirements for employees to undergo Relations
sufficient education and training to perform their Employee support systems and workplace relations
role safely and effectively. Continuing professional assist the organisation to achieve its goals.
development and employee support systems
are important in the retention and growth of high
quality staff.

Standard 12
Workforce Planning and Management
Workforce Planning
Workforce planning supports the organisation’s current and future ability to address needs.
12.1 Ensuring that the long-term and 12.1.1 Workforce management functions and responsibilities are clearly
broader goals of the organisation identified and documented.
are met by workforce planning that
12.1.2 The workforce policy, procedures, plan, goals and strategic
reflects current and future needs of
direction are regularly reviewed, evaluated, and improved as required.
consumers / patients and staff and
is clearly linked to the organisation’s
strategic direction.
12.2 Implementing systems 12.2.1 Contingency plans are developed to maintain safe, quality care
to ensure that the skill mix of if prescribed levels of skill mix of clinical and support staff are not
clinical and support staff meets available, and in order to manage workforce shortages.
consumer / patient needs and
service requirements.
12.3 Minimising fatigue risk 12.3.1 The system for managing safe working hours and fatigue
associated with extended prevention is evaluated, and improved as required.
working hours.
Recruitment and Ongoing Clinician Appointment Processes
The recruitment, selection and appointment system ensures that the skill mix and competence of staff
meets the needs of the organisation.
12.4 Meeting and ensuring 12.4.1 The recruitment, selection and appointment systems are
compliance with: evaluated, and adapted to changing service needs where required.
• legislation
• jurisdictional policy / regulations
• organisational policy / guidelines
for recruitment, selection and
appointment in a healthcare setting.
12.5 Verifying the credentials 12.5.1 Recruitment processes ensure adequate staff numbers
of clinicians prior to commencement and that the workforce has the necessary licences, registration,
of employment / contracts. qualifications, skills and experience to perform its work.
12.5.2 The credentialling system to confirm the formal qualifications,

training, experience and clinical competence of clinicians, which is
consistent with national standards and guidelines and with organisational
policy, is evaluated, and improved as required.
12.6 Ongoing monitoring of 12.6.1 Ongoing monitoring and review of clinicians’ performance is
clinician performance. linked to the credentialling system.

Continuing Employment and Development
The continuing employment and development system ensures the competence of staff.
12.7 Ensuring that personnel 12.7.1 Accurate and complete personnel records are maintained
records contain current relevant and kept confidential.
information as required, including
12.7.2 There is a system to document training for staff which is
evidence of registrations.
identified as necessary by the organisation.
12.8 Integrating the performance 12.8.1 The performance assessment and development system includes:
development system for staff, • review of position descriptions
including contracted staff, with any
• review of competencies
relevant service plans or changing
service requirements. • monitoring of compliance with published codes of
professional practice
• assessment of learning and development needs
• provision of adequate resources for learning and development
• management of identified performance needs.
12.9 Having a system to protect the 12.9.1 Processes are in place for managing a complaint or concern
interests of consumers / patients about a clinician, and there is evidence that they have been used.
and carers, clinicians and other staff,
12.9.2 Processes are in place for managing a complaint or concern
and the organisation, during the
about a member of staff, including contracted staff, and there is evidence
management of a complaint.
they have been used.
Employee Support and Workplace Relations
Employee support systems and workplace relations assist the organisation to achieve its goals.
12.10 Providing clear information 12.10.1 The workplace rights and responsibilities of management
about staff rights and responsibilities and staff are clearly defined and communicated.
including access to grievance
12.10.2 Managers take action on at-risk behaviour of staff.
processes, and taking action
when needed.
12.11 Management and staff 12.11.1 There is a consultative and transparent system to identify,
working cooperatively to achieve manage and resolve workplace relations issues which is evaluated,
effective workplace relations, with and improved as required.
involvement of relevant external
groups where appropriate.
12.12 Implementing strategies to 12.12.1 Strategies to:

create a workplace culture that • motivate staff
fosters and encourages staff.
• acknowledge the value of staff
• support flexible work practices
• promote staff health and wellbeing
are evaluated with staff participation, and improved as required.
12.13 Facilitating access to an 12.13.1 Performance measures are used regularly to assess staff access
effective system to provide support to an employee assistance program and to evaluate the staff support
to the workforce. services, and improvements are made as required.

Standard 13: Information Management

Day procedure centres should have a well set up, monitored, controlled and managed
information system in place. The information system should be set up for both internal and
external use by clinicians and other staff members as well as external entities, for example,
government departments, coroners, researchers, if applicable, and other healthcare providers.
The intention of this Standard is to: Criteria to achieve the Information Management
Standard:
Ensure that information and data are collected and
used to meet the day procedure centre’s needs
and support the delivery of safe, high quality health
1. Health Records Management
care and services. Organisations collect a vast Health records management systems support
amount of information and data on a regular basis1, the collection of information and meet the
therefore it is imperative that systems are in place consumer / patient and organisation’s needs.
for appropriate management of this information,
which ensure compliance with legislative and 2. Corporate Records Management
jurisdictional requirements.
Corporate records management systems support
the collection of information and meet the
Context organisation’s needs.
Information and data are important for:
• the provision of health care and services 3. Collection, Use and Storage
• continuity of consumer / patient care of Information
• organisational and staff performance Data and information are collected, stored and
• organisational safety and risk management used for strategic, operational and service
improvement purposes.
• compliance with legislation, standards
and guidelines.
4. Information and Communication
Good information management principles should be in
Technology
place in all healthcare organisations regardless of size,
location or method of record keeping. Information and The organisation has an integrated approach to the
data management systems should be integrated with planning, use and management of information and
communication technology. Although this Standard communication technology (ICT).
does not dictate the method of record keeping, factors
pertinent to the chosen method need to be considered
when developing management plans. Access to records
needs to be provided to authorised persons in a timely
manner and should be facilitated by a well-organised
filing, tracking and retrieval system.

Health Records Management
Health records management systems support the collection of information and meet the consumer / patient
and organisation’s needs.
13.1 Addressing the needs of the 13.1.1 Health records management systems are evaluated to ensure
organisation by implementing systems that they include:
to manage health records and • reference to all relevant legislation / standards / policy / guidelines
records created by the organisation.
• defined governance and accountability
• the secure, safe and systematic storage and transport of data
and records
• timely and accurate retrieval of records stored on or off site,
or electronically
• appropriate retention and destruction of records
• training for relevant staff in health records management.
13.2 Establishing a system to support 13.2.1 The system for the allocation and maintenance of the
the allocation and maintenance of organisation-specific consumer / patient identifier, including a process
an organisation-specific consumer for checking multiple identifiers, is evaluated, and improved as required.
/ patient identifier for the first
and every subsequent visit to the
organisation by a consumer / patient
to ensure continuity of care.
13.3 Clinical coding and classification 13.3.1 Clinical coding and reporting time frames that meet internal and
that is performed for all consumers external requirements are evaluated, and improved as required.
/ patients accessing services in
accordance with jurisdictional
standards, where available, or
guidelines.
13.4 Implementing systems to ensure 13.4.1 Consumers / patients are given advice / written guidelines on
that consumer / patient access to how to access their health information and requests for access are met.
health records is in accordance with
jurisdictional policy / legislation.

Standard 13
Information Management
Corporate Records Management
Corporate records management systems support the collection of information and meet the organisation’s
needs.
13.5 Addressing the needs of 13.5.1 Corporate records management systems are evaluated to ensure
the organisation by implementing that they include:
systems to manage corporate records • reference to all relevant legislation / standards / policy / guidelines
created by the organisation.
• defined governance and accountability
• the secure, safe and systematic storage and transport of data
and records
• standardised record creation and tracking
• appropriate retention and destruction of records
• training for relevant staff in corporate records management.
Collection, Use and Storage of Information
Data and information are collected, stored and used for strategic, operational and service improvement
purposes.
13.6 Implementing an 13.6.1 Monitoring and analysis of clinical and non-clinical data and
information management plan information occurs to ensure:
and system that addresses the • accuracy, integrity and completeness
needs of the organisation.
• the timeliness of information and reports
• that the needs of the organisation are met
and improvements are made as required.
13.6.2 The information management system is evaluated to ensure

that it includes:
• identification of the needs of the organisation
• compliance with professional and statutory requirements for
collection, storage and use of data
• the validation and protection of data and information
• delineation of responsibility and accountability for action on data
and information
• adequate resourcing for the assessment, analysis and use of data
• data storage and retrieval facilitated through effective classification
and indexing
• contribution to external databases and registers
• training of relevant staff in information and data management.
13.7 Ensuring that reference and 13.7.1 Staff have access to contemporary reference and
resource material meets the needs resource material.
of staff.

Information and Communication Technology
The organisation has an integrated approach to the planning, use and management of information and
communication technology (ICT).
13.8 Ensuring effective governance 13.8.1 The ICT system is evaluated to ensure that it includes:
of an ICT system that includes a • backup
risk management framework and
• security
a strategy for meeting current and
future needs, and which is supported • redundancy
by policy and procedure. • protection of privacy
• virus detection
• preventative maintenance and repair
• disaster recovery / business continuity
• risk and crisis management
• monitoring of compliance with ICT policy and procedures.
13.8.2 Licences are purchased as required to ensure intellectual

property rights and title to products are retained by product owners.

Standard 14: Organisational Systems

Health systems are complex and dynamic, and characterised by constant change and
innovation in the organisation, funding and delivery of health services. They operate in a
context of changing social, economic and political environments. Standard 14 addresses
the systems that assist the management of day procedure centres.
The intention of this Standard is to: Criteria to achieve the Organisational Systems Standard:
Ensure that systems to support the delivery of

quality health care are implemented and governed
1. Strategic and Operational Planning
appropriately. The day procedure centre must have The organisation provides quality, safe health care
an awareness of the need for strong leadership and and services through strategic and operational
direction and this must be demonstrated through planning and development.
clear strategic and operational planning, a vision and
mission, and organisational goals. 2. External Service Providers
External service providers are managed to maximise
Context quality, safe health care and service delivery.
Organisational strategy defines what an organisation
seeks to do and how it plans to do it. While a formal 3. Research Governance
plan may guide overall direction, strategy development
The organisation’s research program develops the
is a continuous process, enabling a day procedure
body of knowledge, protects staff and consumers /
centre to respond to changes in its environment as
patients and has processes to appropriately manage
appropriate.1 Strategic planning is a management
the organisational risk.
tool that helps an organisation to assess and adjust
its direction in response to a changing environment
– to focus its energy, and to ensure that its staff and
stakeholders are working toward the same goals. 2
In some cases, organisations will find it necessary

to utilise external service providers. The system to
manage external service providers needs to cover
the whole engagement process from procurement
and selection, through to the provision of services,
and the evaluation of completed work.
Participation in research is encouraged, in order to

further the body of knowledge and evidence available
to the day procedure centre. Research projects
and initiatives must be carried out within an ethical
framework that is established and accepted by peers
and the community.

Strategic and Operational Planning
The organisation provides quality, safe health care and services through strategic and operational
planning and development.
14.1 The governing body reviewing 14.1.1 The strategic plan that:
progress towards achieving the • includes vision, mission and values
vision, goals and objectives of the
• identifies priority areas for care, service delivery and facility
strategic plan.
development
• considers the most efficient use of resources
• formally recognises relationships with relevant external organisations
is regularly reviewed by the governing body.
14.1.2 Leaders and managers act to promote a positive

organisational culture.
14.1.3 Operational plans developed to achieve the organisation’s goals

and objectives and day-to-day activities comply with appropriate by-laws,
articles of association and/or policies and procedures.
14.2 Ensuring that change and risk 14.2.1 Changes driven by the strategic plan are communicated to,
management are considered in the and evaluated in consultation with, relevant stakeholders.
development of plans.
14.2.2 Change management strategies are implemented to achieve
the objectives of the strategic and operational plans.
14.3 Implementing a formal 14.3.1 Compliance with delegations is monitored and evaluated,
system for delegating authority and improved as required.
for the management of clinical
and non‑clinical services.
14.4 Facilitating the management 14.4.1 Organisational committees:

and monitoring of health services • have access to terms of reference, membership and procedures
through effective committees
• record and confirm minutes and actions of meetings
and meetings.
• implement decisions
and are evaluated, and improved as required.

Standard 14
Organisational Systems
External Service Providers
External service providers are managed to maximise quality, safe health care and service delivery.
14.5 Implementing systems to 14.5.1 There is evidence of evaluation and improvement of systems
manage external service providers. to manage external service providers, which:
• are governed by implemented policy and procedure
• include documented service agreements
• define dispute resolution mechanisms
• monitor compliance of service providers with relevant regulatory
requirements and specified standards.
14.5.2 The organisation evaluates the performance of external

service providers through agreed performance measures, including
clinical outcomes and financial performance where appropriate,
and improvements are made as required.
Research Governance
The organisation’s research program develops the body of knowledge, protects staff and consumers /
patients and has processes to appropriately manage the organisational risk.
14.6 Fostering and 14.6.1 The system that:

encouraging clinical and • determines what research requires ethical approval
health services research.
• oversees the ethical conduct of organisational research
• monitors the completion of required reporting
is evaluated, and improved as required.
14.7 Ensuring research integrity 14.7.1 Systems are implemented to effectively govern research
through governing body oversight. through policy / guidelines consistent with:
• jurisdictional legislation
• key NHMRC statements
• codes of conduct
• scientific review standards.
14.7.2 The governance of research through:

• documented accountability and responsibility
• establishing formal agreements with collaborating agencies
• adequately resourcing the organisation’s human research ethics
committee (HREC), where applicable

Standard 15: Systems for Safety

The delivery of safe, high quality health care requires the development and implementation
of systems to ensure the safety and wellbeing of consumers / patients, staff, visitors and
contractors. Standard 15 addresses the creation of a safe organisational environment through
a comprehensive safety management system.
The intention of this Standard is to: Criteria to achieve the Systems for Safety Standard:
Ensure that the day procedure centre protects the

safety and wellbeing of all those on its premises,
1. Safety Management Systems
through the organisation’s: Safety management systems ensure the safety
• systems for work health and safety (WHS) and wellbeing of consumers / patients, staff, visitors
and contractors.
• management of its workplaces and equipment
• planning and preparedness for emergencies
2. Buildings, Plant and Equipment
• processes for physical and personal security
Buildings, signage, plant, medical devices, equipment,
• appropriate waste and environmental management.
supplies, utilities and consumables are managed safely
and used efficiently and effectively.
Context
The day procedure centre has a responsibility for the 3. Emergency Management
safety and wellbeing of consumers / patients, staff,
Emergency management supports safe practice and
visitors and contractors. Clear lines of accountability
a safe environment.
and responsibility should be established for specific
aspects of safety and quality within the day procedure
centre, and clearly defined within documented policies 4. Physical and Personal Security
and procedures. All aspects of safety management Security management supports safe practice and a
should be regularly evaluated and tested to ensure safe environment.
that organisational safety is not compromised.
5. Waste and Environmental Management

Waste and environmental management supports safe
practice and a safe and sustainable environment.

Standard 15
Systems for Safety
Safety Management Systems
Safety management systems ensure the safety and wellbeing of consumers / patients, staff, visitors and
contractors.
15.1 Implementing a safety 15.1.1 Safety management systems include policies and procedures for:
management system that references • work health and safety (WHS)
relevant:
• manual handling
• legislation
• injury management
• Australian standards
• management of dangerous goods and hazardous substances
• codes of practice
• staff education and training in WHS responsibilities.
• industry guidelines.
15.2 Implementing an organisation- 15.2.1 The system for ensuring WHS includes:
wide system for work health and • identification of risks and hazards
safety (WHS).
• documented safe work practices / safety rules for all relevant
procedures and tasks in both clinical and non-clinical areas
• staff consultation
• staff education and provision of information
• an injury management program
• communication of risks to consumers / patients and visitors
and is implemented, evaluated, and improved as required.
15.2.2 Staff with formal WHS responsibilities are appropriately trained.
15.2.3 A register of dangerous goods and hazardous substances

is maintained and Material Safety Data Sheets (MSDSs) are available
to staff.
15.3 Monitoring compliance with 15.3.1 There is evidence of evaluation and improvement of the radiation
the radiation safety management safety management plan, which:
plan and taking remedial action • is coordinated with external authorities
where required.
• includes radiation equipment, a register for all radioactive substances,
and safe disposal of all radioactive waste
• ensures staff exposure to radiation is kept as low as reasonably
achievable (ALARA)
• keeps consumer / patient radiation to a minimum whilst maintaining
good diagnostic quality
• includes a personal radiation monitoring system and any relevant
area monitoring.

Buildings, Plant and Equipment
Buildings, signage, plant, medical devices, equipment, supplies, utilities and consumables are managed
safely and used efficiently and effectively.
15.4 Implementing a procurement, 15.4.1 The procurement, management, risk reduction and maintenance
management, risk reduction and system includes:
maintenance system that is planned, • buildings / workplaces
prioritised, budgeted for and
• plant
documented.
• medical devices / equipment
• other equipment
• workplace design
• supplies
• utilities
• consumables.
15.4.2 Plant and other equipment are installed and operated

in accordance with manufacturer specifications and plant logs
are maintained.
15.5 Reducing the risk of incidents 15.5.1 Incidents and hazards associated with:
and hazards associated with • buildings / workplaces
buildings, plant, medical devices,
• plant
equipment, utilities, consumables
and supplies. • medical devices / equipment
• other equipment
• supplies
• utilities
• consumables
are documented and evaluated, and action is taken to reduce risk.
15.5.2 The safety and accessibility of buildings / workplaces, and the

safe and consistent operation of plant and equipment, are evaluated,
and improvements are made to reduce risk.
15.6 Ensuring that physical access to 15.6.1 Access to the organisation is facilitated by:
the organisation’s facilities meets the • clear internal and external signage
identified needs of the community.
• the use of relevant languages and multilingual / international symbols
• the provision of disability access
• facility design that meets legislative requirements and/or is based on
recognised guidelines.

Standard 15
Systems for Safety
Emergency Management
Emergency management supports safe practice and a safe environment.
15.7 Implementing systems for 15.7.1 There is evidence of evaluation and improvement of the
prevention, preparedness, response emergency management systems, which include:
and recovery in emergencies, • identification of potential internal and external emergencies
including triage and deployment of
• coordination with relevant external authorities
medical teams where appropriate,
that comply with: • installation of an appropriate communication system
• legislation • development of a response, evacuation and relocation plan
• Australian standards • display of relevant signage and evacuation routes
• codes of practice • planning for business continuity.
15.8 Ensuring correct 15.8.1 There is evidence of evaluation and improvement of staff training
organisational response to and competence in emergency procedures, which includes:
emergencies and disasters. • education at orientation
• annual training in emergency, evacuation and relocation procedures
• regularly conducted emergency practice / drill exercises
• the appointment of an appropriately trained fire officer
• access to first aid equipment and supplies, and training of
relevant staff.
15.9 Assessing compliance of 15.9.1 There is documented evidence that an authorised external
buildings with relevant jurisdictional provider undertakes a full fire report on the premises at least
fire codes and documenting plans in once within each EQuIPNational cycle and/or in accordance with
response to any recommendations jurisdictional legislation.
from inspections.
15.9.2 There is a documented plan to implement recommendations
from the fire inspection.

EQuIPNational Day Procedure
Standard 15: Systems Centres Standards
for Safety
Physical and Personal Security
Security management supports safe practice and a safe environment.
15.10 Implementing policy and 15.10.1 Service planning includes strategies for security management.
systems for the management
15.10.2 The organisation-wide system to identify and assess security
of security risks that reference
risks, determine priorities and eliminate risks or implement controls is
any relevant:
evaluated, and improved as required.
• legislation
15.11 Involving staff and 15.11.1 Staff are consulted in decision making that affects organisational
relevant authorities in decision and personal risk, and are informed of security risks and responsibilities.
making around issues that affect
15.11.2 Security management plans are coordinated with relevant
security management.
external authorities.
15.12 Minimising violence and 15.12.1 The violence and aggression management plan is evaluated
aggression in the workplace through to ensure that it includes:
an organisation-wide violence and • policies / procedures for the minimisation and management
aggression management plan. of violence and aggression
• staff education and training
• appropriate response to incidents.
Waste and Environmental Management
Waste and environmental management supports safe practice and a safe and sustainable environment.
15.13 Implementing a system for 15.13.1 The waste and environmental management system is evaluated
the management of waste. to ensure that it includes:
• development and implementation of policy
• coordination with external authorities
• staff instruction and provision of information on their responsibilities.
15.14 Implementing systems based 15.14.1 Controls are implemented to manage:

on recycling, reducing and reusing • identification
processes and identifying waste
• handling
management streams through
signage to ensure separation • separation and segregation
and segregation of waste within of clinical, radioactive, hazardous and non-clinical waste, and the
the organisation. controls are evaluated, and improved as required.
15.15 Implementing systems to 15.15.1 The system to:

manage resource sustainability. • increase the efficiency of energy and water use
• improve environmental sustainability
• reduce carbon emissions

Guidelines Contents
Criterion 1: Information and Admission to Services 31

Criterion 2: Consumer / Patient Consent 38
Criterion 3: Appropriate and Effective Care 42
Criterion 4: Diverse Needs and Diverse Backgrounds 45
Criterion 5: Assessment, Planning and Delivery of Care 49
Criterion 6: Discharge / Transfer of Care 56
Criterion 1: Workforce Planning 63

Criterion 2: Recruitment and Ongoing Clinician Appointment Processes 68
Criterion 3: Ongoing Employment and Development 74
Criterion 4: Employee Support and Workplace Relations 80
Criterion 1: Health Records Management 88

Criterion 2: Corporate Records Management 94
Criterion 3: Collection, Use and Storage of Information 97
Criterion 4: Information and Communication Technology 102
Criterion 1: Strategic and Operational Planning 108

Criterion 2: External Service Providers 116
Criterion 3: Research Governance 119
Criterion 1: Safety Management Systems 127

Criterion 2: Buildings, Plant and Equipment 135
Criterion 3: Emergency Management 142
Criterion 4: Physical and Personal Security 148
Criterion 5: Waste and Environmental Management 154

Introduction
Safe, appropriate and effective care of consumers / patients depends upon comprehensive
systems of service delivery. Standard 11 addresses the progression of engagement with the
health service by consumers / patients, through to how services are delivered.
The intention of this Standard is to: Criteria to achieve Standard 11

Ensure that the community the day procedure centre
serves has access to high quality healthcare services
1. Information and Admission to Services
that are appropriate, effective and meet their needs. The organisation provides information on available
Consumer / patient and clinician needs should be health services to facilitate admission.
considered from entry / admission to the day procedure
centre, through to discharge or transfer. 2. Consumer / Patient Consent
Consumers / patients are informed of the consent
Context process, and they understand and provide consent
The day procedure centre should define its community for their health care.
and/or regular users of its services, in order to
understand the specific requirements and/or cultural 3. Appropriate and Effective Care
influences of that community. The community will not
Health care and services are evaluated to ensure that
necessarily be defined by geography, and will include
they are appropriate and effective.
the external service providers who refer consumers /
patients. Care delivery processes should consider the
needs of the consumer / patient to ensure that care is 4. Diverse Needs and Diverse Backgrounds
delivered in the most appropriate and effective way. The organisation meets the needs of consumers /
patients and carers with diverse needs and from
5. Assessment, Planning and Delivery

of Care
Assessment, planning and delivery of care ensure that
current and ongoing needs of the consumer / patient
6. Discharge / Transfer of Care

Systems for discharge and transfer support ongoing
care of the consumer / patient.

Standard 11
Criterion 1: Information and Admission to Services

The organisation provides information on available health services to facilitate admission
Day procedure centres must provide adequate Processes should be in place to ensure the currency
information, and in appropriate formats, so that those of information provided by the organisation. Review and
who attend the organisation are informed about updating of information provided by the organisation
services, treatments, options and costs in a clear and needs to account for:
open way.1 Information about external service providers • fluctuations in community demographics which
who may have links with the organisation and details may impact the need for translated information
on how to access advocacy support services are also
• changes in services available through the organisation
important, and are valued by consumers / patients.
When developing or disseminating information about • alterations to admission / entry and referral processes
services, organisations should consider the capacity • consumer / patient feedback.
of the targeted audience to understand the information
provided and mechanisms should be in place to address Consumers / patients will access the health system
these needs, as required by Standard 1, item 1.18. according to clinical and personal need. The goal of
the organisation should therefore be to implement
It is also important that the organisation understands access and admission / entry processes that will meet
that consumers / patients will require different types of those needs.
information at different stages of their care. For example,
consumers / patients who are entering the health An effective admission / entry system is made up of
service for a procedure or test will require information a number of policies and processes which must be
about the admission process, the details and costs of documented and complied with by all staff.
the procedure / test, what forms need to be completed
and what to bring. Consumer / patient needs will differ
from those of referring clinicians who, for example,
need to know what inclusion / exclusion criteria the day
procedure centre has, or what admission processes
their consumers / patients may need to follow.

Standard 11

Information and Admission to Services
The organisation provides information on available health services to facilitate admission.
This criterion will Actions required: Guidelines

be achieved by:
11.1 Informing 11.1.1 There The organisation should ensure that the community which it serves is
consumers / is evidence of adequately informed about the services it provides and how to access
patients and evaluation and them when required. For day procedure centres, the ‘community’ refers to
the community improvement the clinicians who use the service and their consumers / patients / carers,
about services of the quality rather than the broader community.
accessible of information
through the provided to Information about the day procedure centre which would be beneficial to
organisation. consumers consumers / patients and the community includes:
/ patients • scope of services available within the organisation, such as specialty
and referring medical services
clinicians about: • processes for admission / entry
• services • inclusion and/or exclusion criteria
provided
• auxiliary services provided onsite, such as cafes, pathology, etc.
by the
organisation • cost of services including out-of-pocket expenses, where applicable
• access to • how the organisation will handle personal health information,

support irrespective of whether consent is given. This information should be
services, provided at the earliest opportunity and be in line with the National
including Privacy Principles (NPP) 2-5 and jurisdictional privacy legislation
advocacy. • collaborative links between the organisation and specific community /
advocacy / support groups
• scheduling of programs and/or education sessions
• transport and/or parking information.
Processes should be in place to ensure the currency of information

provided by the organisation. Review and updating of information provided
by the organisation needs to account for:
• fluctuations in community demographics which may impact the need
for translated information
• changes in services available through the organisation
• alterations to admission / entry and referral processes
• consumer / patient feedback.
It is also important that the organisation understands that consumers

/ patients will require different types of information at different stages
of their care. For example, consumers / patients who are entering the
health service for a procedure or test will require information about the
admission process, the details and costs of the procedure / test, what
forms need to be completed and what to bring. Consumer / patient needs
will differ from those of referring clinicians who, for example, need to know
what inclusion / exclusion criteria the day procedure centre has, or what
admission processes their consumers / patients may need to follow.

Standard 11

Information and Admission to Services (continued)

be achieved by:
Access to support services, such as advocacy, may be required by some

consumers / patients. Although day procedure centres are not required to
provide advocacy services, information about how consumers / patients
can access these should be available. Other information on external
support services may include links to community-based follow‑up care
services, community groups or health support groups, such as cancer
support. Preferably this information would be included in separate
information pamphlets and be freely available for self-selection by
consumers / patients.
Regular evaluation of the information provided to consumers / patients

should be performed to assess whether the content of the information
is appropriate to meet the needs of the community.
Evaluation should look at both the information about the organisation

itself and about external services, and ensure that it is easily understood
and meaningful to consumers / patients. The information provided to
the community and consumers / patients should be kept up-to-date.
Consultation with consumers, as addressed by Standard 2, item 2.4, can
assist organisations to evaluate and improve the information they provide.
Prompt Points
How does the organisation define its community?
How is information on health services provided to the community?
In what formats is information provided?
How does the organisation ensure that consumers / patients know
how to access relevant advocacy services?
How does the organisation evaluate the information provided to
the community? When was the last evaluation performed and what
improvements were made as a result?

Standard 11


be achieved by:
11.1.2 The Information on health services may be provided in many different formats;

organisation’s the most appropriate formats will depend on the message and for whom
processes for the information is intended. Information about services may rely on:
disseminating • brochures and handouts
information
• websites
on healthcare
services are • news media (including items resulting from press releases)
evaluated, and and documentaries
improved as • paid advertising
required. • signage
• audio formats
• other forms of telecommunication, such as DVDs, online video files
or phone text reminders
• face-to-face meetings, such as education sessions, open days or
information booths in public areas.
Evaluation of the dissemination processes used by the day procedure

centre should be performed regularly.
The organisation should assess whether the formats in which information

is provided and the channels through which it is disseminated are
appropriate to meet the needs of its consumers / patients and the
community. Evaluation of dissemination processes should be carried out
in conjunction with the evaluation of information quality, as addressed
in this Standard, action 11.1.1.
Prompt Points
How does the organisation disseminate information about its services?
How are dissemination processes evaluated? What improvements have
been made?

Standard 11


be achieved by:
11.2 Informing 11.2.1 Healthcare providers employed by the organisation should be aware of

healthcare Healthcare other services that are available within the community through which
providers both providers within continuity of care for consumers / patients upon separation from their
internal and the organisation service may be maintained.
external about have information
health services on relevant When an organisation finds itself regularly referring consumers / patients
available. external to another provider, it should follow up with the external provider and
services. discuss the existing relationship, in order to formalise the relationship if
necessary, and to identify any joint strategies by which they may better
meet consumer / patient needs (refer to this Standard, action 11.2.2).
Both parties to the collaboration should use their usual channels

for dissemination of information to inform their community of the
links between them, and the way in which the provision of care is
improved as a result. Clinical service providers may include visiting
medical officers, general practitioners, allied health practitioners and
community pharmacists.
Community services that may be relevant will vary greatly between

different healthcare organisations but might include special education
services, assistance and support services, child protection and other legal
services, disability services such as Vision Australia or Deaf Australia Inc.,
ethnic and multicultural organisations, National Aboriginal Community
Controlled Health Organisations (NACCHOs), specialty food providers,
providers of equipment and experts in its maintenance, specialty cleaning,
exercise facilities and many others.
The organisation should maintain a service directory which can supply

operational and contact details for relevant external services as required
by the consumer / patient. The directory should be easily accessible, and
maintained to ensure currency of information.
Prompt Points
Does the organisation have formalised collaboration agreements with
external service providers? Does the organisation maintain a directory
of relevant external services / service providers?
How are healthcare providers within the organisation made aware
of external services and providers?
What general services does the organisation provide information about
to consumers / patients? – e.g. community groups, health support
groups or advocacy services? How does the organisation ensure this
information is kept up-to-date?

Standard 11


be achieved by:
11.2.2 Relevant Day procedure centres will have relationships with external service
external service providers who refer consumers / patients to the organisation, and who
providers are may later resume responsibility for their ongoing care. To facilitate these
provided with processes, the day procedure centre should provide its referrers with all
information necessary information about:
on the health • access and admission / entry processes
service and
• the channel(s) through which it should receive referrals
are informed
of referral and • the means and timeframe within which consumer / patient information
entry processes. will be transferred back to the referrer.
In addition, external service providers within the community may speak to

their consumers / patients about services provided by the organisation,
initiating independent contact without formal referral. In order to ensure
that information provided to consumers / patients is accurate and
up‑to‑date, identified external service providers should be notified
of any changes to:
• hours of operation
• access conditions or inclusion / exclusion criteria
• location of specialty services
• contact details
• any other relevant information.
Collaboration between the organisation itself and external facilities,

services, groups and providers has the capability to significantly extend
and enhance the range of services available to the consumer / patient,
and to more thoroughly and efficiently meet the needs of the community.
Prompt Points
How does the organisation communicate information about its services
to external service providers? How does the organisation ensure that
this communication is effective?

Standard 11


be achieved by:
11.3 Meeting 11.3.1 The A critical component of ensuring the admission / entry system is

the needs of organisation effective is regular evaluation. Organisations will have procedures in
consumers / evaluates and place to facilitate admission / entry, which should include dissemination
patients and improves its of information to all necessary parties while respecting the consumer /
the community system for patient’s right to privacy. For planned admissions, this information may
for admission / admission / be contained within a completed admission form or referral letter.
entry. entry, which
includes: Day procedure centres should consider their admission / entry processes
from the perspective of the consumer / patient and aim to streamline
• clear
practices as much as possible. Although it may be necessary from a
inclusion
safety perspective to clarify information, repeated requests may become
and/or
frustrating and tiresome. The logic for repeated requests for information
exclusion
should be made clear to consumers / patients.
criteria
• minimisation Where duplication is necessary, such as in consumer / patient
of duplication identification, addressed in Standard 5, or blood transfusion, addressed
• utilisation of in Standard 7, the reason should be explained to the consumer / patient.
information
Information provided within referral documents should be utilised wherever
in referral
possible. This information could include results of previous investigations,
documents
medications that have been or should be given, and any other instructions
from other
or information about the consumer / patient. Relevant information
service
contained in referral documents should become part of the consumer /
providers
patient health record.
received on
admission Day procedure centres should define inclusion and/or exclusion criteria
of the to assist them in ensuring that consumers / patients are appropriate for
consumer / the level of care and types of services offered. This may result in the day
patient. procedure centre sourcing information on other service providers deemed
suitable for care. In some cases, this may be the local public hospital.
Prompt Points
How does the organisation prioritise consumer / patient care?
At what point(s) in the care journey does this occur?
Does the organisation have exclusion criteria? If so, on what basis
are these implemented? How does the organisation assist excluded
consumers / patients to access care?

Standard 11
Criterion 2: Consumer / Patient Consent

Consumers / patients are informed of the consent process, and they understand and provide consent
for their health care
Consent is a significant aspect of the assessment of There are a number of ways in which consent can
consumer / patient needs from both a clinical and be provided, including:
non‑clinical perspective. • written consent, through the use of signed consent
forms or consent statements
Informed consent refers to when consumers / patients
(and their carers and/or families) understand the • verbal consent, which must be documented
information provided to them about their condition, the in the consumer / patient’s health record
available treatment options and the risks and benefits of • implied consent, where a consumer / patient does
each option, and then give their permission to undertake not object to a procedure but passively complies,
a designated course of action.6 It is the responsibility of such as taking medication or submitting to
the clinician and the organisation to implement policies an injection.
and procedures to provide a comprehensive and robust
consent system. These processes will be governed by
a number of overarching elements including:
• legislation
• jurisdictional and organisational policy
• ethical and professional guidelines
• evidence-based best practice.

Standard 11

Consumer / Patient Consent
for their health care.

be achieved by:
11.4 11.4.1 The Organisations should be aware of all legislative requirements and any
Demonstrating organisation has relevant guidelines, and regularly review existing practices. Consent can
that the consent implemented include financial, procedural, ethical and/or research consent.
process is policies and
managed procedures The requirements for gaining consent should be defined in the
through systems that address: organisation’s policy; this will influence how the procedural details are
of governance addressed.7 The consent policy should reflect jurisdictional legislation
• how consent
which are and address the following:
is obtained
consistent with • the day procedure centre’s responsibilities in regard to gaining consent
• situations
organisational, • the procedures, care, treatment and/or investigation options and costs
where
jurisdictional that require written, verbal or implied consent
implied
and legislative
consent is • the process used to obtain consent, including the ways that
requirements.
acceptable information may be provided to the consumer / patient (verbally,
• situations brochures, using interpreters)
where • how consent is to be documented in the consumer / patient’s
consent is health record
unable to • when a surrogate decision maker, rather than the consumer / patient,
be given may give consent
• when • the use of interpreters / interpreter services when the consumer /
consent is patient is not proficient in the primary language of the organisation’s
not required representatives
• the limits of • the duration of the consent
consent.
• situations where procedures, care and treatment normally requiring
consent may be given without consent.
Consent for surgery and for any variation to procedures or treatments

needs to be formally recorded. The consent process should be
undertaken by the procedural clinician preferably prior to admission, but if
not, at admission and before administration of any pre-operative sedation.
The day procedure centre is responsible for obtaining consent for the
costs of hospitalisation. Further information on consent is available at:
http://www.healthinsite.gov.au/topics/Informed_Consent
It is important to recognise that attendance at a day procedure centre

does not imply consent. However, depending on the services provided,
some day procedure centres will require a single consent for a number
of procedures over time, such as for recurrent treatments. In this case,
policy should direct how long a single consent is valid, and the process for
renewing consent to a procedure and/or treatment. Consumers / patients
should be advised, and provided with information about this process.
Day procedure centres should ensure that consumers / patients have

provided informed consent prior to any investigations, treatments or
procedures. The procedures / treatments that require informed consent
should be defined by each day procedure centre. Consent should be
obtained and documented in accordance with the organisation’s policy.

Standard 11

Consumer / Patient Consent (continued)

be achieved by:
The relationship between a healthcare organisation and the treating

clinician will impact upon the organisation’s responsibilities in the
consent process. In the private sector, there are cascading levels of
consent; for example, the treating clinician will usually obtain consent
for recommended investigations, treatment or procedures and costs
within their own rooms prior to providing that health care. In these cases,
there should be a copy of the documented, signed consent obtained
by the treating clinician, or an ‘acknowledgement of the consent’, in the
consumer / patient health record.
Day procedure centres are not required to provide specific costs for
treating clinicians, anaesthetists, psychiatrists and such, but should inform
consumers / patients that these costs will be in addition to the hospital
costs. Private consumers / patients should be directed to inquire directly
to the clinician’s rooms for cost estimates.
As part of the consent process, consumers / patients should be

advised of:
• fasting times
• treatments
• medications
• financial issues
• the application of the National Privacy Principles
• rights and responsibilities
• any need for their agreement not to drive post-operatively, and
arrangements to be made for an adult to accompany them.
Organisations should have specific policy and/or procedures to address

circumstances where procedural consent has not been provided, and
relevant medical practitioners should be advised of these.
Policy should address when consent is unable to be given at the time

of admission to the day procedure centre. Specific situations where
consent conditions do not apply should be covered by policy according
to jurisdictional requirements and organisational / professional ethics.
Emergency situations are likely to be included.7
Prompt Points
How does the organisation ensure that consent policies and
procedures are consistent with legislative and jurisdictional
requirements?
How are consent processes communicated to staff?
How do staff know how to access the consent policy?

Standard 11

Consumer / Patient Consent (continued)

be achieved by:
11.4.2 The Whatever the consent process is, organisations should ensure that the
consent system process is followed, that consumer / patient consent is provided for
is evaluated, all relevant procedures and that it is documented in the health record.
and improved Whether consent is provided to the Visiting Medical Officer (VMO) prior
as required. to admission, or on admission to the day procedure centre, evaluation
of the process will highlight any changes and/or improvements that
are necessary.
Feedback from consumers / patients, staff or others should be utilised in

the evaluation process. This feedback may be positive or it may highlight
opportunities for improvement.
Prompt Points
How is compliance with the consent system monitored? What
improvements have been made to the consent system since the last
evaluation?
How does the organisation ensure consent processes are satisfactory?
What improvements have been made to maintain or improve the quality
of consent?

Standard 11
Criterion 3: Appropriate and Effective Care

Health care and services are evaluated to ensure that they are appropriate and effective
In health care, appropriateness is about doing what This criterion requires healthcare organisations to focus
is necessary, and not doing what is not necessary. on three key strategies for effective care. They are:
Appropriate care is reflected in positive care outcomes, • using interventions / treatments that are determined
and in the extent to which the consumer / patient’s to be most effective (best practice)
needs and wants are met in accordance with current
• using evidence in the development and delivery
best practice.8 Appropriateness refers to the relative
of care and services and in the development and
weight of the benefits and harms of a medical or
implementation of policy and other practices
surgical intervention. An appropriate procedure is one
in which the expected health benefit (e.g. increased life • mapping and documenting key processes to ensure
expectancy, relief of pain, reduction in anxiety, improved that they will be undertaken in a consistent manner
functional capacity) exceeds the expected negative in order to minimise variation.
consequences (e.g. mortality, morbidity, anxiety, pain,
Day procedure centres should consider the
time lost from work) by a sufficiently wide margin that
following questions10 :
the procedure is worth doing, exclusive of cost.9
• What is the right thing to do?
The day procedure centre should have policy / by‑laws, • Did we do the right thing? (appropriateness)
guidelines and procedures in place to ensure that
• Did we do the right thing 100% right? (effectiveness)
consumers / patients receive appropriate care in the
most appropriate setting, while avoiding wherever The day procedure centre should determine how it will
possible inappropriate care in an inappropriate setting. evaluate the appropriateness and effectiveness of the
It should be recognised that a day procedure centre care and services it provides.
may not always be the most appropriate setting for
consumer / patient care.

Standard 11

Appropriate and Effective Care
Health care and services are evaluated to ensure that they are appropriate and effective.

be achieved by:
11.5 11.5.1 The The best way for a day procedure centre to ensure that it provides care
Implementing organisation and services in the most effective way is to:
systems to ensures • understand its most common care processes, including the
ensure that appropriate and admission and pre-operative processes
consumers / effective care
• document the best way to carry out those processes
patients receive through:
appropriate and • put mechanisms in place to ensure that all who are involved,
• processes used
effective care understand and carry out the process in this expected way.
to assess the
and services in appropriateness Consumer / patient feedback on care outcomes and service provision is
the appropriate of care a useful measure of satisfaction. Evaluation methodologies can be used
setting.
• an evaluation to analyse progress and identify any opportunities for improvement.
of the
appropriateness A discussion with the consumer / patient prior to discharge can alert
of services the consumer / patient to variations that could / should be reported to
provided the day procedure centre. Variation from the expected outcome can
measure the quality of care delivered. Some measures include:
• the involvement
of clinicians, • recovery within best practice or appropriate timeframe
managers and • wound healing time
consumers • dressing uses and effectiveness
/ patients in • complication rate
the evaluation
• incidence of pain
of care and
services. • incidence of nausea and vomiting
• incidence of treatment related side effects
• incidence of changes to consumer / patient mobility arising directly
from the procedure.
Service planning should include an evaluation of the appropriateness

of the services provided.
To assist in limiting the potential for over-utilisation of services or the

performance of inappropriate services, day procedure centres might:
• integrate the development of the services into existing and planned
health services for the community
• have adequate mechanisms for credentialling and peer review
of clinicians
• define the range of procedures to be performed
• not undertake cases which are not applicable (the ultimate decision
as to the suitability of a consumer / patient for clinical practice
for a day procedure centre is that of the surgeon / anaesthetist or
in line with the documented scope of clinical practice for the day
procedure centre and its medical officers / staff)

Standard 11

Appropriate and Effective Care (continued)

be achieved by:
• be able to organise appropriate post-operative care including

transfer arrangements if the consumer / patient deteriorates
• identify consumer / patient needs
• follow approved clinical guidelines
• use appropriate type of sedation / anaesthetic agents according
to their license agreement
• consider any proposed new procedures in terms of their
appropriateness.
Prompt Points
What is the organisation’s process for implementing best available
evidence into clinical practice?
How does the organisation determine which criteria it will use to
measure appropriateness of care? What indicators are used?
11.5.2 Policies / The appropriateness of the setting in which care is provided is

guidelines are determined by matching the consumer / patient’s need for treatment
implemented with the setting in which it should be provided; this may vary from
that address the individual to individual.
appropriateness of
the setting in which Appropriate services can be provided in inappropriate settings;
care is provided. day procedure centres should ensure that services provided are
commensurate with the scope of practice of the organisation.
The environment should ensure compliance with WHS requirements, be

clean and well maintained and provide areas for privacy when needed.
Consumer / patient surveys may highlight areas requiring improvement.
Examples of specific action taken to improve the environment

could include:
• changes in room temperature control following complaints or
measurements of low body temperature
• alteration of patient booking process in response to complaints
regarding privacy issues for patients telephoned at work
pre‑admission.
• revision of recovery discharge protocols following ‘long’ stay
in first‑stage recovery.
Prompt Points
How is appropriateness of setting included when any proposed
change to a clinical service is assessed for feasibility?

Standard 11
Criterion 4: Diverse Needs and Diverse Backgrounds

diverse backgrounds
Equal opportunity and freedom from discrimination It is the organisation’s responsibility to develop policies
on the basis of age, race, religion, gender, sexual and procedures that fulfil the relevant legislative
orientation and disability are legislatively governed in requirements and that recognise and provide for
Australia at both Federal and State / Territory levels. the physical, mental, cultural and/or linguistic needs
Within the healthcare system, this translates to an of the consumers / patients accessing its services.
obligation to create an environment where recognition The day procedure centre should develop policies and
of diversity is embedded within the culture of the procedures to address:
organisation and where all consumers / patients, • understanding diverse consumer / patient needs
whatever their individual circumstances, receive and backgrounds
equality of care. Recognising that each person is a
• understanding and analysing changing
unique and complex being is integral to understanding
demographics
and responding effectively to healthcare needs at an
individual, family or community level. • encouraging consumer / patient participation in
decision making
Those individuals whose personal condition or situation • providing relevant and accessible information
makes it difficult for them fully to participate in their own
• developing an appropriately trained workforce
health care are said to have special needs. The personal
condition or situation may be: • meeting the specific needs of different groups
within its community.
• poor literacy, whether from a non-English speaking
background or not
• affected by trauma
• affected by medication / drugs
• age (either very young or very old / frail)
• a disability, which covers a vast range
of impairments.

Standard 11

diverse backgrounds
Diverse Needs and Diverse Backgrounds

be achieved by:
11.6 11.6.1 The Diversity is a broad concept that includes all Australians. It refers to
Establishing organisation the various qualities that define the individual and exist across society
the needs of obtains as a whole. It includes characteristics or factors such as age, race,
the community demographic ethnicity, language, gender, sexual orientation, religion, beliefs, family
in order to data to: and/or social structure, and ability, including disability; as well as
meet legislative • identify the socio-economic level, educational attainment, personality, marital and
requirements, diverse needs parental status, general life and work experience, and status within the
inform the and diverse general community.
delivery of backgrounds
services and Depending on the type of services offered, expected diverse needs
of consumers
assess whether such as for vision or hearing impairment, should be a regular
/ patients and
those needs consideration by the day procedure centre. Other areas of diverse
carers
are met. need that may be considered include consumers / patients with limited
• monitor and mobility, bariatric consumers / patients and paediatric consumers /
improve access patients. Where appropriate facilities cannot be provided, areas of
to appropriate diverse need may be addressed through inclusion / exclusion criteria,
services as covered in action 11.3.1.
• improve cultural
competence, Assessments should be undertaken to identify consumer / patients’
awareness needs, for example Muslim women requesting female nurses,
and safety. interpreter service needs for consumers / patients who do not
speak English and any issues for consumers / patients with physical
disabilities, or other medical conditions.
Accurate and suitably detailed communication between providers and

consumers / patients is fundamental to quality health care. Various
options exist for providing culturally and linguistically diverse consumers
/ patients with the required information. Fact sheets in a variety of
languages are a first step towards the provision of all relevant data.
Day procedure centres are not expected to provide information in every

language. The day procedure centre should identify the characteristics
of the consumer / patient base of their visiting medical officers,
document those requirements and provide printed information in the
languages identified. There are a range of translated fact sheets already
available on the internet on official sites, such as State / Territory health
departments, government sites, the National Prescribing Service (NPS),
etc., and these should be utilised.
Prompt Points
How does the organisation identify the different groups
(Culturally and Linguistically Diverse (CALD) and/or special needs)
for which it should provide targeted services?
How often does the organisation reassess the demographics
of the community that it serves? How is this carried out?

Standard 11

diverse backgrounds
Diverse Needs and Diverse Backgrounds (continued)

be achieved by:
11.7 Ensuring 11.7.1 Policies and Understanding cultural, spiritual and language needs is an important
that diverse procedures that part of responsive health care. In addition to such considerations, it
populations consider cultural is important to acknowledge a person’s individual situation and the
are provided and spiritual needs potential impact this has on how the person will perceive, access and
with care and are implemented use a healthcare organisation, and respond to care.
services that to ensure that
meet their care, services and As consumer / patient group expectations vary, day procedure centres
needs. food are provided should implement policy / guidelines to guide practices that increase
in a manner that responsiveness to individual healthcare needs within the resources
is appropriate available. Policies and procedures aimed at meeting the cultural and
to consumers / spiritual needs of consumers / patients should be linked to the day
patients with procedure centre’s assessment processes (addressed in item 11.8),
diverse needs which will identify these needs.
and from diverse
The provision of food services is limited in a day procedure centre,
backgrounds.
however cultural diversity and special needs should be considered
when planning food provision, for example providing options for
diabetics and those with allergies, and vegetarian selections, which
will also address the needs of Muslims.
Prompt Points
How does the organisation determine whether the services it
provides for its CALD and special needs consumers / patients
are appropriate?
What specific services has the organisation instituted based upon
its understanding of the community that it serves?

Standard 11

diverse backgrounds
Diverse Needs and Diverse Backgrounds (continued)

be achieved by:
11.7.2 Mechanisms Not all day procedure centres will need to implement specific
are implemented mechanisms to improve the care delivered to diverse populations;
to improve however there needs to be a process for day procedure centres to
the delivery of identify their patient base, in order to validate that the implementation
care to diverse of any specific mechanisms may not be relevant.
populations, where
relevant, through: Partnering with community groups and organisations both locally and
nationally, which provide support and assistance for individuals with
• demonstrated
particular needs, from certain backgrounds and/or with specific health
partnerships
issues, can help to ensure the appropriateness of the services that the
with local
organisation provides.
and national
organisations Within the organisation itself, staff should be encouraged to undergo
• providing further training in order to enhance their ability to provide care for a
staff with diverse consumer / patient base.
opportunities
for training. Day procedure centres should strive for the creation of a culturally
competent working environment, with culture being integrated into
the delivery of health services so as to improve health and wellbeing
for both the individual and the community.11 In pursuing this aim, it is
important to recognise that staff members will bring their own culture
to any clinical encounter, and that the health system itself, as an
institution, also has a culture of its own. Reflection on practice and
upon one’s own culture is an inherent element of cultural competence.
Prompt Points
With what community groups does the organisation interact in
order to best meet the needs of its CALD and special needs
consumers / patients?
What opportunities and resources are provided for staff willing
to undergo training in areas relevant to the organisation’s
diverse community?

Standard 11
Criterion 5: Assessment, Planning and Delivery of Care

are identified and met
Assessment is the process by which the current and Planning and delivery of care is the core business of all
ongoing needs of the consumer / patient are identified healthcare organisations. The key considerations in care
and documented. An episode of care begins with planning and delivery are:
assessment and requires contact between clinical staff • care is planned and documented according to
and the consumer / patient. An ineffective or incomplete the assessment of consumer / patient needs
assessment will increase the risk of errors that may
• there is input from the consumer / patient and
affect health outcomes, and/or consumer / patient
relevant care providers
satisfaction with the service.
• there is consideration that a second opinion may
An effective assessment process should identify any be sought
existing risks to the consumer / patient’s ongoing health • care planning and delivery are based on the best
and wellbeing, and create an opportunity for health available evidence
promotion by healthcare providers, who are in a position
• care is delivered by competent individuals and
to discuss factors that impact upon the individual’s
multidisciplinary teams, when required
health status, such as diet, exercise, smoking or
alcohol consumption, in the context of their reason • care is coordinated between all members of the
for accessing the health service. team (including carers)
• the needs of high-risk consumers / patients are
identified and managed appropriately
• the environment within which care is provided is
comfortable, caring and appropriate to consumer /
patient needs.

Standard 11

Assessment, Planning and Delivery of Care

be achieved by:
11.8 Ensuring 11.8.1 Guidelines Holistic assessment should identify the physical, spiritual, cultural,
assessment is are available and psychological and social needs of the consumer / patient. In addition to
comprehensive accessible by staff reflecting consumer / patient needs, the assessment process should be
and based to assess physical, specific to the needs of the organisation, and so may vary significantly
upon current spiritual, cultural, between organisations.12, 13
professional psychological and
standards and social needs. Day procedure centres should provide information on how staff
evidence-based can access relevant evidence-based guidelines, which may be
practice. through the Australian government’s clinical guidelines portal:
http://www.clinicalguidelines.gov.au
Consider what is assessed – physical and medical condition

(including with relevant consumer / patient input), financial and social
(including after care) issues.
Assessment in a day procedure centre may include:

• previous history
• clinical examination
• consumer / patient preparedness, both physically and
psychologically
• medication history, including allergies and complementary medicines
• nutritional status, including risk screening for dietary issues
• special needs of consumers / patients as addressed in items 11.6
and 11.7, such as:
• wheelchair access
• interpreter services
• dietary requirements
• physical / auditory / intellectual disability requirements.
Availability of and access to this information should ensure that

appropriate persons are kept informed and the admission process is
not delayed or cancelled due to inadequate assessment information.
Information collected about a consumer / patient should be relevant, in

a standardised format and stored in the health record. This will ensure
its availability to other staff.
Specific assessment forms related to the procedure assist the collection

of appropriate and relevant information and facilitate communication
between care providers with the aim of reducing duplication.

Standard 11

Assessment, Planning and Delivery of Care (continued)

be achieved by:
Efficient flow of care delivery demonstrates coordination in a

day procedure centre. Duplication of activities may be reduced
through the use of health records / forms that allow easy location
of appropriate information.
Methods of information collection and provision need to facilitate

communication. The day procedure centre should be aware of any gaps
in information or any changes to collection tools that might be required.
Prompt Points
What guidelines / other resources are available to the organisation‘s
staff to assist them to assess consumer / patient needs?
How does the organisation access evidence-based guidelines?
How are they made available to relevant staff?
11.8.2 Guidelines Best-practice guidelines have been developed to improve the health

are available and outcomes of Aboriginal and Torres Strait Islander people.
accessible by staff
on the specific The Australian Indigenous HealthInfoNet is a website that aims to inform
health needs of practice and policy in Indigenous health and provides access to many
self-identified relevant guidelines and protocols. Access to the website is available at:
Aboriginal and http://www.healthinfonet.ecu.edu.au/about
Torres Strait
Further best-practice guidelines for specific Aboriginal and Torres
Islander consumers
Strait Islander health issues are also available online.14-16 Day procedure
/ patients.
centres are not required to have these guidelines on-hand, but should
know where they can be accessed.
There is a requirement to have a system to identify Aboriginal and

Torres Strait Islander consumers / patients. This can routinely be a
part of registration / admission (e.g. name, address, sex, date of birth,
next of kin).
The ‘Closing the Gap’ program is a commitment by all Australian

governments to improve the lives of Indigenous Australians, and in
particular provide a better future for Indigenous children. Further
information about this program is available from the Healthinfonet,
or the Department of Families, Housing, Community Services and
Indigenous Affairs website: http://www.fahcsia.gov.au/sa/indigenous/
progserv/ctg/Pages/default.aspx
Prompt Points
How are Aboriginal and/or Torres Strait Islander consumer / patient
health records identified? Is the standard question, “Are you
of Aboriginal or Torres Strait Islander origin?” part of normal
work practices?
Is identification of Aboriginal and/or Torres Strait Islander consumers
/ patients used to guide clinical treatment? If so, how?

Standard 11


be achieved by:
11.9 Meeting 11.9.1 The Day procedure centres should work in partnership with the
the needs of assessment consumer / patient, and carer where appropriate, when completing
consumers process is assessments. The decision to involve a support person / carer should
/ patients evaluated to ensure be based on the consumer / patient’s ability to understand questions
through a timely, that it includes: and instructions, as well as the complexity of the procedure to
comprehensive • timely be performed.
assessment assessment
process. Reassessment may be considered following an unexpected reaction
with consumer
to anaesthetic, including slow recovery, for example.
/ patient
and, where Day procedure centres are not required to provide information
appropriate, on results, etc., as these are generally not available. Information
carer on expected recovery and the necessary knowledge to perform
participation self-care should be part of the discharge information provided to
• regular consumers / patients.
assessment of
the consumer / The quality and timeliness of information provision should facilitate
patient need for transitions of care within, and beyond, the organisation. Good record
pain / symptom keeping and the sharing of health records, particularly when enabled
management by electronic transfers of information, are needed for safe transition
between services and healthcare providers.17 Failed information transfer
• provision of
occurs most commonly at junctions in the provision of care (handover)18
information to
and can have serious safety implications.19 Clinical handover is
the consumer /
addressed in detail in Standard 6, items 6.1 – 6.5, and discharge /
patient on their
transfer of care is addressed in this Standard, under items 11.12 – 11.14.
health status.
Communication is also a vital aspect of pain management, which
should form part of the consumer / patient assessment. As pain is
subjective, it is necessary that the consumer / patient and, where
appropriate, his or her carer are fully involved in this aspect of
assessment. Following the initial consultation, and the implementation
of a treatment regime, a regular review should take place, in order to
address any ongoing issues of pain severity and the response of the
consumer / patient to treatment. 20
Measuring and monitoring systems that might be considered for the

evaluation of assessment systems and processes include:
• process indicators, such as the proportion of consumers / patients
who have medication reconciliation or a falls risk assessment
included in their assessment
• accuracy, legibility and completeness of entries in the
assessment record
• consumer / patient satisfaction surveys – where questions are
relevant to assessment
• retrospective evaluation of a video or audio recording of
consumer / patient assessment(s).

Standard 11


be achieved by:
Prompt Points
Are there completed assessments in consumer / patient health
records? Do they follow a consistent structure / format?
What formal information is provided to consumers / patients as
part of the assessment process? For example, a ‘Preparing for
Surgery’ brochure.
What measures are used to evaluate the effectiveness of the
assessment process? How do health record audits demonstrate
compliance with assessment processes? Following evaluation,
what actions have been taken to improve compliance?
11.9.2 Results Day procedure centres should ensure that results of any relevant
of pre-admission pre‑admission investigations are available as needed on the day of
investigations service. Following discharge / transfer, these results should also
follow the form part of the discharge summary along with information on new
consumer / patient investigations, the treatment provided in the day procedure centre, and
through the any other information deemed necessary, which should be forwarded to
referral system. other service providers or practitioners to whom a consumer / patient
is referred.
Information regarding follow-up needs should also be provided as

appropriate; examples include scientist follow-up in the case of IVF,
community nursing, hospital in the home and so on.
As consumers / patients move through a multidisciplinary care process,

it is important that their diagnostic test results are available. Repeating
tests within a short time interval has long been identified as a potentially
wasteful practice.
Prompt Points
What processes ensure that pathology and imaging results are
available to all clinicians who may need them for decision making?
How does the health record system link consumers / patients, their
care plans and ongoing monitoring data with test and image results?
How is this information accessed?
How are test / imaging results transferred when the consumer /
patient is discharged?

Standard 11


be achieved by:
11.10 Planning 11.10.1 Planning Care planning needs to be ongoing, commencing with first contact with
and delivering and delivery of care the day procedure centre. This may be called a care plan, admission
care based upon are evaluated to form, critical or clinical pathway, check sheet, care path or any other
assessment ensure that it is: title identified by the day procedure centre.
of consumer / • effective
patient needs. A core care plan may exist for consumers / patients undergoing similar
• comprehensive procedures and could be tailored to any consumer / patient’s needs
• multidisciplinary if required.
• informed by
A flow chart, checklist or procedure check may cover the areas for
assessment
care planning. Consider the activities carried out and the interventions
• documented required. The clinical service provided will have a variety of interventions
in the health that are carried out by various persons. Developing a pathway covering
record the activities performed ensures a comprehensive plan of care
• carried out with regardless of situational variation.
consumer /
patient consent Coordination of the care episode is facilitated by team cohesion and
and, where knowledge of responsibilities, minimising duplication of service.
appropriate,
Part of the review process for policies and procedures is to
carer
ensure that policy remains in line with, and referenced to relevant
participation.
jurisdictional requirements.
Carer involvement in care delivery enhances the consumer / patient’s

understanding and could include:
• assistance with pre-admission treatments, such as bowel
preparation
• assistance with an explanation of the procedure / treatment
• provision of transport
• overnight observation in the consumer / patient home
• follow-up treatments
• dressing changes where clear instruction has been provided
and it is deemed appropriate for the carer to undertake
• consumer / patient support and home care.
Partnerships between consumers / patients, carers, staff and

others involved in care delivery is important where the stay is short
and responsibility for self-care is taken sooner than for longer
hospital admissions.

Standard 11


be achieved by:
Care planning and coordination includes ensuring that the outcomes

of the care delivered are evaluated. Evaluation of care planning and
delivery could involve review of:
• processes around care coordination and communication within the
day procedure centre and with external providers
• the internal referral processes
• clinical handover of information
• consumer / patient understanding of their care.
Prompt Points
What clinical pathways / care plans are used in the day
procedure centre?
Are clinical pathways / guidelines used in care planning referenced
to evidence-based sources? How frequently are these reviewed
and updated?
11.11 Ensuring 11.11.1 Planning Discharge preparation should commence early and include various
that the for discharge / persons, information and resources.
assessment transfer of care
process includes is evaluated to Consider discharge preparation:
planning for ensure that it: • the pickup person / escort home
discharge and • commences at • travel distance to home
use of the assessment • ‘no driving’ policies
referral system.
• is coordinated • conditions at home, such as stairs, access to toilet or bedroom
• consistently • the carer’s contact details and their awareness of possible issues
occurs and requirements following discharge
• is • contact numbers after discharge, such as the doctor or
multidisciplinary emergency contact
where
• discharge arrangements regarding home care where this is
appropriate
identified as required and available.
• meets
consumer / Prompt Points
patient and What information collected and recorded during assessment
carer needs. is relevant to existing discharge processes?
How and when has the discharge / transfer of care system been
evaluated? What were the findings? As a result of investigations,
have any changes to the assessment process been made
or planned?

Standard 11
Criterion 6: Discharge / Transfer of Care

Systems for discharge and transfer support ongoing care of the consumer / patient
Discharge refers to the release of a consumer / patient An example of proactive discharge planning with
from care 21 or the movement of a consumer / patient consumer / patient involvement might include assigning
from one setting of care to another. 22 A discharge one person to work with consumers / patients prior to
summary developed by the day procedure centre should their discharge 23 to:
be provided to the appropriate person upon consumer / • arrange follow-up appointments
patient discharge. Where consumers / patients are
• confirm medication reconciliation
transferred to another facility, information that ensures
safe and effective clinical handover should be available • conduct consumer / patient education with
when needed. an individualised instruction booklet
• conduct post-discharge follow-up to ensure
There is an expectation that a discharge summary will there have been no problems in relation to
be provided to: discharge planning
• the consumer / patient and, if appropriate, the carer • provide education materials to the primary
• the healthcare provider to whom the consumer / care provider.
patient is discharged
• the referring healthcare provider
• the health record.
Day procedure centres should ensure that there is

policy / guidelines that address the requirements for
transfer of care and discharge, as well as a system for
implementing the policy / guidelines and a method for
evaluating whether it is working. The evaluation should
include input from consumers / patients and treating /
referring health professionals.

Standard 11

Discharge / Transfer of Care
Systems for discharge and transfer support ongoing care of the consumer / patient.

be achieved by:
11.12 Ensuring 11.12.1 Discharge / Well-informed consumers / patients who understand the planning of
that appropriate transfer information their care are more capable of managing their condition proactively,
clinical is discussed with and potentially decreasing rehospitalisation. 23
information the consumer /
is made patient and a Written and verbal information should be provided to the consumer /
available in a written discharge patient on discharge / transfer and should include details on
timely manner summary and/or medications, self care, possible complications, adverse reactions and
to external discharge precautions as well as emergency contact details and plans for ongoing
healthcare instructions are care / post-discharge arrangements.
providers and provided.
Details on follow-up appointments should be provided to the
consumers /
consumer / patient to assist in appropriate attendance.
patients,
to facilitate Discharge information developed by the day procedure centre should
ongoing care. be provided to the appropriate individuals or services; this includes
the referring clinician and the consumer / patient, as well as any other
service to which the care of the consumer / patient is transferred.
In some cases, the treating healthcare provider within the day

procedure centre may be the same as the healthcare provider caring
for the consumer / patient following discharge from the organisation.
On condition that the health record is accessible to the healthcare
provider in both the organisation and following discharge, the copy
of the discharge summary in the health record is sufficient to satisfy
the requirement for the discharging healthcare provider to receive a
copy. The purpose of the discharge summary is to ensure that the
consumer / patient, the referring healthcare provider and any other
relevant healthcare providers are aware of, and understand, ongoing
plans and their responsibilities in continuing management of the
consumer / patient.
Examples of information and instructions that should form a regular

process include:
• post-procedure instructions
• discharge checklist
• prescriptions and associated instructions
• cannula removal
• medical / carer certificate
• follow-up appointments
• discharge summary.

Standard 11

Discharge / Transfer of Care (continued)

be achieved by:
Prompt Points
What processes are in place for discharge / transfer of consumers /
patients? How are consumers / patients involved in the process?
Are discharge summaries ready at the time of transfer / discharge
of the consumer / patient?
Does the organisation check that consumers / patients and carers
have received appropriate information relating to their condition
and discharge / transfer? How does the organisation evaluate the
consumer / patient’s understanding of the information provided?
11.12.2 An example of proactive discharge planning with consumer / patient

Arrangements involvement might include assigning a specific discharge person to
with other service work with consumers / patients prior to their discharge 23 to:
providers and, • arrange follow-up appointments
where appropriate,
• confirm medication reconciliation
the carer are made
with consumer / • conduct consumer / patient education with an individualised
patient consent instruction booklet
and input, and • conduct post-discharge follow up to ensure there have been
confirmed prior to no problems in relation to discharge planning
discharge / transfer • provide education materials to the primary care provider.
of care.
While the scale will be different for day procedure centres than for
large multipurpose hospitals or acute care departments, the same
principles apply:
• establish referral points – organisations will benefit if details
of contacts can be integrated into an organisation-wide or
department‑wide listing, and regularly updated
• build relationships within and outside the health service
• communicate with the consumer / patient and/or his or her carer
about the ongoing care requirements and the potential plan
• formalise ongoing care arrangements through appointments
or contracts
• confirm arrangements in the discharge summary or accompanying
documents sent to referral organisations.
Information regarding discharge follow-up or ongoing care needs

to be provided to appropriate persons including the carer, the GP,
referring clinician and post-procedure specialists as relevant.
Details on follow-up appointments or next admission should be

provided to the consumer / patient to assist in appropriate attendance.
Prompt Points
Does the discharge / transfer process enable enough time
for discussion of ongoing care with the consumer / patient
and/or carer?

Standard 11

Discharge / Transfer of Care (continued)

be achieved by:
11.13 11.13.1 Formalised Risk is defined as the chance of something happening that will impact
Implementing follow up occurs on objectives. Consumers / patients at risk include the aged, obese
a system that for identified at‑risk consumers / patients or those with a chronic condition.
facilitates consumers /
follow up of patients. Consumers / patients identified as being at risk should have ‘flags’
identified at-risk within their health record. Health record audits will ensure that this
consumers / system is being utilised and improvements / staff training can occur
patients. if necessary.
Telephone follow up of a deteriorating consumer / patient should be

part of this system.
Formalised follow up for at risk consumers / patients involves a planned

process that occurs after the consumer / patient has been discharged
or transferred from the day procedure centre. Systems to recognise
and ‘tag’ consumers / patients who are at risk must be in place.
This may include a telephone call, advising a date for review with a
health provider or organisation of a community support visit. This is all
documented in the health record prior to discharge or transfer.
Prompt Points
Which consumers / patients are followed up post-discharge?
What is the method of follow up? What is the timing of this contact
and why has this timing been chosen?
What factors does the organisation use to determine whether
consumers / patients might be at risk of difficulties after discharge?
11.14 11.14.1 Policy and A death in a day procedure centre would be considered a sentinel
Implementing procedures for event. However, occasionally consumers / patients will die in a day
policy and the management procedure centre and a policy covering the process to be followed in
procedures of an unexpected the occurrence of this rare and tragic event is needed.
that address death consistent
mortality with jurisdictional As with other organisational policies, all staff should be aware of
management. legislation, policy the mortality management policy, however, education need only be
and common provided to staff members who would have to manage the process.
law are available,
Prompt Points
and staff receive
relevant education. What policy and procedures are in place on managing an
unexpected death? How is staff education provided?
What are the relevant legislation or common law obligations
and does policy reflect this?

Standard 11
References
1. Australian Commission on Safety and Quality in Health Care (ACSQHC). Australian charter of healthcare rights
(for consumers). Sydney NSW; ACSQHC; 2008.
2. Office of the Federal Privacy Commissioner. Overview of the Private Sector Provisions. Information Sheet 1.
Canberra ACT; Office of the Australian Information Commissioner; 2001 (updated 2007).
3. Office of the Federal Privacy Commissioner. Guidelines to the National Privacy Principles. Canberra ACT;
Office of the Australian Information Commissioner; 2001.
4. Office of the Federal Privacy Commissioner. National privacy principles. Private Sector Information sheet 1A.
Canberra ACT; Office of the Australian Information Commissioner; 2008.
5. Office of the Privacy Commissioner. Information Privacy Principles. Public Sector Information Sheet.
6. World Health Organization (WHO). Best practice protocols: Clinical procedures safety. Geneva CH; WHO; 2007.
7. ACT Health. Procedure: Consent to treatment. Canberra; ACT Health; 2008.
8. International Society for Quality in Health Care (ISQua). The ISQua surveyor training standards programme.
Dublin IRL; ISQua; 2009.
9. Brook RH, Chassin MR, Fink A et al. A method for the detailed assessment of the appropriateness of medical
technologies. Int J Technol Assess Health Care 1986; 2(1): 53-63.
10. Leape LL. Patient safety: What have we learned? Where are we going? 4th Australasian Conference on Safety
and Quality in Health Care; Melbourne VIC; 2006.
11. Stewart S. Cultural competence in health care. Sydney NSW; Diversity Health Institute SWAHS; 2006.
12. Australian Department of Health and Ageing (DoHA) and Australasian College for Emergency Medicine (ACEM).
Approved private emergency department program. Canberra ACT; DoHA; 2001.
13. Royal College of Pathologists of Australasia (RCPA). Pre-operative assessment. RCPA manual. Sydney NSW;
RCPA. Accessed from http://www.rcpamanual.edu.au/index.php?option=com_clinical&task=show_
clinical&id= 664&Itemid=27 on 19 October 2012.
14. National Heart Foundation of Australia (NHF). Position statement: Indigenous tobacco control. Canberra ACT;
NHF. Accessed from http://www.heartfoundation.org.au/information-for-professionals/aboriginal-health/Pages/
default.aspx on 19 October 2012.
15. National Health and Medical Research Council (NHMRC). Strengthening cardiac rehabilitation and secondary
prevention for Aboriginal and Torres Strait Islander peoples: A guide for health professionals. Melbourne VIC;
Australian Government and the NHMRC; 2005.
16. Cardiac Society of Australia and New Zealand (CSANZ) and National Heart Foundation of Australia
(NHF). Diagnosis and management of acute rheumatic fever and rheumatic heart disease in Australia:
An evidence-based review. Canberra ACT; NHF. Accessed from http://www.heartfoundation.org.au/
SiteCollectionDocuments/Diagnosis-Management-Acute-Rheumatic-Fever.pdf on 19 October 2012.

Standard 11
References
17. Department of Human Services. Victorian public hospital specialist clinics – Access guidelines. Melbourne;
Victorian Government; 2009.
18. Philibert I and Leach D. Re-framing continuity of care for this century. Qual Saf Health Care 2005;
34(8): 394‑396.
19. Garling P, SC. Final report of the special commission of inquiry: Acute care services in NSW public hospitals.
Sydney; NSW Special Commission of Inquiry; 2008.
20. National Palliative Care Program, Australian Department of Health and Ageing (DoHA). CareSearch:
Pain assessment tools. Canberra ACT; DoHA. Accessed from http://www.caresearch.com.au/caresearch/
ClinicalPractice/Physical/Pain/AssessmentTools/tabid/748/Default.aspx on 19 October 2012.
21. MedlinePlus Medical Dictionary. Medical Dictionary. Merriam-Webster. Accessed from

http://www.merriam‑webster.com/medlineplus/at%20risk on 19 October 2012.
22. Ma E, Coleman E, Fish R et al. Quantifying posthospital care transitions in older patients. J Am Med Dir
Assoc 2004; 5(2): 71-74.
23. Jack BW, Chetty VK, Anthony D et al. A reengineered hospital discharge program to decrease rehospitalization:
a randomized trial. Ann Intern Med 2009; 150(3): 178-187.

Introduction
Workforce planning is a continuous process of matching workforce requirements to the
organisation’s objectives, and anticipating the human resource implications when undertaking
particular operational or strategic activities. Workforce management is the policies, practices
and systems that influence employees’ behaviours, attitudes and performance.1

Ensure that the organisation recruits and manages its
workforce in a manner that supports the delivery of safe,
1. Workforce Planning
high quality health care. Workforce planning needs to Workforce planning supports the organisation’s current
consider the changing environmental and social factors and future ability to address needs.
which will impact on the availability and needs of the
workforce, to ensure that the day procedure centre’s 2. Recruitment and Ongoing Clinician
current and future workforce needs will be met.
Appointment Processes
The recruitment, selection and appointment system
Context ensures that the skill mix and competence of staff meets
Recruitment policies and procedures should aim to the needs of the organisation.
assemble the right skill mix of staff to undertake the
activities of the day procedure centre. Human resources 3. Continuing Employment and
management systems should be in place to promote
an environment and culture that strive toward building
Development
effective staff relationships through participatory The continuing employment and development system
management, effective leadership and sound ensures the competence of staff.
professional practice.
Workplace policies and procedures need to

4. Employee Support and Workplace
communicate the minimum performance level expected Relations
by defining the requirements for employees to undergo Employee support systems and workplace relations
sufficient education and training to perform their assist the organisation to achieve its goals.
role safely and effectively. Continuing professional
development and employee support systems
are important in the retention and growth of high
quality staff.

Standard 12
Criterion 1: Workforce Planning

Workforce planning supports the organisation’s current and future ability to address needs
Workforce planning is the systematic and ongoing Comprehensive workforce planning takes time, requires
process of analysing the day procedure centre’s meaningful stakeholder engagement and collaboration,
workforce needs and determining action to ensure that and should cover all key elements of workforce
the right people with the right skills are available when needs, including assessment, recruitment, retention,
needed. Workforce planning should recognise and development and contingency. Workforce planning
respond to the changing environment. 2 should be linked to the day procedure centre’s strategic
planning process. Planning will be proportional to the
A number of external changes that will affect workforce role, function and size of the day procedure centre.
planning and management in healthcare organisations
in upcoming years have been identified. The potential Healthcare organisations are a dynamic environment
impact of these and other environmental factors in which new challenges are constantly presented;
should be considered by the day procedure centre. organisational strategic and operational plans may flag
They include: impending changes. There should be regular evaluation
• the need to provide more flexible working of the workforce policy, plan, goals and strategic
arrangements direction to ensure that those challenges are met.
• changes from State / Territory-based to national
professional registration and continuing education
• expanding roles for nurses
• medical innovations and changes to medical
equipment and techniques
• changing gender balance in some health professions
• the ageing of the nursing workforce
• demand exceeding supply in many health
professions, and the associated reliance on
overseas-trained professionals.

Standard 12

Workforce Planning
Workforce planning supports the organisation’s current and future ability to address needs.

be achieved by:
12.1 Ensuring 12.1.1 Workforce The flexibility, multi-skilling and mix of staff are important within a
that the management day procedure centre, assisting it to carry out its diverse activities;
long‑term and functions and this should be considered in all stages of appointment.
broader goals of responsibilities are
the organisation clearly identified The day procedure centre’s approach to workforce planning will differ
are met by and documented. depending on whether it aims to address immediate needs (the next
workforce shift), short-term needs (less than one year) or longer-term goals
planning that (three to five years).
reflects current
The processes of workforce planning can be conducted formally
and future needs
through written annual or quarterly plans, or occur on a daily basis,
of consumers /
for example, through reviews of theatre schedules for following days’
patients and
lists. It is important to review any of these activities to assess whether
staff and
the day procedure centre’s needs are being met, or whether changes
is clearly
would improve care delivery and/or staff satisfaction.
linked to the
organisation’s Formulating a plan to cover staffing requirements, with information
strategic concerning the appropriate skills and number of staff, will help with the
direction. daily management of the day procedure centre. The plan could form
part of the strategic direction and business goals. For example, if the
day procedure centre was developing services to include paediatric
dental surgery, it would be necessary to plan for qualified staff.
Using professional guidelines on the number and skills of staff

required for particular procedures, such as the guidelines from the
Australian and New Zealand College of Anaesthetists (ANZCA), the
Australian College of Operating Room Nurses (ACORN) and State /
Territory legislation, will help to ensure that appropriate levels of staff
are available, employed and rostered for the day procedure centre’s
services, including coverage for leave.
All managers must be aware of their specific responsibilities as a

supervisor of their staff. Managers can have a profound effect on
the implementation of human resource policies and overall staff
performance 3, and supervisors have a responsibility for staff employed
below them. A manager’s human resource (HR) responsibilities
and organisational key performance indicators (KPIs) in workforce
management should be clearly documented within his or her position
description, and signed off.
Prompt Points
Who is responsible for preparing and implementing the
workforce plan?
Who takes responsibility for appointments, induction, training,
staff development, HR policies and procedures, HR budgeting,
organisational culture and work health and safety (WHS)? Where are
these responsibilities recorded?

Standard 12

Workforce Planning (continued)

be achieved by:
12.1.2 The Management of the organisation’s workforce should take place within

workforce policy, a framework of policies and procedures that communicate at least the
procedures, plan, minimum performance level required and the legal aspects of workforce
goals and strategic management. The workforce should be educated in and have access
direction are to this documentation, so that it is informed of its responsibilities and
regularly reviewed, better able to fulfil its role in assisting the organisation to meet its goals
evaluated, and and objectives.
improved as
required. With respect to workforce planning and management, policies and
procedures should cover at least:
• legal and ethical aspects such as agreements, awards and contracts
• job design
• recruitment
• selection and appointment
• orientation, induction and integration
• code of conduct
• performance management
• pay, leave and conditions
• learning and development
• managing diversity
• workplace relations.
The planning processes can be formal through for example, written

annual or quarterly plans, or on a daily basis through reviews of theatre
schedules for following days’ lists. It is important to review any of these
activities to assess whether the day procedure centre’s needs are being
met, or changes would improve care delivery and/or staff satisfaction.
Guidelines have been developed by Victoria’s Department of Human

Services to assist rural planners to conduct workforce planning when
there is no access to human resource expertise and sophisticated
data systems. This resource may be useful for day procedure centres,
and is available online1 at: http://www.health.vic.gov.au/ruralhealth/
downloads/rural_health_workforce_planning_guidelines.pdf
Prompt Points
How does the workforce plan address the goals and objectives
outlined in the organisation’s strategic plan?
What are the key factors affecting workforce supply?
What characteristics of the workforce and labour supply were
considered when developing the workforce plan?
How does the organisation know that workforce policies and
procedures are current and relevant?

Standard 12


be achieved by:
12.2 12.2.1 Workforce shortages can occur on a short-term, shift-by-shift basis.

Implementing Contingency plans Available staff crises can be managed using a contingency plan which
systems to are developed may include strategies such as reprioritising tasks, allocating tasks
ensure that to maintain safe, to different staff members, and relying on a pool of filler staff, which
the skill mix quality care if is often based on previous employees and sourcing casual staff
of clinical and prescribed levels of from agencies.4
support staff skill mix of clinical
meets consumer and support staff The impact of internal changes (for example, the practice manager
/ patient needs are not available, going on maternity leave) and the external environment (such as
and service and in order to increasing number of aged consumers / patients) on the human
requirements. manage workforce resources needs of the day procedure centre should be considered
shortages. on an ongoing basis, and appropriate changes made.
Relationships with nursing agencies that understand the day procedure

centres’ requirements and can respond at short notice and/or provide
repeat placements should be a part of the contingency plan.
Prompt Points
How does the day procedure centre make sure that the skill
mix is still suitable when there are changes such as to service
requirements, casemix, cost containment, new processes
and procedures?
How does workforce planning reflect the organisation’s longer-term
strategic plan?
How does the organisation ensure that the right people with the
required skills and behaviours are available when and where they
are needed on a day-to-day basis?

Standard 12


be achieved by:
12.3 Minimising 12.3.1 The system Fatigue represents a serious risk to consumers / patients and staff
fatigue risk for managing safe alike, and must be proactively managed to avoid incidents.
associated working hours and
with extended fatigue prevention Fatigue caused by long working hours can impair judgement and
working hours. is evaluated, competence.5 There is a risk of diminished quality of care, and a risk
and improved to the health and safety of the individual.6 Fatigue is personal, hard to
as required. identify unequivocally and, consequently, difficult to measure and/or
regulate. It should not be confused with habituation, lack of motivation
or boredom, although these may contribute to fatigue.7
Staff surveys may suggest that fatigue could be problematic for

an organisation, however because of variations between individual
physiology and reservations of some members of the workforce to
report (even anonymously) that their capability could be affected by
workplace demands, more objective measures should also be used
to assess this issue. Depending on the records available, a measure
of continuous hours worked by individuals is a more reliable guide
to potential for fatigue. Organisations should consider what data are
already being collected that might give an indication of continuous
hours being worked; for instance, theatre scheduling may indicate
hours worked.
Policy and/or guidelines on safe working hours and fatigue

management should be developed with staff input and made readily
available to the entire workforce, including non-employee workers
such as visiting medical officers (VMOs).
Prompt Points
How is fatigue-related risk systematically identified?
What longer-term planning is being conducted to minimise risks
associated with fatigue?
How is fatigue, or the potential for fatigue, managed in employees /
casual staff who may be engaged in other employment?

Standard 12
Criterion 2: Recruitment and Ongoing Clinician Appointment Processes

The recruitment, selection and appointment system ensures that the skill mix and competence of staff meets
the needs of the organisation
Recruitment, selection and appointment processes If recruitment activities are outsourced to an external
must meet legislative requirements. Equal opportunity service provider, agreements should clearly outline
and anti-discrimination legislation requires that the exactly what process is to be followed and any specific
recruitment process, including the selection criteria, activities that need to be undertaken, for example,
is consistent with job specifications. Employers should checking candidate credentials. Where processes are
operate in accordance with the Commonwealth Acts undertaken by the outsourced provider, day procedure
covering fair work and workplace relations, work health centres should review results for themselves and make
and safety (WHS) and privacy. In addition, there are sure that it has been done. The results should form part
different Acts operating within each State / Territory, of the employee records.
with detailed regulations particularly pertaining to
WHS and workplace relations issues. A range of
Commonwealth and State / Territory legislation protects
against discrimination based on stated criteria, such
as race, age and gender. Restrictive criteria may also
lead to indirect discrimination.
Recruitment, selection and appointment processes

should be considered in conjunction with organisational
strategic and operational plans. Recruitment
goals should align with the broader organisational
goals identified through workforce planning.
The organisational resources available to undertake
recruitment and appointment activities should be
evaluated when developing plans and procedures to
ensure that the processes are thorough, performed
consistently and undertaken by trained staff.

Standard 12

Recruitment and Ongoing Clinician Appointment Processes
The recruitment, selection and appointment system ensures that the skill mix and competence of staff
meets the needs of the organisation.

be achieved by:
12.4 Meeting 12.4.1 The Day procedure centres should have an established appointment and
and ensuring recruitment, reappointment procedure that is easy to follow and ensures that
compliance with: selection and appropriately skilled and experienced staff are recruited and selected.
• legislation appointment It may be helpful to have this displayed in a flow-chart format for
systems are easy reading.
• jurisdictional
evaluated, and
policy / The recruitment and appointment process should include the
adapted to
regulations following steps:
changing service
• organisational needs where • communicating or advertising the job vacancy
policy / required. • collection of applications and short-listing candidates
guidelines
• interviews, references and credential checks, and any
for recruitment,
further testing
selection and
appointment • providing a signed letter of appointment and/or an
in a healthcare employment contract.
setting.
Orientation provides new staff with a background to the organisation,
for example, the vision, mission and values and an introduction to the
organisational culture. 2 Orientation programs should be developed
to meet the specific needs of the day procedure centre and in
response to the characteristics of the participants and their role
within the organisation.
All new staff should participate in an orientation program that

is appropriate to the requirements of the day procedure centre.
This includes a program for permanent staff, as well as orientation
for short‑term or agency staff.
To assist in evaluation of the orientation process, consider staff

orientation during the performance review. Day procedure centres
can use the feedback on how recently appointed staff felt after
appointment as an evaluation of the process.
Prompt Points
Which sections of legislation and regulations inform the policies
that govern recruitment, selection and appointment? How does
the organisation ensure that the requirements of legislation and
regulations are met?
If the recruitment process is outsourced, what documentation from
the external provider demonstrates that it meets legislative and
regulatory requirements?

Standard 12

Recruitment and Ongoing Clinician Appointment Processes (continued)

be achieved by:
12.5 Verifying 12.5.1 The flexibility, multi-skilling and mix of staff are important within a day
the credentials of Recruitment procedure centre, assisting it to carry out its diverse activities; this
clinicians prior to processes ensure should be considered in all stages of appointment.
commencement adequate staff
of employment / numbers and that Workforce shortages experienced by the day procedure centre may be
contracts. the workforce has mitigated through creative management strategies; however long-term
the necessary sustainability needs to be considered. Recruitment processes should
licences, address required staff numbers as outlined in the day procedure
registration, centre’s service plan and work to fill these vacancies.
qualifications, skills
An essential risk management process for all organisations is
and experience to
appropriate pre-employment screening. Screening is mandatory in
perform its work.
some States / Territories for certain positions, such as those that
involve working with children. When recruiting for clinical positions,
all appointments should be reviewed; this can be part of the medical
advisory group’s function if not performed by a credentialling
committee, as addressed in action 12.5.2. Where casual staff are
sourced from agencies, it is important to confirm that all agency staff
have themselves been screened and have met the standards of the
contracting healthcare facility. These may be more specific, or higher,
than the standards of the agency.
It is important that all claimed qualifications and experience are

verified. Pre-employment checks may include contact with past line
managers, dates of employment confirmed with payroll departments
and criminal history checks. Academic achievements or professional
licensing should be confirmed with appropriate colleges or licensing
boards. Evidence of qualifications and/or registrations should also
be verified by employers and it is important that original documents
are cited or, where this is not possible, that copies are notarised.
Organisations should retain copies of any licenses, qualifications
or certificates in employees’ personnel records.
Prompt Points
Describe the pre-employment screening process undertaken for
a managerial staff member. How does the process change when
the staff member will occupy a clinical role?
How does the recruitment process support the organisation to
ensure the best person is recruited to a position? How is the
process evaluated?

Standard 12


be achieved by:
12.5.2 The ‘Credentials’ reflect factors that may contribute to a clinician’s

credentialling performance, but provide no measure of actual performance;
system to confirm while ‘credentialling’ involves the forming of an opinion about a
the formal clinician’s performance by a peer-level committee qualified to assess
qualifications, that performance.
training, experience
and clinical The purpose of credentialling is to ensure that claimed qualifications
competence of and experience are verified. It is an essential component of any
clinicians, which consumer / patient safety or clinical governance framework.
is consistent with
The process for assessing the credentials of a clinician is outlined
national standards
by the Standard for Credentialling and Defining the Scope of Clinical
and guidelines and
Practice.8 The credentialling system should be linked to the system
with organisational
for determining clinician scope of practice, which is addressed by
policy, is evaluated,
Standard 1, item 1.10. Consideration of scope of practice needs
and improved
to occur, to ensure that clinicians have the skills and experience
as required.
to undertake specific procedures, and that they are appropriate
for the organisation in terms of equipment available, nursing staff
expertise, etc.
Robust systems for conducting pre-employment checks of

overseas‑trained clinicians must be implemented and include a
review of references, claimed work experience, additional training
and previous employment.
Prompt Points
What statutory requirements and guidelines did the organisation
consult in developing its policy / by-laws governing credentialling?
What credentials must a clinician present to the credentialling
committee when being considered for appointment? How does
the committee confirm these credentials? Is this different for
overseas‑trained clinicians?

Standard 12


be achieved by:
12.6 Ongoing 12.6.1 Ongoing The day procedure centre must have a system for monitoring the
monitoring monitoring and ongoing performance of clinicians.
of clinician review of clinicians’
performance. performance The organisation should work with clinicians on an ongoing basis
is linked to the to review clinical outcomes, adverse events, and/or complaints.
credentialling This process may form part of clinical / peer review meetings. Close
system. attention should be paid to any indications of underperformance such
as persistence with out-dated practices, clinical disinterest or poor
procedural outcomes.
As well as demonstrating that all relevant registrations and

memberships have been maintained, the clinician must provide details
of any further endorsements / accreditations achieved, relevant
education / training undertaken, and all healthcare-related activities
since the previous credentialling.
The process for re-credentialling and redefining the scope of practice

should be as stringent as that followed for the initial credentialling;
no assumptions should be made about a clinician’s qualifications
or performance.
It should be clearly stated when re-credentialling of clinicians

will occur. All clinicians should be re-credentialled on a regular
and ongoing basis throughout the period of their employment /
appointment, in accordance with any contracts or by-laws and
jurisdictional legislation and policies.
Although employment contracts should outline the responsibility of

clinicians to maintain their credentials and registration, the onus is on
the healthcare organisation to implement a system for re-credentialling
all clinicians. This becomes particularly important if recruitment and
credentialling processes are managed externally to the organisation.
Where licences / registration require renewal, there should be an
alert system primed to the expiry date for all staff licences to ensure
that where the organisation does not administer the renewal process,
renewal details are confirmed.
In a day procedure centre where the clinician is the owner / operator,

the process of ongoing monitoring and performance review may not
have the required scrutiny. There are ways this can be addressed, for
example, policy may state that the ongoing monitoring, performance
review and credentialling performed at another health service
where the clinician has visiting rights could be accepted by default,
provided that the scope of practice is aligned with that of the day
procedure centre. Alternatively, day procedure centres could invite a
senior consultant / academic in the particular clinical field to join the
appointment / credentailling committee, and contribute to decisions.

Standard 12


be achieved by:
The re-credentialling of clinicians should be linked to the system

for reviewing a clinician’s scope of practice, which is addressed by
Standard 1, item 1.10.
Prompt Points
Under the terms of the organisation’s policy / by-laws, how
often is a clinician’s performance monitored and reviewed?
How is this done?
How does the organisation check the registration of clinicians
on an ongoing basis? What system is in place to monitor
clinician registration?
Does the organisation use the AHPRA database of clinicians
to check registration? What processes are in place to monitor
professions not managed under AHPRA?
Does the system for monitoring clinician registration notify the
organisation when the clinician receives a notification from their
professional Board? What action is taken if this occurs?

Standard 12
Criterion 3: Continuing Employment and Development

The continuing employment and development system ensures the competence of staff
The performance of all staff, including contracted staff, Performance assessments should not focus solely on
is important to the overall success and outcomes of a the historical performance of duties but evaluate and
healthcare organisation. It is therefore imperative that plan for future staff development and professional
the day procedure centre implements a performance growth. Day procedure centres should have a
review system for staff that aligns employees’ goals, well‑resourced learning and development system that
skills, talents and performance outcomes with the identifies the development and education needs of
organisation’s vision, mission and goals by supporting the organisation and individual staff.10 Planning should
continuous learning and competence development, by define the objectives of learning before determining the
clarifying expectations and performance standards, mode for delivery of education, and should evaluate the
and providing evaluation, feedback and recognition of effectiveness and cost-benefit of any program against
performance. The performance review system should these pre-identified goals.
be designed to promote and support the professional
development of the organisation’s employees.9
Position descriptions are an integral part of staff

performance reviews as they can provide a benchmark
for staff roles and responsibilities against which
performance can be evaluated. Position descriptions are
dynamic documents and need to be updated regularly to
reflect changes in clinicians’ competency and scope of
practice, service delivery and organisational delegation
of duties and responsibilities. All staff members should
have a documented, dated position description which is
kept in their personnel record and outlines the schedule
for regular performance appraisals.

Standard 12

Continuing Employment and Development
The continuing employment and development system ensures the competence of staff.

be achieved by:
12.7 Ensuring 12.7.1 Accurate Personnel records should be accurate, complete, confidential and
that personnel and complete only available to authorised personnel as outlined in the organisation’s
records contain personnel records policy and procedures. The personnel records system contains
current relevant are maintained and personal information and must be managed according to the
information kept confidential. National Privacy Principles11, which should be referenced in the
as required, organisation’s policies and procedures. Strategies to protect personnel
including information include:
evidence of • specifying staff with limited and unlimited access to specific files
registrations. including the use of password protection
• restricting physical movement of staff files or specifying the
computer terminals through which information is accessed
• defining the circumstances in which specified information may
be disclosed.
The management of personnel records is linked to Standard 13

on information management, item 13.5.
Information commonly included in personnel files or stored in a

Human Resources Information System includes:
• personal details, employment details, position description,
terms and conditions of employment, relevant educational
and professional qualifications
• the employment contract and records of referee and other
validation checks
• AHPRA registration number (where applicable), and dates
of any professional registration checks
• scope of practice (where applicable)
• designated financial authority
• records of staff orientation
• attendance at fire / emergency management training
• education and training, including mandatory training such
as child protection systems
• records of annual performance reviews
• records of leave
• records of any compensable injuries
• records of vaccinations or confirmed immune status
• disclosed health information, such as allergies or carer
responsibilities
• any formal disciplinary action.

Standard 12

Continuing Employment and Development (continued)

be achieved by:
The retention and disposal of personnel records should also be

managed according to legislative requirements and/or jurisdictional
guidelines; some parts of a personnel file will have varying lengths of
retention. Regardless of the contents, all personnel records must be
disposed of in a way that protects and maintains confidentiality.
Prompt Points
How does the organisation store personnel records? How does
the organisation ensure that personnel records are kept updated
and confidential?
Who has access to personnel records? On what basis is access
to personnel records granted? Are staff aware of processes
for accessing their own personnel records?
12.7.2 There Mandatory training requirements differ between jurisdictions, however

is a system to across many jurisdictions mandatory training relates to first aid, work
document training health and safety (WHS) and privacy.
for staff which
is identified as In addition to legislated staff training, organisations may identify other
necessary by the necessary training that is specific to organisational systems, programs,
organisation. equipment or administrative structures.
A system to record the completion of mandatory training should

allow managers the ability to check and monitor staff completion
rates. Day procedure centres may demonstrate compliance through
evidence that:
• approved training programs are provided by appropriately
qualified trainers
• training is attended by sufficient numbers of relevant staff to
manage risks to the day procedure centre and to its consumers /
patients (for example, that a sufficient number of staff and visiting
medical staff have accessed and attended emergency training)
• records of attendance are included in / linked to the personnel
records of individual staff.
Prompt Points
What proportion of staff has attended mandatory training in
handling an emergency such as a fire? What records are used
to track attendance?
What other training is mandatory in the organisation’s jurisdiction?

Standard 12


be achieved by:
12.8 Integrating 12.8.1 The All staff should be informed how their performance will be managed
the performance performance and the results of their performance review.
development assessment and
system for development Performance review of all staff should12:
staff, including system includes: • be assessed and documented at least three months after initial
contracted staff, • review of employment, as agreed in the contract, and then annually or
with any relevant position according to the employment contract
service plans or descriptions • be based on the staff member’s position description, and consider
changing service any changes to that position description
• review of
requirements.
competencies • be in accordance with organisational requirements
• monitoring • identify strengths in performance
of compliance • include the active participation of managers and staff
with published
• involve setting performance goals
codes of
professional • follow up on issues from previous reviews.
practice Annual performance review provides an opportunity for managers to
• assessment determine the career goals of their staff and suggest specific education
of learning and / training to address identified areas of development. Aligning individual
development goals with the goals of the unit, department and organisation wherever
needs possible, should build the staff-employer relationship and promote
• provision staff retention.
of adequate
All staff should have a documented, dated position description,
resources for
which is kept current and includes specification of responsibilities,
learning and
accountabilities, job functions and activities and the frequency and
development
process of performance appraisal.
• management
of identified Prompt Points
performance How is the performance assessment system designed so that
needs. performance reviews are conducted in an objective, constructive
manner? How are the process and outcomes of performance
management monitored against the organisation’s requirements?
How is the performance of contracted staff reviewed and reported?

Standard 12


be achieved by:
12.9 Having a 12.9.1 Processes The AHPRA national health professional Boards each have a code of
system to protect are in place professional conduct by which their members are expected to abide.
the interests of for managing The Boards receive complaints about, and notifications of, issues that
consumers / a complaint or are affecting professional performance.
patients and concern about
carers, clinicians a clinician, and Organisations should be cognisant that the Health Practitioner
and other there is evidence Regulation National Law Act 2009 (Cth) obliges those healthcare
staff, and the that they have professionals that fall under the auspices of this law to notify the
organisation, been used. relevant professional Board of impaired behaviour that might lead
during the to the public being placed at risk of harm by healthcare professionals
management (see S.140 of the Act quoted above).13 Decisions in response
of a complaint. to such notifications will be made by the Boards of the relevant
professional bodies.
There are many ways that the organisation could be alerted to

a concern about a clinician, including:
• receipt of a complaint from a consumer / patient, family member,
or person external to the organisation
• receipt of a complaint or concern raised by other clinicians
or staff within the organisation
• an external investigation, such as coronial inquiries, or by
a centralised complaint body, such as the health services
ombudsman or similar independent body
• during the investigation of an incident or routine case
review processes
• during review of consumer / patient records for another purpose
• during routine peer reviews.14
Processes for dealing with complaints against clinicians should be

outlined in the organisation’s policies and procedures or by‑laws.
A system should be in place to document the actions taken
by management when dealing with or investigating complaints
against clinicians.
If the day procedure centre has not received a complaint against

a clinician, a documented process describing how they would deal
with this type of complaint in the event of receiving one would be
appropriate to address this action.
Prompt Points
How does the organisation’s system / process for managing
a complaint about a clinician meet legislative requirements?
How does the organisation ensure protection for whistle-blowers
during the investigation process?
How does the investigation process protect a complainant?

Standard 12


be achieved by:
12.9.2 Processes A complaint may be made against any staff member and will not
are in place necessarily relate to consumer / patient safety and quality of care.
for managing
a complaint or The day procedure centre should implement a wide-ranging system to
concern about facilitate the reporting of complaints, and which is capable of dealing
a member of with conduct issues of all staff. This system should also allow for the
staff, including documentation of actions taken by the day procedure centre when
contracted staff, dealing with or investigating a complaint against a member of staff.
and there is
All complaints should be managed according to policy, however the
evidence they
potential for complaints in the following areas should be particularly
have been used.
considered and policies and procedures reviewed to ensure that
appropriate measures are taken15 :
• bullying and harassment
• discrimination
• child-related allegations
• sexual misconduct, particularly if non-consensual, and indecency
• physical violence
• conflicts of interest
• corruption
• attendance while under the influence of drugs or alcohol.
If the day procedure centre has not received a complaint against a staff
member, a documented process describing how they would deal with
this type of complaint would be appropriate to address this action.
Prompt Points
How does the system / processes for the management of
complaints against non-clinical staff compare to that of clinicians?
What is the process for investigating complaints?
How is the complaints system / processes evaluated?

Standard 12
Criterion 4: Employee Support and Workplace Relations

Employee support systems and workplace relations assist the organisation to achieve its goals
‘Workplace relations’ is a system to balance the needs To maintain an enthusiastic workforce, management
of employees and employers; the goal is to achieve must meet all three goals. Indeed, employees who
optimal performance of both the individual and the work for companies where just one of these factors is
organisation. Regulating relationships in the workplace missing are three times less enthusiastic than workers
underpins the culture of the day procedure centre, its at companies where all elements are present. Goals
values and goals, and ensures productivity, efficiency cannot be substituted: improved recognition cannot
and a positive environment. Positive outcomes rely on replace better pay, money cannot substitute for taking
communication and cooperation; the goal is high staff pride in a job well done, and pride alone will not pay
satisfaction and morale, high productivity and retention the mortgage. Day procedure centres must consider
of quality staff. Workplace relations should be open, strategies which will allow them to meet these three
transparent, honest, supportive and non-confrontational. goals of workers.
Mediation is preferable to arbitration.
In all professions, most workers seek three overarching

goals from their work16 :
• equity: to be respected and to be treated fairly
in areas such as pay, benefits and job security
• achievement: to be proud of one’s job,
accomplishments and employer
• camaraderie: to have good, productive relationships
with fellow employees.

Standard 12

Employee Support and Workplace Relations
Employee support systems and workplace relations assist the organisation to achieve its goals.

be achieved by:
12.10 Providing 12.10.1 The Employment is both an obligation and a privilege, and all employees
clear information workplace rights should be made aware in writing of the details of their rights
about staff and responsibilities and responsibilities.
rights and of management
responsibilities and staff are In Australia, many rights and responsibilities of workers and of
including access clearly defined and employers are recorded in jurisdictional legislation. Under the Fair Work
to grievance communicated. Act 2009 (Cth)17 there are ten minimum standards of employment
processes, and which apply across all jurisdictions. They address hours and timing
taking action of work, leave entitlements, termination and redundancy, and the
when needed. provision of a Fair Work information statement.
Employee responsibilities with associated disciplinary action for any

breach will be outlined in organisational policy, which will also delineate
employee rights. These issues should be addressed during orientation.
Additional rights and responsibilities are associated with legislation,

professional codes of practice and guidelines.
Physicians and other clinicians who operate from an independent

practice will have obligations arising from their business arrangements
with the organisation, and in this context it is extremely important that
the respective rights and responsibilities of both business entities are
stated clearly in their agreement. Registered clinicians are expected to
abide by these conditions, and could be reported to their professional
Board for failure to comply.
Prompt Points
What rights and responsibilities are outlined in employment
agreements for different categories of staff employed by,
or contracted to, the organisation?
How are rights and responsibilities communicated to staff
and/or contractors?

Standard 12

Employee Support and Workplace Relations (continued)

be achieved by:
12.10.2 Managers At-risk behaviour involves actions and reactions from clinicians and
take action on other staff that put consumer / patient care and safety at risk, and can
at-risk behaviour range from lack of hand washing and use of personal protection, to the
of staff. effects of substance misuse. Day procedure centres should consider
how identified at-risk behaviour would be managed.
Signs that may alert a manager to disruptive or at-risk behaviour within

a team include increased turnover or difficulties in getting casual staff
to return, complaints from consumers / patients or staff, an increase in
reported incidents, or performance problems with individuals or teams.
An early management response to potentially dangerous behaviour

may prevent further issues, as many causes of at-risk behaviour, such
as sleep deprivation, overwork, poor health or stress related to work or
to personal matters, are temporary.
The Health Practitioner Regulation National Law Act 2009 (Cth) obliges
those healthcare professionals that fall under the auspices of this law
to notify the relevant professional Board of impaired behaviour that
might lead to the public being placed at risk of harm18, as addressed in
action 12.9.1. Organisations should consider this Act when developing
systems around identifying and responding to at-risk behaviour.
Prompt Points
Does the organisation have a formalised system / process for
dealing with disruptive or dangerous staff behaviour?
What training is available to managers to assist them to recognise
and manage at-risk behaviours by team members?
12.11 12.11.1 There Workplace relations encompasses a variety of issues, including

Management is a consultative communication, consultation, discrimination, harassment (bullying,
and staff working and transparent etc.), fair distribution of work, rostering, fixed-term employment
cooperatively to system to identify, contracts, hours of employment and conditions for part-time and
achieve effective manage and casual staff, staff grievances and disputes, violence between
workplace resolve workplace staff, discipline, termination and redundancy, staff satisfaction and
relations, with relations issues compliance with organisational policies and procedures.
involvement of which is evaluated,
relevant external and improved The acceptance of statutory and moral responsibilities in supporting
groups where as required. employees’ needs and assisting access to appropriate services will
appropriate. facilitate the employee / employer relationship.

Standard 12


be achieved by:
Strategies that may be used to implement effective workplace relations

could include:
• distributing documents on rights and responsibilities, for example,
codes of conduct, prevention of harassment and discrimination,
natural justice, standards of workplace behaviour, work health and
safety (WHS) standards, access to industrial information
• active involvement of managers, employees and, where
appropriate, their representative associations
• formal training and development for managers and staff
• incident monitoring that identifies workplace issues
• a staff grievance process or other system to manage potential
misunderstandings / disputes
• monitoring compliance with policies and procedures and
statutory requirements
• association with relevant external groups including unions,
mediators, counselling services
• a formal mechanism for staff representation and evidence of regular
consultation and communication between staff and management
• appropriate monitoring of the workplace relations management
system.
Workplace grievances should be managed in an effective and fair

way for all parties concerned. Organisations need to ensure that:
• grievance procedures are understood by both management
and staff
• all staff have access to effective and fair processes
• relevant jurisdictional / legislative requirements are met.
Prompt Points
Does the organisation have a formal grievance procedure for
workplace disputes?
How does the organisation make available to staff information
about workplace relations policies and procedures?
How does the organisation evaluate the effectiveness of workplace
relations mechanisms?
What unions or other external groups does the organisation have
established links with?

Standard 12


be achieved by:
12.12 12.12.1 Motivation is the key to a committed performance by staff. Incentives

Implementing Strategies to: need not be financial: they are best driven by specific goals and
strategies • motivate staff may be offered to individuals or to all members for contributing to
to create a team outcomes.
• acknowledge
workplace culture
the value of Other drivers include training and development, flexible working
that fosters and
staff arrangements, social interaction, improvements to the work
encourages staff.
• support flexible environment, or more interesting tasks.19 Immediate positive feedback,
work practices verbally or in a note, is a very important driver of behaviour by workers.
• promote staff
All workers want to believe that their efforts make a difference and
health and
are noticed. People enter ‘helping’ professions because they want
wellbeing
to improve other people’s situations. However, when being ‘helpful’
are evaluated with is fundamental to a role, it may be expected and not acknowledged.
staff participation, Managers in health care are likely to see instances of great
and improved commitment, persistence, quality of work and/or caring by individuals
as required. or teams within organisations.
Receiving recognition for achievements is one of the most fundamental

human needs. The acknowledgement may be formal or informal,
tangible or intangible, public or private. Examples of methods that
organisations and/or managers may use to acknowledge
performance include:
• formal awards, such as employee-of-the-year, or similar
• thank-you notes
• celebratory meals for the team
• time-in-lieu following periods of hard work
• bonus payments
• opportunities to attend conferences or other events
• ensuring that internal and external compliments are passed on.
The nature of the work within a healthcare setting may preclude some
forms of flexible work practice, however organisations should consider
individual circumstances in their decision making.
In the event of employee illness or distress, day procedure centres

will be able to support that person through the provision of time off or
compassionate leave or through referral to relevant services.
Other aspects of employee assistance could include:

• vaccination against Hepatitis B
• pathology testing as per Medicare charges only
• supply of first aid and follow-up care
• the provision of a ‘flu’ vaccination to assist both the day procedure
centre and the staff member, as the occurrence of sick leave due to
‘flu’ symptoms may be reduced
• counselling for staff involved in traumatic incidents associated
with work.

Standard 12


be achieved by:
Prompt Points
What scope does the organisation provide for managers to
acknowledge excellent performance in a timely, sincere and
personalised manner?
What strategies has the organisation employed aimed at motivating
staff? How are staff motivation strategies evaluated?
Does the organisation allow flexible working arrangements?
If so, in what ways does the organisation support this?
12.13 Facilitating 12.13.1 An Employee Assistance Program (EAP) is a proven strategy for

access to an Performance assisting employees and their families with personal and work-related
effective system measures are problems, difficulties and concerns which they may experience from
to provide used regularly to time to time, and which affect the work performance of an employee.
support to the assess staff access Supporting staff through EAPs will demonstrate a caring workplace.
workforce. to an employee
assistance program Comprehension of employee needs and identification of solutions
and to evaluate are part of a manager’s role. Understanding the effect of providing
the staff support access to employee assistance will aid management in the provision
services, and of appropriate services.
improvements are
Performance measures for employee support services may include
made as required.
surveys demonstrating staff knowledge about, or measures of uptake
of, EAP services. However, because of the nature of their services,
staff liaisons with the workplace EAP should be confidential, and
so any measures used must be anonymous. Data may be provided
to the organisation from the EAP provider on staff access levels or
breakdown of key issues identified, which may be used to design
internal training programs or inform staff health promotion programs.
Prompt Points
How is the availability of EAP services communicated to staff?
Does the organisation monitor levels of EAP service use by staff
and if so, how? What use is made of the information?

Standard 12
References
1. Victorian Rural and Regional Health and Aged Care Services. Rural health workforce planning guidelines.
Melbourne VIC; Dept of Human Services; 2006.
2. Dessler G, Griffiths J and Lloyd-Walker B. Human resource management. 2nd edn. Sydney NSW;
Pearson Education Australia; 2004.
3. Keegan A, Huemann B and Turner R. Beyond the line: exploring the HRM responsibilities of line managers,
project managers and the HRM department in four project-oriented companies in the Netherlands, Austria,
the UK and the USA. Int J Hum Res Man 2012; 23(15): 3085-3104.
4. Blythe J, Baumann A, Zeytinoglu I et al. Full-time or part-time work in nursing: Preferences, tradeoffs and
choices. Healthcare Quarterly 2005; 8(3): 69-77.
5. Nocera A and Khursandi DS. Doctors’ working hours: can the medical profession afford to let the courts
decide what is reasonable? Medical Journal of Australia 1998; 168(12): 616-618.
6. Australian Medical Association (AMA). National code of practice – hours of work, shiftwork and rostering
for hospital doctors. Canberra ACT; AMA; 2005.
7. Association of Anaesthetists of Great Britain and Ireland (AAGBI). Fatigue and anaesthetists. London UK;
AAGBI; 2005.
8. Australian Council for Safety and Quality in Health Care. Standard for credentialling and defining scope
of clinical practice. Canberra ACT; Australian Council for Safety and Quality in Health Care; 2004.
9. de Cieri H and Kramer R. Human Resource Management in Australia: Strategy, People, Performance.
Sydney NSW; McGraw-Hill Australia; 2003.
10. Gephart M, Marsick V, Van Buren M and Spiro M. Learning organizations come alive. Training and Development
1996; 50(12): 34-35.
11. Office of the Federal Privacy Commissioner. National privacy principles. Private Sector Information sheet 1A.
12. University of Denver. Performance review and development system. Denver USA; Denver University.
Accessed from http://www.du.edu/hr/employment/performance_management.html on 7 August 2012.
13. Medical Board of Australia. Guidelines for mandatory notifications. Melbourne VIC; Medical Board of Australia.
Accessed from http://www.medicalboard.gov.au/Codes-Guidelines-Policies.aspx on 7 August 2012.
14. Australian Commission on Safety and Quality in Health Care (ACSQHC). Review by peers. A guide for
professional, clinical and administrative processes. Sydney NSW; ACSQHC; 2010.
15. Hunter New England Area Health Service (HNEAHS). Managing a concern or complaint about a clinician.
Newcastle; NSW Health. Accessed from http://www.hnehealth.nsw.gov.au/cg2/professional_practice/
concern_or_complaint_about_a_clinician on 7 August 2012.
16. Sirota D, Mischkind LA and Meltzer MI. Stop demotivating your employees! Harvard Management Update 2006.
Accessed from http://www.sirota.com/pdfs/Stop_Demotivating_Your_Employees_Harvard_Management_
Update_Jan_2006.pdf on 7 August 2012.
17. Fair Work Australia. The National Employment Standards (Part 2-2). Canberra ACT; Fair Work Australia.
Accessed from http://www.fwa.gov.au/documents/awardmod/nes.pdf on 26 March 2012.
18. AHPRA Medical Board of Australia. Consultation paper on codes and guidelines comprising guidelines on
advertising and guidelines on mandatory notification. Melbourne VIC; Medical Board of Australia; 2010.
19. NSW Department of Industrial Relations. Managing people. Sydney; NSW Government. Accessed from
http://www.industrialrelations.nsw.gov.au/pdfs/managing_people.pdf on 7 August 2012.

Introduction
Day procedure centres should have a well set up, monitored, controlled and managed
information system in place. The information system should be set up for both internal and
external use by clinicians and other staff members as well as external entities, for example,
government departments, coroners, researchers, if applicable, and other healthcare providers.

Ensure that information and data are collected and
used to meet the day procedure centre’s needs
1. Health Records Management
and support the delivery of safe, high quality health Health records management systems support the
care and services. Organisations collect a vast collection of information and meet the consumer /
amount of information and data on a regular basis1, patient and organisation’s needs.
therefore it is imperative that systems are in place
for appropriate management of this information, 2. Corporate Records Management
which ensure compliance with legislative and
jurisdictional requirements. Corporate records management systems support
the collection of information and meet the
organisation’s needs.
Context
Information and data are important for: 3. Collection, Use and Storage
• the provision of health care and services of Information
• continuity of consumer / patient care Data and information are collected, stored and
• organisational and staff performance used for strategic, operational and service
• organisational safety and risk management improvement purposes.
• compliance with legislation, standards and
guidelines. 4. Information and Communication
Technology
Good information management principles should be in
place in all healthcare organisations regardless of size, The organisation has an integrated approach to
location or method of record keeping. Information and the planning, use and management of information
data management systems should be integrated with and communication technology (ICT).
communication technology. Although this Standard
does not dictate the method of record keeping, factors
pertinent to the chosen method need to be considered
when developing management plans. Access to records
needs to be provided to authorised persons in a timely
manner and should be facilitated by a well-organised
filing, tracking and retrieval system.

Standard 13
Criterion 1: Health Records Management

and organisation’s needs
Records management involves the planning, control, Relevant staff should have training on how consumers /
monitoring and protection of records and documents. patients can access their records, management of
For the purpose of this criterion, ‘records’ refer to administration systems, electronic health records,
all health records, both electronic and paper-based. the management of paper records, legibility and
The policy, procedure and/or guideline for health completeness of record keeping, and retention and
records management should refer to Australian disposal of records. Explaining the reasons for policies
standards and to all relevant Federal, State and Territory and procedures for the management of health records
Acts including privacy laws. Information on privacy laws and the risks associated with poor record keeping will
is available for individual States / Territories from the assist in compliance. The goal should be to promote
Office of the Australian Information Commissioner.1 responsible health record keeping as a cooperative team
activity essential for safe, multidisciplinary care, which
Consumer / patient health records have multiple uses may help to overcome perceptions that it is merely
and many people have legitimate access to them. As a bureaucratic obligation. As with any other training,
more organisations begin to move to electronic health attendance should be documented in the relevant
records, appropriate security measures will become personnel files.
increasingly important. The risks in health record
security have become more than a matter of controlling
access to the storage area of paper files. Standard 1,
action 1.19.2, addresses appropriate access to
consumer / patient health records.

Standard 13

Health Records Management
and organisation’s needs.

be achieved by:
13.1 Addressing 13.1.1 Health In different jurisdictions, there is likely to be legislation that addresses:
the needs of the records • the retention of health records 2, 3
organisation by management
• access of consumers / patients to their own records
implementing systems are
systems evaluated to ensure • the release of personal information to other practitioners and
to manage that they include: third parties
health records • reference to • the recording of treatment and medical service information
and records all relevant by medical professionals
created by the legislation / • confidentiality and privacy of personal health information.
organisation. standards /
policy / Policies and procedures for the day procedure centre’s health records
guidelines management system should include the following areas:
• defined • information privacy

governance and • updating of information, such as consumer / patient information
accountability • storage
• the secure, safe • damage
and systematic • retrieval
storage and
• retention
transport
of data and • destruction
records • unique identification
• timely and • personal identification
accurate • clinical classification.
retrieval of
records stored When implementing policies and procedures for the management
on or off site, of health records, organisations need to ensure that they comply
or electronically with any Federal or State / Territory legislation and jurisdictional
• appropriate requirements. Reference should also be made to other relevant
retention and professional guidelines and Australian standards applicable to health
destruction of records management.
records
Storage space can often be an issue for day procedure centres
• training for and there are several factors which need to be considered when
relevant staff in implementing innovative storage solutions either onsite or through an
health records external contractor, such as:
management.
• ease and timeliness of records retrieval
• security and confidentiality of records
• risk of damage or loss.

Standard 13

Health Records Management (continued)

be achieved by:
The length of time required to maintain health records is dictated

by legislation and organisations should have a planned schedule for
routine culling and destruction of health records which exceed this
period. Methods of destruction will depend on the type of media
used, for example shredding paper or wiping clean hard drives, but
must maintain consumer / patient privacy. If destruction services
are outsourced to an external provider, the organisation should seek
assurances that their methods meet legislative requirements.
Whether health records are paper-based or electronic, it is important

that staff are trained in the correct procedures for their management.
The training needs of clinical staff will vary from those of administrative
staff. Factors to consider when planning training / education:
• the time commitment required to learn a new system / task
• the risks associated with incorrect compliance with records
systems and processes
• the availability of skilled staff to teach / mentor staff who are
learning, and monitor their output
• whether there is the budget and equipment for in-house training
of groups
• whether there are suitable outsourced courses available.
Prompt Points
What systems are in place for health record storage, retrieval and
destruction? How are staff advised of these procedures?
How does the organisation manage hard copy and electronic
records in a way that makes it easy for approved people to find the
information they need?
How are complaints from clinical staff who are unable to locate
health records / files within a record managed by the organisation?
What current staff members or groups have recently received
health records training? How is training provided at orientation?
How is attendance documented?

Standard 13


be achieved by:
13.2 Establishing 13.2.1 The system The Healthcare Identifiers Act (Cth) 3 was passed in June 2010, and the
a system to for the allocation associated Healthcare Identifiers Regulations 20104 set out provisions
support the and maintenance relating to the assignment, collection, use, adoption and disclosure of
allocation and of the organisation- healthcare identifiers. Organisations should ensure that they comply
maintenance of specific consumer / with the requirements of this legislation.
an organisation- patient identifier,
specific including a process A unique identifier is an organisation-produced number, code, or
consumer / for checking letters, of whatever sort, given to a single consumer / patient for
patient identifier multiple identifiers, the first and every subsequent attendance at the organisation.
for the first and is evaluated, The unique identifier helps to identify each consumer / patient and
every subsequent and improved ensures continuity of care. Safety and quality can be compromised
visit to the as required. if the consumer / patient is not correctly identified, and when wrong
organisation by or insufficient health information is used for care.
a consumer /
Development of policy and procedure will include:
patient to ensure
continuity • personal details that should be collected to adequately allocate the
of care. consumer / patient unique identifier, as well as the organisation’s
approved identifiers as addressed in Standard 5 on Patient
Identification and Procedure Matching
• systems to support the allocation and maintenance of the
unique identifier
• cross-referencing of unavoidable multiple records
• the need for phonetic searches of names that sound alike but
are spelt differently
• the need for alias searches to identify people who use more than
one name
• processes to differentiate between people with the same name
• processes for tracking provision of care where consumers /
patients access services anonymously.
An electronic consumer / patient master index or central index, used

to store the unique identifiers, can range from a simple database
to complex systems, depending on organisational size, corporate /
regional infrastructure and available resources.
Prompt Points
What system-based precautions prevent different sites /
departments issuing a second identifier for the same person?
How are multiple identifiers checked? What process is followed
when multiple identifiers are discovered?
How will individual health identifiers (HPI-I) and health provider
identifiers (HPI-O) be managed?

Standard 13


be achieved by:
13.3 Clinical 13.3.1 Clinical Clinical classification is the process of translating healthcare data,
coding and coding and such as that relating to diseases, complications, co-morbidities
classification that reporting time and interventions, from a consumer / patient health record into a
is performed for frames that coded format using a relevant classification system. This allows the
all consumers / meet internal comparison, analysis and interpretation of collected data. Coded data
patients and external may have many applications including clinical and non-clinical decision
accessing requirements making, external reporting, quality improvement activities, funding
services in are evaluated, mechanisms and benchmarking.
accordance with and improved
jurisdictional as required. Coding policies and procedures help to ensure that data are accurate.
standards, where They recognise the need to check accuracy and monitor input for
available, or whatever classification system is used. National organisations, such
guidelines. as the National Casemix and Classification Centre (NCCC), have
expertise in clinical coding and can provide advice on clinical coding
and reporting. Coding performance indicator results can be trended
and compared to those from other organisations to determine whether
the organisation meets best practice, and to identify opportunities
for improvement.
Mechanisms to assist staff to meet internal and external timelines

include:
• ongoing coding education for relevant staff
• access to support mechanisms, such as standards and guidelines
• monitoring coding workload and the allocation of resources
• monitoring turnaround time and mentoring / education for staff
on areas of weakness
• networking with other organisations that use the same classification
system to identify alternative mechanisms
• assisting staff under time pressures to prioritise their workloads and
manage their obligations more effectively, by removing interruptions
or other pressures.
Prompt Points
What are the coding requirements of the day procedure centre?
Where required, what training / qualifications are held by staff
involved in clinical classification?
Do clinical coding staff have access to the most recent editions
of ICD -10-AM codes? How are they available?
Is secure messaging used to transfer data to external sources?
How do staff know what the internal and external reporting
timeframes are?

Standard 13


be achieved by:
13.4 13.4.1 Consumers Health records (paper or electronic) and related information created
Implementing / patients are given and maintained for the ongoing management of each consumer /
systems to advice / written patient are the property of the organisation. This information is deemed
ensure that guidelines on how a personal record, and while the consumer / patient does not have
consumer / to access their ownership of the record, he or she does have the right to access it.
patient access health information
to health records and requests for The organisation should have processes in place to:
is in accordance access are met. • inform consumers / patients how to access their health information
with jurisdictional • manage requests for health information by consumers / patients
policy /
• provide appropriate access to consumer / patient’s health
legislation.
information.
The National Privacy Principles 5-8 and the Privacy Act 1988 (Cth) can
assist organisations to implement systems to protect the privacy
of consumer / patient information. Legislation and guidelines for
the management of health information exists in most States and
Territories as well as at a Commonwealth level, however there may
be differences between how public and private institutions handle
information. For specific details of relevant legislation related to
privacy in the States and Territories of Australia see the website
of the Office of the Australian Information Commissioner:
http://www.privacy.gov.au/law/states
Prompt Points
Where is the organisation’s information on consumer / patient
access to their health record available? How are consumers /
patients advised about access to their health record? How are
consumers / patients assisted to understand the content of their
health record when access is given?
What advice is given to consumers / patients about transferring
information to another health professional?
How are staff made aware of the procedures for consumer / patient
health record access? How are compliance with procedures and
timeliness of response to consumer / patient requests for health
record access monitored?

Standard 13
Criterion 2: Corporate Records Management

Corporate records management systems support the collection of information and meet the organisation’s needs
The policy / procedure / guideline for corporate records How corporate records are managed will depend on
management should refer to Australian standards and to the type of record, the requirements of the organisation
all relevant Federal, State and Territory Acts1 including and the relevant standards, guidelines and Acts.
privacy laws. Information on privacy laws is available For example, meeting minutes will be managed in
for individual States / Territories from the Office of the different ways, and the type of meeting will dictate
Australian Information Commissioner.1 where and how the records need to be stored, and
how long they need to be retained. Final versions of
Records are an organisation’s corporate memory. key corporate files such as Board meeting minutes,
They provide evidence of actions and decisions and annual reports and policy documents should be
represent a vital asset to support daily functions and filed in an unalterable format and archived in a
operations. Records support policy and procedure manner that preserves the content for long-term
formation and managerial decision making, protecting storage and accessibility, even as key personnel and
the interests of the day procedure centre as well as the technology change.
rights of staff and consumers / patients, and help in the
delivery of services in a consistent and equitable way. Day procedure centres should ensure that any
They also support consistency, continuity, efficiency documents that may be necessary to provide title to
and productivity in program delivery, management assets are kept indefinitely. This includes documents
and administration. relating to physical assets, such as contracts and
title deeds, and also to intangible assets such as
intellectual property, for example, copyright assignment
or license agreements. If there is any possibility of
litigation, documents relevant to that litigation should
(or where legislated, must) be retained.

Standard 13

Corporate Records Management
Corporate records management systems support the collection of information and meet the organisation’s
needs.

be achieved by:
13.5 Addressing 13.5.1 Corporate The purpose of this action is not to inspect the content of corporate
the needs of the records records, but to assess the manner in which they are created, stored
organisation by management and used within the day procedure centre. Organisations should
implementing systems are ensure that there is a comprehensive system implemented for the
systems evaluated to ensure management of corporate records. Corporate records may include,
to manage that they include: but are not limited to, minutes of any meetings, memos, personnel
corporate • reference to records, governance decisions, plans, financial records and any other
records all relevant documents developed and/or received by the organisation.9
created by the legislation /
organisation. Policies and procedures should address the requirements for retention,
standards /
storage, archiving and destruction of all corporate records and provide
policy /
guidance about use, storage and retention of less formal means of
guidelines
internal and external communication including hard-copy mail, email
• defined and SMS messages.
governance and
accountability The format of paper-based records and how they are created is often
• the secure, safe apparent by their appearance. However, systems for creation of legal
and systematic records, for example minutes of meetings of Boards, may be subject
storage and to specific processes such as storage in a tamper-proof journal, and
transport policy and procedures should address how these records are created
of data and and by whom.
records
In the case of electronic records, security levels, file paths and access
• standardised should be considered and the requirements for creation documented.
record creation Standardised record creation and filing, whether paper-based or
and tracking electronic, assists in locating records and ensuring that retention and
• appropriate destruction schedules are met.
retention and
destruction of Currency of corporate records is important and, similarly to health
records records, their retention and destruction requirements may be governed
by Federal and State / Territory legislation. Organisations should have
• training for
a schedule in place for corporate record retention and destruction that
relevant staff
meets legislative and jurisdictional requirements.
in corporate
records Staff training programs on record keeping remain important and should
management. cover topics such as:
• what is a record?
• why records need to be kept
• record keeping obligations of all staff
• how to file records in corporate record-keeping systems
• when and how to dispose of records.
A training program for record keeping and records management

should be established and provided for staff with records management
responsibilities, other staff with records use responsibilities and
new recruits.

Standard 13

Corporate Records Management (continued)

be achieved by:
Prompt Points
How are corporate records distinguished from health records in
organisational policies and procedures? How does the organisation
ensure compliance with records management policy? Which, if any,
corporate records are audited regularly to ensure adherence to
policy and procedures?
What checks are done to ensure that staff are aware of their
responsibilities when creating, handling, and storing records?
What are the organisation’s retention policies / procedures for
tax records? Asset records such as contracts and title deeds?
Financial records?

Standard 13
Criterion 3: Collection, Use and Storage of Information

Data and information are collected, stored and used for strategic, operational and service improvement purposes
Four major categories of information within healthcare An information system will:

organisations are: • manage knowledge-based resources according
• health record information to established practices and standard
• key corporate information documented processes
• information shared within an organisation • provide details of external databases, information
networks, bodies of expert help
• information communicated externally.
• inform staff of what information is available and
Organisations should consider these categories how to access it
when developing information management plans. • include information sources to support the
File formats, the storage media chosen, how the system organisation’s clinical, educational, administrative,
is backed up, access restrictions and other factors research and technical information needs
will be influenced by legislation governing retention,
• implement and manage processes to continuously
confidentiality issues and whether the information will
evaluate and improve the quality of knowledge-based
be shared with other organisations and data systems.
resources and services.

Standard 13

Collection, Use and Storage of Information
Data and information are collected, stored and used for strategic, operational and service improvement
purposes.

be achieved by:
13.6 13.6.1 Monitoring Policies and procedures for information and data management and
Implementing and analysis collection systems may include:
an information of clinical and • identifying and planning for the organisation’s information needs
management non‑clinical data
• defining and capturing data and information from various sources
plan and system and information
and in compliance with all statutory requirements
that address occur to ensure:
the needs of the • linking and combining different types of data and information
• accuracy,
organisation. within and outside the organisation
integrity and
completeness • analysing data and transforming them into information that is easily
interpreted by the user
• the timeliness
of information • transmitting and reporting data and information
and reports • managing all types of records
• that the • storing data and information so that they are easy to retrieve
needs of the • educating and training users in appropriate and ethical ways
organisation of collecting and using data and information
are met
• obtaining input from users to ensure the data collected and
and improvements reported are useful and relevant
are made as
• ensuring data and information are available at points of care
required.
for care planning and decision making
• processes to monitor the quality of data and information,
including data reliability, accuracy and validity from both internal
and external sources
• comparing organisational performance and outcomes internally
over time, and externally with other healthcare organisations and
best-practice standards
• systems and procedures for managing financial data.
Analysing data typically takes the form of one or more of the following:
• testing data against specific rules
• checking peer group consistency – comparing similar practice
outcomes from comparable organisations
• comparing practice or group statistics with published national
benchmarks or historical data
• spotting data that ‘just don’t look right’ under visual examination
(sometimes called outliers).
Analysis may be outsourced to other organisations, such as

submission of clinical indicator data to ACHS or another centralised
body. However, interpretation of trends detected by data analysis relies
on an understanding of organisational systems, recent events and the
consumer / patient pool. Data need to be analysed and interpreted
by people who understand the influences that have impacted the
processes being measured, and even the measurement itself.

Standard 13

Collection, Use and Storage of Information (continued)

be achieved by:
Prompt Points
How has the organisation identified and described its needs for
information management?
How does the organisation provide access to data within and across
all units?
13.6.2 The Organisations may produce an overwhelming volume of information

information and certain types of information need to be managed in different ways.
management The data and information management system should ensure that data
system is evaluated and information are available, accessible and relevant to the strategic
to ensure that and operational needs of the organisation. In addition, organisations
it includes: will need to ensure that there are sufficient resources to manage this
• identification of information.
the needs of the
Rather than just being an aid to care delivery, quality data should drive
organisation
resource allocation and trigger healthcare interventions. There are
• compliance with three key factors influencing data quality:
professional
• clear definition of data sets and the data elements within them
and statutory
requirements • consistent collection processes that recognise ‘fitness for purpose’
for collection, • careful validation (and, if necessary, cleansing) before data are
storage and use entered into electronic systems, or aggregated into larger datasets,
of data or incorporated into summary statistics.
• the validation
Data management should comply with relevant privacy protocols,
and protection
such as the Privacy (Private Sector) Regulations 2001 (Cth)
of data and
on personal privacy protection. Information is available at:
information
http://www.privacy.gov.au
• delineation of
responsibility Organisations should have systems in place to manage data collection,
and data entry and data validation to reduce the risk of errors and maintain
accountability high levels of data quality. Standardised processes should be in
for action place to validate data used to support decision making, reporting and
on data and funding applications. This should ideally be performed at the time
information of data entry in order to reduce time and resources reworking data
• adequate at a later stage.
resourcing for Responsibility and accountability for action taken in regards to data
the assessment, and data quality should be clearly defined in staff position descriptions
analysis and and delegation policies and staff adequately trained in all relevant
use of data procedures. Staff should be well-informed and competent in areas
• data storage of data collection and data entry, and should also be involved in the
and retrieval data validation and analysis processes.
facilitated
through
effective
classification
and indexing

Standard 13


be achieved by:
(continued) The ways in which data and information are stored will depend on the
type of data or information, as well as the media in which they are held.
• contribution Organisational policies should consider10 :
to external
• the clinical and business data that are most sensitive from the
databases and
perspectives of the organisation’s consumers / patients, clinicians,
registers
and administrators
• training of
• where the most sensitive clinical data reside
relevant staff
in information • the origin and nature of any risks.
and data
The organisation should determine what controls will best manage the
management.
risks associated with data storage and protect sensitive and critical
data. Security of data should be managed centrally and security
systems should be regularly tested.
Each organisation should be aware of mandatory external data

collection and reporting requirements in relation to both admission
data and financial reporting. Organisations should have systems in
place where required data and information are easily accessible and
meet reporting timelines.
Prompt Points
How are staff notified of lines of responsibility for data and
information management?
How is the policy for validation and protection of data and
information implemented? How is this system evaluated?
What training is provided to staff? How are staff requiring training
identified? Are there programs to improve the generic computer
skills of ‘frontline’ staff?
Is training provided as part of orientation? Is training provided
on the specific applications used within the organisation?

Standard 13


be achieved by:
13.7 Ensuring 13.7.1 Staff Staff access to, and utilisation of, reference, research and other
that reference have access to resource materials 9 are of crucial importance in supporting
and resource contemporary evidence‑based practice and improving quality programs and
material meets reference and services in health care.
the needs resource material.
of staff. An organisation’s processes for managing reference, research and
other resource materials should be based on current and future needs
and utilise links with relevant external databases, information networks,
bodies of expert help and administrative or research knowledge.
New staff may require training in order to understand the information

available to them and to become efficient and effective in accessing
information when it is most needed.
Information is essential for safe clinical practice. Planning should

consider the impact upon continuity of care if online information was
unavailable. Hard copy versions of essential information, such as
the MIMS medication manuals and major decision trees, should be
available as back up in the event of an electronic systems failure.
Evaluation of information materials should consider the

cost‑effectiveness of different options for information provision.
Any evaluation should also identify which information is absolutely
key for safe practice and ensure that alternative access in cases
of electronic systems failure is considered.
Prompt Points
How are the needs of staff for reference and resource
tools identified?
How are reference and resource materials made available to staff?
What is the use rate by staff?
How are the usage and cost effectiveness of information
provision analysed?

Standard 13
Criterion 4: Information and Communication Technology

The organisation has an integrated approach to the planning, use and management of information
and communication technology (ICT)
An information and communication technology (ICT) It may also be useful to consider the following issues:
plan supported by policy and procedures for all aspects • responsibility for management of the organisation’s
of ICT management is required. This will develop information technology
the organisation’s capacity to effectively manage
• users’ needs and expectations
ICT applications and infrastructures to support the
organisation’s operations and business. The plan • the form(s) in which information will be kept
should be proportional to the size, role and complexity • the relationship(s) between information held
of the day procedure centre and similarly, the range in various forms
and program of ICT in the organisation. • how systems will be linked and work together,
including support for management of the systems
Effective use of ICT requires an integrated approach
to the planning and use of technology. Planning helps • data uniformity through the definition of key
to ensure that the ICT improves the effectiveness and data elements
efficiency of the day procedure centre’s management • the standard operating environment
of information via collection, aggregation and analysis • version control of documents
of data.
• State / Territory, national and international guidelines
Day procedure centres may include information and standards
management and ICT within the overall strategic and • legal issues, such as authorised use of software
business plans. Whatever approach is taken, planning • confidentiality
and execution should reflect the organisation’s
• ICT purchases requiring consultation with key
information needs and available resources, and build
personnel, purchasing against set criteria related
toward identified strategic goals. Consultation should
to business requirements
occur during planning, to ensure that a range of needs
and expectations are considered. • applications and infrastructure
• coordination of service-specific databases
• education for relevant staff in ICT use, organisational
policy and procedures, and staff responsibilities
• management if systems are upgraded / changed
to ensure access to existing data
• the need for specific types of management planning
systems to enhance an organisation’s ICT systems,
such as behaviour management, cost management,
ICT change management, ICT project management,
availability management and capacity management.

Standard 13

Information and Communication Technology
The organisation has an integrated approach to the planning, use and management of information and
communication technology (ICT).

be achieved by:
13.8 Ensuring 13.8.1 The ICT Healthcare organisations are becoming increasingly reliant on
effective system is evaluated information and communication technology (ICT) not only for data
governance of to ensure that storage but communication purposes, and for the use of specialist
an ICT system it includes: medical equipment. Increased reliance can mean increased risk to
that includes a • backup operational activities and consumer / patient safety should an incident
risk management or failure occur.
• security
framework and
a strategy for • redundancy It is for this reason that organisations should implement comprehensive
meeting current • protection of ICT management policies and procedures, which include contingency
and future needs, privacy and business continuity planning. Contingency planning aims to
and which is protect ICT services by:
• virus detection
supported • identifying threats to the system and to uninterrupted provision
• preventive
by policy and of services, and reducing organisational vulnerability
maintenance
procedure. • ensuring that there is an uninterruptible power supply to maintain
and repair
essential services and that this is maintained on a regular basis
• disaster
recovery / • using protective technologies such as malware (virus, worm,
business Trojan horse, spyware, adware and rootkit) detection systems and
continuity firewalls to reduce risks to computer information systems
• risk and crisis • ensuring backup is adequate, regular and maintained, and
management simultaneously protected from damage at the organisation’s
site, while being accessible in a crisis; testing the backup to
• monitoring of
ensure systems become operational when needed and making
compliance with
improvements if required
ICT policy and
procedures. • preparing staff and/or consultants to respond to different types
of interruptions to the service to ensure staff awareness and
competence in downtime procedures, as well as staff familiarity
with procedures for maintaining services in the event of a computer
system failure
• understanding priorities for recovery and restoration of services
following an interruption
• maintaining the integrity of information, so that it cannot be
modified without proper authorisation.
No matter how good a risk management system is, problems and

crises will occur. Systems should be in place to manage these when
and as they occur.

Standard 13

Information and Communication Technology (continued)

be achieved by:
As with all systems in health care, organisations should consider a risk

management framework that includes a prioritisation schedule when
addressing risks to ICT. This should include:
• emergency operating procedures
• a recovery plan(s) with systems priority
• disaster and contingency planning
• software, hardware, telecommunication networks
• technical expertise to control and maintain operational processes
• planned preventive maintenance processes
• security and processes to manage breaches of security;
protecting security of data by controlling file access
• use of firewalls and other electronic devices, which control
the flow of data in and out of the organisation
• remote access procedures
• regular backup processes and storage of back-up data,
for example, away from electromagnetic sources or off-site
• accidental and deliberate corruption or sabotage
• disposal of hard drives or computers
• security of faxes, email and telephones, including mobile phones,
and the preservation of confidentiality.
• Policy and procedures for sending faxes and emails that contain
sensitive information help minimise risk.
Day procedure centres should consider the most cost-effective way

of accessing expertise in ICT whether through external contracted
services or an experienced staff member.
Prompt Points
How is ICT governed? Who has ultimate responsibility for ICT? How
is compliance with the ICT policy and procedures monitored?
What checks are made to determine whether the organisation’s
system(s) meets requirements for both appropriate access and
privacy of different classes of records?
How often are back-up strategies and disaster plans tested?
When was the last time they were tested? How well did the system
work and what changes were needed?
Where is the risk and crisis management plan stored? How often is
it reviewed? Who contributed to the plan?

Standard 13

Information and Communication Technology (continued)

be achieved by:
13.8.2 Licences Software licensing and copyright regulations are obligatory to ensure
are purchased that intellectual property rights and title to products are retained
as required to by the product owners. Organisations should ensure that there are
ensure intellectual appropriate licences for all software being used on their computers.
property rights and
title to products Staff should be made aware of the need to operate systems within
are retained by the legal requirements of the respective licence arrangements.
product owners. Policy should list approved software and include procedures
for the review and introduction of other software.
Prompt Points
How does the organisation decide licence requirements for
software? How are allocated licences registered / documented?
What procedures are followed if additional licences are needed?

Standard 13
References
1. Office of the Australian Information Commissioner. State and territory privacy laws. Canberra ACT;
Australian Government. Accessed from http://www.privacy.gov.au/law/states on 22 October 2012.
2. United Medical Protection (UMP). Medico-legal handbook: A guide to legal issues in medical practice.
Sydney NSW; UMP; 2003.
3. Attorney-General’s Department. Healthcare Identifiers Act 2010. Canberra ACT; Australian Government.
4. Attorney-General’s Department. Healthcare Identifiers Regulations 2010. Canberra ACT; Australian Government.
5. Office of the Federal Privacy Commissioner. Guidelines to the National Privacy Principles. Canberra ACT;
Office of the Australian Information Commissioner; 2001.
6. Office of the Federal Privacy Commissioner. Overview of the Private Sector Provisions. Information Sheet 1.
Canberra ACT; Office of the Australian Information Commissioner; 2001 (updated 2007).
7. Office of the Federal Privacy Commissioner. National privacy principles. Private sector information sheet. Vol. 1.
Canberra ACT; Office of the Privacy Commissioner; 2006.
8. Office of the Privacy Commissioner. Information Privacy Principles. Public Sector Information Sheet.
9. National E-Health Transition Authority (NEHTA). Acronyms, abbreviations & glossary of terms. Sydney NSW;
NEHTA; 2005.
10. RSA – Frost & Sullivan. Information risk management for healthcare organizations: Six best practices
for protecting your health information. Palo Alto USA; Frost & Sullivan; 2008.

Introduction
Standard 14: Organisation Systems
Health systems are complex and dynamic, and characterised by constant change and
innovation in the organisation, funding and delivery of health services. They operate in a
context of changing social, economic and political environments. Standard 14 addresses
the systems that assist the management of day procedure centres.

Ensure that systems to support the delivery of
quality health care are implemented and governed
1. Strategic and Operational Planning
appropriately. The day procedure centre must have The organisation provides quality, safe health care
an awareness of the need for strong leadership and and services through strategic and operational planning
direction and this must be demonstrated through and development.
clear strategic and operational planning, a vision
and mission, and organisational goals. 2. External Service Providers
External service providers are managed to maximise
Context quality, safe health care and service delivery.
Organisational strategy defines what an organisation
seeks to do and how it plans to do it. While a formal 3. Research Governance
plan may guide overall direction, strategy development
The organisation’s research program develops the
is a continuous process, enabling a day procedure
body of knowledge, protects staff and consumers /
centre to respond to changes in its environment as
patients and has processes to appropriately manage
appropriate.1 Strategic planning is a management
the organisational risk.
tool that helps an organisation to assess and adjust
its direction in response to a changing environment
– to focus its energy, and to ensure that its staff and
stakeholders are working toward the same goals. 2
The delivery of health care requires the input and

collaboration of a number of service providers. In many
cases, it will not always be feasible for these services
to be provided by employed staff and organisations will
find it necessary to utilise external service providers.
The system to manage external service providers
needs to cover the whole engagement process from
procurement and selection, through to the provision
of services, and the evaluation of completed work.
The process should be transparent and administered
fairly across all services and suppliers.
Participation in research is encouraged, in order to

further the body of knowledge and evidence available
to the day procedure centre. Research projects
and initiatives must be carried out within an ethical
framework that is established and accepted by peers
and the community.

Standard 14
Criterion 1: Strategic and Operational Planning

The organisation provides quality, safe health care and services through strategic and operational planning
and development
Strategic planning is a process that articulates the In setting strategic directions, day procedure centres
organisation’s vision and mission, its values, and should determine what needs to be done in relation
planned objectives; that is, what it intends to achieve for to meeting their objectives and addressing the major
its community. The strategic plan identifies the long-term issues and opportunities identified in the strategic
direction of the day procedure centre and considers: analysis process. Determinations should include what
• risks to the organisation, both internal and external overall accomplishments the day procedure centre
should achieve, and the overall methods, or strategies,
• resource availability and efficient allocation
required to achieve these.1
• current evidence of best-practice care and quality
improvement initiatives
• jurisdictional and national policies and directives.
The outcome of effective health service strategic

planning is clarity of direction for service development
and resource investment. This direction should be
evidence-based and reflect strategic objectives,
service policies and population needs and priorities.
Major strategic planning activities include:
• strategic analysis
• seizing the future and being responsive to the
environment in which the organisation operates
• setting strategic directions
• being clear about the organisation’s objectives
• being aware of the organisation’s resources
• action planning.1

Standard 14

and development
Strategic and Operational Planning
and development.

be achieved by:
14.1 The 14.1.1 The Strategic planning is a process that articulates the vision and
governing strategic plan that: mission of the organisation, its values, philosophy or goals. These
body reviewing • includes vision, are statements that give direction, identify and demonstrate the
progress towards mission and day procedure centre’s objectives, purpose or reason for being.
achieving the values The development of goals and plans should involve staff, previous
vision, goals and consumers / patients or relevant community persons and service
• identifies
objectives of the providers, such as the use of suppliers for planning equipment
priority areas
strategic plan. upgrades. Ophthalmic day procedure centres might use local
for care,
optometry services for referral planning, and the Medicare Local may
service delivery
also help in some ways. Use of relevant data sources may help in the
and facility
development of appropriate plans, for example research publications,
development
government reports and announcements, professional and business
• considers intelligence from both formal and informal networks, benchmark data,
the most community groups and associations.
efficient use
of resources Changes in the environment which will impact an organisation’s
• formally strategic plan include:
recognises • changes in legislation and regulation at both a national
relationships and jurisdictional level
with relevant • government department restructures and takeovers
external
• workforce challenges and recruitment issues
organisations
• changes to government policies and funding models that
is regularly
may impact the organisation
reviewed by the
governing body. • advances in technology and emerging medical procedures.
Long- and short-term organisational and service planning incorporates

the corporate objectives identified in the strategic plan. For example,
if the strategic plan outlines the development of a new service, based
on the needs of the visiting medical officers (VMOs), the corporate
objective would be to prepare a financial plan and timeframe, and
consider specific funding options for developing and providing
that service.
Participation in daily management by the day procedure centre’s

leaders, executive or managers, however titled, is important to
demonstrate guidance and leadership. The simple internal structure
of a day procedure centre allows supportive communication and more
immediate feedback, assisting the achievement of team cohesion.
This will enable commitment to organisational direction.

Standard 14

and development
Strategic and Operational Planning (continued)

be achieved by:
While a formal plan may guide overall direction, strategy development

is a continuous process, enabling the organisation to respond to
changes in its environment as appropriate.1 The organisation should
implement a schedule for regular review of the strategic plan in order
to accommodate any such changes. Furthermore, progress toward
achieving the objectives set out in the strategic plan should also be
monitored and action taken in the event that these targets may not be
met. Establishing performance measures during the planning phase
will assist with reviewing the plan.
Prompt Points
How often does the governing body review progress against
the vision, goals and objectives outlined in the strategic plan?
What performance measures does the organisation use to
monitor progress?
How does the organisation consult with and engage stakeholders
during strategic planning?
What processes are used to identify both internal and external
challenges? How does the organisation anticipate and ensure
adaptability to changes to address these challenges?
14.1.2 Leaders and Organisational culture refers to the prevailing pattern of beliefs,
managers act to attitudes, values and behaviours within an organisation 3, which
promote a positive is often built upon underlying assumptions.4 Culture incorporates
organisational a set of structures, routines, rules and norms that guide and
culture. constrain behaviour.
In health care, a positive organisational culture values high quality,

safe consumer / patient care, responsible use of resources, community
service, and ethical behaviour.5 Organisational culture should be
outlined in the vision, aims, goals and objectives of the strategic plan
and, most importantly, be demonstrated throughout the organisation
in everyday practice and interactions – that is, there should be
consistency between what is said and what is done.
Strong cultures are built on consistent, visible role modelling and

leadership, consistent feedback on both positive and negative
performance, and constant communication and sharing of experiences
around what is important to the day procedure centre.6
A positive culture that rewards teamwork and innovation can

produce clear quality and safety benefits to consumers / patients.7
For example, there is a strong relationship between lower consumer /
patient mortality and progressive human resources practices, such as
staff appraisal, teamwork, sophisticated training and development. 8
Cultural strength is also positively associated with consumer /
patient satisfaction.6

Standard 14

and development

be achieved by:
Prompt Points
How is organisational culture measured and monitored?
Is a cultural survey administered regularly? How are results used
by the day procedure centre?
14.1.3 Operational Day procedure centres do not operate in a vacuum and there are both
plans developed internal and external factors which impact their activities. Operations
to achieve the within a day procedure centre will be guided and governed by
organisation’s overarching policies, by-laws and articles of association.
goals and
objectives and An operational plan is a short-term plan that details the methods
day-to-day or strategies by which the strategic plan will be accomplished, and
activities comply can be developed for specific programs and/or services. It identifies
with appropriate responsibilities and timeframes in a format that can be easily
by-laws, articles of understood, and usually sets out the day-to-day activities required to
association and/ accomplish the day procedure centre’s strategic objectives. It is for this
or policies and reason that the strategic plan and operational plans should be aligned.
procedures. Performance indicators should link the strategic and operational
plans so that strategic progress can be monitored by achievements
made operationally.
Management must ensure that all activities outlined in the operational

plan are compliant with the rules and regulations accepted by the
day procedure centre. Failure to comply with by-laws and articles of
association can have serious legal ramifications for both individuals
and the organisation as a whole. Furthermore, the need to reduce risks
to consumer / patient, staff and community safety is paramount.
Prompt Points
How do operational plans help to achieve the day procedure
centre’s objectives and day-to-day activities?
How does the day procedure centre ensure that operational plans
comply with by-laws and articles of association?
How does the day procedure centre ensure that changes to
external policies, organisational by-laws or articles of association
are incorporated into operational plans?

Standard 14

and development

be achieved by:
14.2 Ensuring 14.2.1 Changes Few organisations these days are not embracing change. Shifts in the
that change and driven by the external environment, and the rapid development of new improvements
risk management strategic plan are and initiatives, are major factors in changes within the healthcare
are considered in communicated system. A critical question that day procedure centres face is how
the development to, and evaluated to prioritise effort to get the best outcomes, and not to run into
of plans. in consultation ‘change fatigue’.
with, relevant
stakeholders. Communicating the vision and rationale for change and service
improvement, and engaging and facilitating others to work
collaboratively to achieve real improvement, are essential components
when instituting change.
A key strategy is to establish an agenda that positions the day

procedure centre to be in charge of its improvement program and able
to strive to make things happen according to plan, as productively and
usefully as possible.9, 10
A commitment to working and engaging constructively with internal

and external stakeholders should also form part of the change and
organisational planning agenda. It is essential that the diversity of
viewpoints amongst stakeholders be respected and represented in any
organisational plans or service improvements. Collaboration is critical
in delivering measurable and radical health improvements in a complex
and changing health and social care environment.
Prompt Points
What communication and distribution channels are utilised for
informing management, staff, stakeholders and the community
of changes to the strategic and operational plans?
What diverse groups of stakeholders are consulted or engaged
in planning and change management processes? How are
stakeholders involved in the evaluation of strategic planning
and outcomes?

Standard 14

and development

be achieved by:
14.2.2 Change Change management is the process of managing the effective

management implementation of organisational strategies, ensuring that permanent
strategies are changes in objectives, behaviours, relationships, processes and
implemented systems are achieved to the day procedure centre’s advantage.
to achieve the
objectives of the Change management has been recognised as a complex, dynamic
strategic and process, during which unanticipated events and behaviours may
operational plans. emerge. Change is seen as a learning process that is not linear and
sequential, but a continuous process of transition involving continual
adjustment of objectives, unanticipated events and disruption.11
A willingness and ability to adapt to changing circumstances,
along with the development of flexible strategies, assists the
day procedure centre to continue to achieve its overall strategic
objectives and mission.
Communicating the vision and rationale for change and service

improvement, and engaging and facilitating others to work
collaboratively to achieve real improvement, are essential components
when instituting change. Leadership is critical in establishing the
organisational climate that people experience – whether the context
is a hospital, a community setting or a day procedure centre.
How prepared people are to expend the extra effort required to
implement change is impacted by this climate. Strong and clear
leadership is critical in inspiring people to make changes and in
getting diverse stakeholders to work effectively together.12
While changing organisational structure is a popular thing to do, this

often results in poor outcomes, with the benefits sought by those who
initiate restructuring only rarely being achieved. Instead, there are
strong arguments for making improvements to systems and cultures.
This means striving to influence and shape how people tackle change,
their behaviours and practices, attitudes and values, which are the
fundamental building blocks of successful and sustainable change.
Utilising an interactive, problem-solving approach along with a range
of tools helps to promote change and measure progress.13
Prompt Points
What processes are used to determine and analyse key factors
in the day procedure centre’s environment?
How does the day procedure centre anticipate and ensure
adaptability to changing circumstances?

Standard 14

and development

be achieved by:
14.3 14.3.1 Compliance Appropriate delegation to managers and senior staff for the operation
Implementing a with delegations of clinical and non-clinical services assists them to fulfil their duties
formal system is monitored and meet expectations regarding their roles and the implementation
for delegating and evaluated, of management decisions. Expectations regarding accountability
authority for the and improved for safety and quality within specified areas of responsibility should
management as required. be clearly outlined and linked to performance measures. A formal
of clinical and delegation system ensures that clear lines of accountability exist,
non‑clinical particularly where temporary delegations are enacted.
services.
Delegated authority should be recorded and communicated; an
email or prominently displayed notice stating timing and reasons
for temporary delegations should be sufficient.
Delegation policies may include as a minimum:

• the limits of delegation
• the instrument of delegation
• how the policy was formulated
• implementation and compliance monitoring.
Regular review of the delegation structure, including whenever there is

a significant change such as an alteration to a role, the day procedure
centre or its services, will ensure that delegations remain appropriate.
Review can also determine:
• the degree of awareness amongst managers of their
own delegations
• the system of accountability for ensuring compliance
with delegations
• whether the level of delegation is appropriate considering the
role of the individual in the day procedure centre and the scope
of his or her responsibilities.
Prompt Points
Is there a formal delegation system in operation? How are clear
areas and scope of responsibility defined and documented,
particularly for temporary delegations?
When was the delegation system last reviewed, and what
recommendations were implemented? Has this resulted
in improvements?
How is accountability monitored and addressed if standards are
not being upheld? Is this undertaken within a climate of support
and accountability?

Standard 14

and development

be achieved by:
14.4 Facilitating 14.4.1 A formal organisational structure outlines the leadership within the
the management Organisational day procedure centre, lines of responsibility and an appropriate
and monitoring of committees: committee structure that can facilitate the management and monitoring
health services • have access of healthcare services. 2 To operate effectively, committees will have
through effective to terms of well-defined terms of reference, membership, levels of authority and
committees reference, decision making, lines of accountability and reporting requirements,
and meetings. membership as well as documented decisions and meeting minutes.
and procedures
Formal organisational structures include:
• record and
• clarity regarding composition, such as appointments of senior
confirm minutes
managers and clinicians, representation of disciplines, professional
and actions
bodies and committee structures
of meetings
• delegation of authority appropriate to individual roles and
• implement
responsibilities within the day procedure centre for the operation
decisions
of clinical and non-clinical services
and are evaluated,
• linkages with stakeholders and facilities
and improved as
required. • reporting mechanisms within the day procedure centre and
to stakeholders.
The day procedure centre should regularly review its governance

and assurance arrangements to assess if all the threads of
quality, performance and governance are aligned and integrated.
Consideration should be given to whether committee structures, their
terms of reference, relationships and their ‘supports’ (staff, advisors,
systems and processes) are all fit for the purpose and flexible enough
to cope with changing priorities and risks.14
Steps should also be taken to assess and monitor that the quality
of meeting minutes and other documentation supports effective,
informed and meaningful information flow and decision making.
Prompt Points
What is in place to guide the day procedure centre’s structure,
management roles and responsibilities, terms of reference,
committees, minutes of meetings and use of attendance registers?
How are committee structures, terms of reference and reporting
lines determined and clearly defined? How are meeting minutes
shared and with whom?
How does the day procedure centre ensure that meeting
minutes are of high quality and accurately reflect discussions
and decisions made?

Standard 14
Criterion 2: External Service Providers

External service providers are managed to maximise quality, safe health care and service delivery
External service providers may supply regular, periodic To ensure standards of quality and integrity, senior
or one-off services to both clinical and non-clinical managers must ensure probity requirements are met,
areas of the day procedure centre. Services can include and understand the structures that support decision
cleaning, food delivery, biomedical engineering, infection making in relation to service provision to facilitate
control, fire safety, gardening, computer support, quality compliance. For example, there may be an identified
consultancy or other external services. Agreements with expenditure above which services will be tendered.
these bodies or other external parties may be formal or
informal. Whatever the arrangement, the day procedure Increasingly, tendered services are commissioned
centre needs to consider its responsibilities in providing using online processes; policy needs to be updated to
quality services to its internal and external customers reflect this. The day procedure centre’s policies should
and its liability for the service environment. reflect jurisdictional legislation and any belief systems,
structural frameworks, financial drivers or other goals
Common services which may be provided by external that will guide service provision for the business.
suppliers include: Day procedure centres should document nominated
• food preparation and delivery staff with the delegated authority to select suppliers
of specific services.15
• linen and laundry services
• equipment installation and maintenance
• waste management
• nursing staff
• IT or legal staff
• security.

Standard 14

External Service Providers
External service providers are managed to maximise quality, safe health care and service delivery.

be achieved by:
14.5 14.5.1 There Clear delineation of responsibilities within the day procedure centre in
Implementing is evidence of relation to contractors and other external providers will assist efficient
systems to evaluation and communication processes and better fulfilment of requirements.
manage external improvement of
Contracts and agreements need to abide by jurisdictional legislation.
service providers. systems to manage
A process to determine which contracts need legal oversight during
external service
their preparation must be agreed upon and documented by the
providers, which:
management of the day procedure centre. Agreements with high value
• are governed or risk should have legal oversight.
by implemented
policy and Day procedure centres may also maintain lists of preferred suppliers
procedure for specific projects. This is most common for tradespeople who may
be needed, but not always available, at short notice. There should be
• include
a documented process for the selection of preferred suppliers and a
documented
process to review the outcome of the service provided.16 Care must
service
be taken when appointing external contractors, particularly where a
agreements
conflict of interest could be construed.
• define dispute
resolution A contract or service agreement is important for both the day procedure
mechanisms centre and the service provider to ensure quality maintenance of
the service. The fundamental responsibility for quality rests with
• monitor
the contracting healthcare organisation and its governing body. In
compliance
establishing the legal arrangement, the day procedure centre needs to
of service
include the level of service expected and the evidence of compliance
providers
with that service’s regulatory or industry standards required.
with relevant
regulatory Contracts and service agreements must include measures and
requirements timelines against expectations of service provision. Performance
and specified indicators and their measures may be simple or complex, but must
standards. be specific, achievable and relevant.
Contract reviews should be planned to occur, such as on an annual
basis for short-term contracts. This ensures that the service is
evaluated and that the day procedure centre’s needs are being met.
It is important that appropriate action is taken if improvements are
required. This action may be a change in service provider or review
of provider duties, for example to include staff education.
Prompt Points
Is there a system to track agreements with external service
providers? Does the system alert the day procedure centre to
agreements / contracts that have reached term or time for review?
How is performance of external service suppliers managed?
What dispute resolution mechanisms are in place for
the organisation?
Is performance against agreed performance measures reviewed
before contracts for service provision are renewed or at
predetermined times in long-term agreements? What action is
taken when performance fails to meet performance measures?

Standard 14

External Service Providers (continued)

be achieved by:
14.5.2 The Evaluation and monitoring of supplier performance may relate to price,
organisation service and/or quality, and the measures for evaluation should be
evaluates the decided in advance and recorded in the contracted agreement.
performance
of external Monitoring may be as simple as sending an appropriately qualified
service providers person to check the satisfactory completion of a trades job, or might
through agreed involve regular audits for quality and accuracy of services or timeliness,
performance as may be more appropriate for ongoing suppliers of food, laundry or
measures, pathology services. Some contracted services may be expected to
including clinical provide details of their tasks and workloads, particularly where fees
outcomes vary with the volume of work. For example, waste disposal services
and financial may report on volumes of different classes of waste and any aberrant
performance where separation of classes of waste. Pathology services might list services
appropriate, and by type, with cost and volume.
improvements are
Irrespective of whether the day procedure centre’s staff were included
made as required.
in the selection of their service providers, they should monitor the
service received and have channels by which they can feed back any
concerns. Records of feedback from staff, consumers / patients and
visitors regarding service provision should be addressed individually
as appropriate, and retained for cumulative review against the agreed
standards for supply of the service.
Examples of performance measures include:

• turnaround times for recruitment advertising, haematology samples
or imaging
• feedback forms for education services or employment
assistance schemes
• staff survey and/or complaints for security performance
• timeliness and numbers moved for transport services
• scores according to a specific standard for infection control
• consumer / patient surveys and complaints for food and
food service.
Prompt Points
How is compliance with external standards and any other
performance measures stated on contracts checked
and maintained?
How are a supplier’s reported service levels and costings
cross‑checked / audited?
How does the organisation use education, incentives and/or hold
providers to account, to improve the quality / value of service
received from external suppliers?
How is performance measured and reported to the senior
management team?

Standard 14
Criterion 3: Research Governance

The organisation’s research program develops the body of knowledge, protects staff and consumers / patients
and has processes to appropriately manage the organisational risk
Day Procedure centres that are not involved in research • day-to-day administration and management
of any kind may apply to have this criterion designated (research may cause surges of activity, competing
as Not Applicable by contacting the ACHS Customer for resources with other consumers / patients
Service Managers. or staff)
• researchers and research staff (who require training
Research involves a systematic and rigorous inquiry
and may be diverted from other tasks)
or investigation, to discover or confirm facts or
principles. The ultimate purpose of healthcare research • other staff, particularly liaison people such as those
is to improve consumer / patient care. Advances in at reception (who should be aware of the project,
surgical technique, the development of new drugs, if not all its details)
new or improved treatment options and refinements • the community of the day procedure centre.
to treatment regimes rely on research. However, it is
imperative that where research requires the participation Where a project has implications in only a limited
of consumers / patients / subjects, they are not placed number of these areas, it may be possible to
at risk by a research experiment, or at no greater claim ‘Not Applicable’ status for some actions.
risk than posed by their disease condition or current Organisations should discuss these issues with
treatment, no matter how laudable the anticipated their Customer Service Manager.
research outcome.
All EQuIP member organisations are expected to
Research projects undertaken in healthcare settings be monitoring the quality of their care delivery and
take a range of formats; those most likely to be seen continually improving their processes. Small research
in a day procedure centre would be: projects will be used to test and monitor improvements
as they are introduced, through the process of
• the trialing of new procedures as part of a project
Continuous Quality Improvement (CQI). If CQI is the
coordinated by their owners, the WHO or a
only form of research undertaken by the day procedure
government body
centre, the organisation may be able to claim an
• consumers / patients enrolled or monitored as part exemption from this criterion.
of a clinical trial managed for a pharmaceutical
company or university Which QI projects are defined as research to fulfil the
• clinicians who undertake and publish primary requirements for this criterion? The answer should be
research within their own specialty area using data determined by the scale and risk associated with the
derived in the day procedure centre setting projects. Quality Improvement projects with at least
two of these features:
• investigations to compare different approaches
to providing clinical care, usually within the facility 1. Funding by a body outside the organisation
(many Quality Improvement projects are of this type). 2. Approval of the project by a Human Research Ethics
Committee (HREC)
The types and scale of the research projects being
3. An objective to develop a marketable product
undertaken by a day procedure centre will determine
that might be adopted by other organisations
which actions within this criterion are applicable to their
(e.g. a wound care solution, alternative bandaging
circumstances. From an organisational perspective,
technique, software tool)
research activity offers both benefits and risks,
and presents logistical and managerial challenges. 4. Coordination by a central agency, such as a
When responding to this criterion, day procedure State / Territory health department or the Australian
centres should consider the types of research Commission on Safety and Quality in Health Care
undertaken and the implications of that research 5. Planning for publication in a peer-reviewed journal
in terms of: 6. Impact on non-participating staff and/or consumers
• organisational governance (financial and / patients
legal implications, clinical and ethical risks, ... would be considered to have the scale and reach
benefits to society) both within and beyond the organisation to be counted
• ethics as research for the purposes of this criterion.
• risks to, and obligations to, participating
consumers / patients / subjects

Standard 14

Research Governance
The organisation’s research program develops the body of knowledge, protects staff and consumers /
patients and has processes to appropriately manage the organisational risk.

be achieved by:
14.6 Fostering 14.6.1 The Where research is a significant activity for the organisation, it would
and encouraging system that: be anticipated that there is a framework within which it is undertaken
clinical and • determines that should apply in a day procedure centre context. The framework is
health services what research a construct of governance; it considers current and existing research
research. requires ethical results, organisational expertise and experience, and uses these to
approval guide new and relevant research activities. The framework will assist
the day procedure centre to facilitate good research concepts, and
• oversees
to direct project planning and applications for funding. Performance
the ethical
measures may relate to funding achievements, publication in peer-
conduct of
reviewed journals, or commercialisation of developments realised
organisational
through research.
research
• monitors the As part of its commitment to fostering and encouraging research,
completion the management of the day procedure centre should appropriately
of required support the use of resources by those carrying out the research, and
reporting ensure the implementation of the policy and guidelines under which the
is evaluated, research is to be conducted.
and improved
It is important that the need for review by a Human Research
as required.
Ethics Committee (HREC) is not confused with the need for
research governance.
The day procedure centre’s management should be aware of

research that presents specific risks or opportunities. In addition to
the researcher’s responsibility, organisations should aim to ensure
that projects receive appropriate HREC oversight. This requires their
understanding that if the day procedure centre is engaged in clinical
or health services research, the governing body is responsible for
the governance of that research. In relation to clinical research, the
responsibility does not rest, by default or any other means, with the
HREC. Such committees have a different role that is related to the
research, which should be clearly defined within the day procedure
centre’s policy and guidelines, but it is not for the governance of
the research.
Day procedure centres that do not establish their own committee, or

in which the establishment of such a committee would be impractical,
may make use of the services of another organisation’s committee,
usually upon payment of an appropriate fee. The website of the
NHMRC provides an overview of HRECs, including a comprehensive
state-by-state list of all registered HRECs and information on such
issues as fees.17
In the absence of an HREC, day procedure centres should have

a designated executive member / group that is familiar with the
National Statement on Ethical Conduct in Human Research18, and
can review any research project proposal, and assist in determining
the need for HREC involvement.

Standard 14

Research Governance (continued)

be achieved by:
Research that involves humans and that has any risk of causing harm
physically, psychologically or spiritually, or that potentially could breach
confidentiality or privacy, must always be submitted to a properly
constituted HREC. This includes research where members of the
organisation’s staff are the participants.
Day procedure centres that undertake only low-risk projects and do

not need HREC approval might consider evaluating their research
governance through:
• recording and monitoring consultations about research projects
with the designated executive member / group
• monitoring the executive member / group’s knowledge of relevant
parts of the National Statement.
Prompt Points
How does the organisation demonstrate its commitment
to fostering and encouraging research?
What is an example of a research project undertaken within
this organisation?
14.7 Ensuring 14.7.1 Systems Clinical research involving human subjects, and the organisational
research are implemented to policy that governs it, should be consistent with the key National
integrity through effectively govern Health and Medical Research Council (NHMRC) statements.
governing body research through
oversight. policy / guidelines In addition to these three key statements, research is governed by laws
consistent with: (Federal and/or State / Territory), and by other guidelines and codes
of conduct, which deal with matters such as privacy, confidentiality,
• jurisdictional
consent, bio-safety and professional standards.
legislation
• key NHMRC The research policy / guidelines adopted by an organisation would
statements be expected to be appropriate for, and congruent with, the level
• codes of of risk associated with research activities undertaken by the day
conduct procedure centre.
• scientific review The application of a standard across research practices within the
standards. day procedure centre will provide many benefits to all involved.19
The Institute of Clinical Research, based in the United Kingdom,
has a number of relevant resources accessible from
http://www.icr-global.org/resources
Prompt Points
How does the organisation ensure widespread awareness of,
and alignment with, legislated requirements and the standards
developed by the NHMRC?
How often are the governance policies and performance measures
reviewed? What changes have been made in response to a review
of policies or performance measures?

Standard 14


be achieved by:
14.7.2 The The purpose of research governance is to ensure research integrity

governance of through accountability, transparency and responsibility. 20, 21 The three
research through: key components of research governance are:
• documented • the protection of consumers / patients, carers and staff involved
accountability in research: this includes such matters as consent, the provision
and of appropriate and safe facilities in which clinical research may be
responsibility undertaken, and the monitoring of consumers / patients’ wellbeing
• establishing • the protection of researchers: this includes training, facilities,
formal processes for the proper conduct of research, and appropriate
agreements employment arrangements
with • the protection of the organisation: this includes matters that
collaborating might pose a risk to the organisation or bring the organisation
agencies into disrepute, for example, the risk to the reputation of that
• adequately organisation posed by dishonest research, financial risk, intellectual
resourcing the property risk, commercial arrangements, and liability with regard
organisation’s to consumer / patient harm.
human
research ethics As part of its commitment to fostering and encouraging research, the
committee management of the day procedure centre should appropriately support
(HREC), where the use of the organisation’s resources by those carrying out the
applicable research and ensure the implementation of the policies and guidelines
under which the research is to be conducted.
is evaluated,
and improved as All participants in research, including participating consumers /
required. patients, bear a degree of responsibility for the correct conduct of
the research. A day procedure centre that intends to undertake or
collaborate in research must first put in place a research policy that will
frame and support the correct management of any research program
it undertakes or collaborates in. In addition to covering organisational
risk management and project management, the research policy should
outline minimum standards for the protection of research subjects /
participants, staff assisting with the research project and other
staff, including:
• the responsibilities of all parties
• participant indemnity
• participant consent processes
• the protection and support of researchers and assisting staff
• management of inquiries and complaints.
In the interest of transparency, the day procedure centre’s research

policy should be made available to consumers / patients, staff,
and any other interested party.

Standard 14


be achieved by:
The NHMRC has published a model framework for consumer and

community participation in health and medical research 22 and
a resource pack is available to assist in the implementation of
the framework. 23 These documents are important references for
organisations undertaking research and should be incorporated
into the day procedure centre’s research policy. They provide
advice for organisations on why consumer and community
participation in research is important, what is meant by ‘involvement’
and ‘participation’ and how to achieve it at various levels of
research. It is relevant to many different types of research and the
governance thereof.
As with many specialised work areas, the purposes and processes of

research may not be evident to the community, or even to uninvolved
staff within the day procedure centre. By including staff and members
of the public in open discussion and planning, the goals, techniques
and successes of research may be better communicated, and any
misunderstandings overcome by building networks, expanding
knowledge and raising levels of awareness.
Prompt Points
How does the organisation demonstrate its commitment
to fostering and encouraging research?
Is the organisation involved in collaborative research?
What formal research agreements has the organisation
entered into?

Standard 14
References
1. McNamara C. Basic description of strategic planning (including key terms to know). Minneapolis USA:
Authenticity Consulting. Accessed from http://www.managementhelp.org/plan_dec/str_plan/basics.htm
on 15 August 2012.
2. Bryson JM. Strategic planning for public and nonprofit organizations: A guide to strengthening and sustaining
organizational achievement. 3rd edn. San Francisco USA; Jossey Bass; 2004.
3. Forster P. Queensland health systems review. Final report. Brisbane; Queensland Govt; 2005.
4. Schein EH. Coming to a new awareness of organizational culture. Sloan Manage Rev 1984; 25(2): 3-16.
5. Australian Safety and Compensation Council (ASCC). National standard for manual tasks. Canberra ACT;
ASCC; 2007.
6. Mallak LA, Lyth DM, Olson SD et al. Culture, the built environment and healthcare organizational performance.
Managing Service Quality 2003; 13(1): 27-38.
7. Berlowitz DR, Young GJ, Hickey EC et al. Quality improvement implementation in the nursing home.
Health Serv Res 2003; 38(1): 65-83.
8. West MA, Borrill C, Dawson J et al. The link between the management of employees and patient mortality
in acute hospitals. Int J Hum Res Man 2002; 13(8): 1299-1310.
9. Braithwaite J. Organizational change, patient-focused care: an Australian perspective. Health Serv Manage Res

1995; 8(3): 172-185.
10. Kotter J. Leading Change. Boston USA; Harvard Business Press; 1996.
11. Telford K, Maddock A, Isam C and Kralik D. Managing change in the context of a community health
organisation. Aust J Prim Health 2006; 12(2): 156-166.
12. National Health Service (NHS) Institute for Innovation and Improvement. NHS leadership qualities framework.
London UK; NHS; 2006.
13. Braithwaite J. An empirical assessment of social structural and cultural change in clinical directorates.
Health Care Anal 2006; 14(4): 185-193.
14. National Health Service (NHS). Integrated governance handbook: A handbook for executives and
non‑executives in healthcare organisations. London UK; Department of Health; 2006.
15. NSW Health. Delegations manual – Combined (Administrative financial staff). Sydney; NSW Health. Accessed
from http://www.health.nsw.gov.au/resources/policies/manuals/comb_delegations.asp on 15 August 2012.
16. Ombudsman Victoria. Probity controls in public hospitals for the procurement of non-clinical goods and
services. Melbourne VIC; Ombudsman Victoria; 2008.
17. National Health and Medical Research Council (NHMRC). Overview of human research ethics committees.
Melbourne VIC; NHMRC. Accessed from http://www.nhmrc.gov.au/health_ethics/hrecs/overview.htm
on 15 August 2012.
18. National Health and Medical Research Council, Australian Research Council (ARC) and Australian Vice
Chancellors Committee. National statement on ethical conduct in human research. Canberra ACT;
Australian Government; 2007.

Standard 14
References
19. Institute for Clinical Research (ICR). Clinical research professional standards for professional practice:
Raising the standards for clinical research. Bourne End UK; ICR; 2005.
20. National Health and Medical Research Council (NHMRC), Australian Research Council (ARC) and Universities
Australia. Australian code for the responsible conduct of research. Melbourne VIC; NHMRC; 2007.
21. National Health and Medical Research Council (NHMRC). Values and ethics: Guidelines for ethical conduct
in Aboriginal and Torres Strait Islander health research. Melbourne VIC; NHMRC; 2003.
22. National Health and Medical Research Council (NHMRC). A model framework for consumer and community
participation in health and medical research. Canberra ACT; Australian Government; 2004.
23. National Health and Medical Research Council (NHMRC). Resource pack for consumer and community
participation in health and medical research. Canberra ACT; Australian Government; 2004.

Introduction
The delivery of safe, high quality health care requires the development and implementation
of systems to ensure the safety and wellbeing of consumers / patients, staff, visitors and
contractors. Standard 15 addresses the creation of a safe organisational environment through
a comprehensive safety management system.

Ensure that the day procedure centre protects the
safety and wellbeing of all those on its premises,
1. Safety Management Systems
through the organisation’s: Safety management systems ensure the safety and
• systems for work health and safety (WHS) wellbeing of consumers / patients, staff, visitors
and contractors.
• management of its workplaces and equipment
• planning and preparedness for emergencies
2. Buildings, Plant and Equipment
• processes for physical and personal security
Buildings, signage, plant, medical devices, equipment,
• appropriate waste and environmental management.
supplies, utilities and consumables are managed safely
and used efficiently and effectively.
Context
The day procedure centre has a responsibility for the 3. Emergency Management
safety and wellbeing of consumers / patients, staff,
Emergency management supports safe practice and
visitors and contractors. Clear lines of accountability
a safe environment.
and responsibility should be established for specific
aspects of safety and quality within the day procedure
centre, and clearly defined within documented policies 4. Physical and Personal Security
and procedures. All aspects of safety management Security management supports safe practice and
should be regularly evaluated and tested to ensure that a safe environment.
organisational safety is not compromised.
5. Waste and Environmental Management

Waste and environmental management supports safe
practice and a safe and sustainable environment.

Standard 15
Systems for Safety
Criterion 1: Safety Management Systems

Safety management systems ensure the safety and wellbeing of consumers / patients, staff,
visitors and contractors
A safety management system is a comprehensive and Formal review of the efficiency of safety management
integrated system that ensures that all work at the day systems will inform the day procedure centre of
procedure centre is conducted safely. It should be fully measures that will need to be taken to either alter a
documented, accessible and comprehensible to those work practice or eliminate it. In addition, the review
that need to use it. The safety management system will identify any further issues that may need attention.
recognises the potential for errors and establishes Applying the lessons following the management review
control measures that are fully implemented, to ensure stage is one of the most important parts of the safety
that errors do not result in incidents or near misses.1, 2 management system and will support improvements
It comprises a set of work practices and procedures for to safety.
monitoring and improving the safety and health of all
aspects of operation.
The day procedure centre’s implementation of its

safety management systems will be carried out in
conjunction with the design and layout of its physical
environment. While the physical environment is in
part an outcome of the organisation’s planning and
management of its buildings and plant, the concept
of ‘physical environment’ also encompasses the safe
and effective use of space – that is, it addresses issues
such as what equipment is available and where it is
used, the design and placement of workstations, how
workflow is organised so as to maintain efficiency and
meet the requirements of infection control procedures,
the reduction / elimination of falls risks, and so forth.
The design and layout of the physical environment
is a critical aspect of an organisation’s management
of work health and safety (WHS), and in particular of
manual handling. The day procedure centre should
not only regularly evaluate its existing systems, making
improvements as required, but plan ahead for any
anticipated changes in service delivery and/or the size
and composition of its workforce.

Standard 15
Systems for Safety

Safety Management Systems
visitors and contractors.

be achieved by:
15.1 15.1.1 Safety A safety management system includes:

Implementing management • policy: effective work health and safety (WHS) policies set a clear
a safety systems include direction for the organisation to follow
management policies and
• planning: there is a planned and systematic approach to
system that procedures for:
implementing health and safety policies. Individual responsibilities
references • work health and should be clearly outlined and may be stated in position
relevant: safety (WHS) descriptions or similar and in policies and procedures
• legislation • manual handling • implementation: the policies, procedures and resources are put in
• Australian • injury place to manage all aspects of the control measures that ensure
standards management safe operation of the facility
• codes of • management • assessment: performance and compliance are measured against
practice of dangerous agreed standards to reveal when and where improvement is
• industry goods and needed
guidelines. hazardous • management review: the organisation learns from all relevant
substances experience and applies the lessons.
• staff education
and training Implemented policy and procedures will reflect the requirements
in WHS of jurisdictional legislation, as well as relevant Australian standards,
responsibilities. codes of practice and industry guidelines where appropriate.
Written policies for WHS may include (but are not limited to):
• manual handling
• radiation safety
• slips / trips / falls
• electrical safety
• noise control
• dangerous goods and hazardous substances
• smoking
• ergonomics – assessments of all working environments
including workstations
• violence and aggression
• management of incidents and near misses
• staff immunisation – a risk-based program in accordance
with the Australian Immunisation Handbook 3
• needlestick injury and bodily fluid exposure prevention
• staff injury management
• provision of protective clothing and equipment.

Standard 15
Systems for Safety

Safety Management Systems (continued)

be achieved by:
Prompt Points
Are policies appropriately referenced to demonstrate awareness
of regulatory obligations? How often are they reviewed and updated
to reflect changes in regulations?
What changes to the safety management system have been made
in response to monitoring of reported incidents or other feedback?
How was the implementation of the change managed? Are these
processes, and any resulting changes, linked to risk management
procedures, and the monitoring of risks (such as through the
risk register)?
15.2 15.2.1 The system Risk management and the implementation of a safety management
Implementing for ensuring WHS system requires the identification and elimination or mitigation of
an organisation- includes: existing risks in both clinical and non-clinical areas.
wide system for • identification
work health and Safe work practices represent the practical implementation of policy
of risks and
safety (WHS). requirements and are intended for application specifically within the
hazards
context of the individual day procedure centre. Safe work practices
• documented should be developed and implemented with staff consultation, and
safe work address potential risks to consumers / patients, staff, and visitors.
practices /
safety rules Within a day procedure centre, the coordination and monitoring of
for all relevant safety elements can be delegated to one person. If the system and
procedures program is well planned and organised the facilitation process will flow
and tasks in smoothly. For example, if the program is detailed in a flow chart, then
both clinical the responsibility could be rotated between staff on a yearly basis.
and non-clinical There will then be growth in safety-related learning that may result in
areas reductions in incidents or insurance premiums.
• staff
Staff should be provided with all relevant information during orientation,
consultation
and educated in any changes made to policies and procedures as
• staff education a result of evaluation. Advice relating to all aspects of WHS should
and provision of be available to staff. There should be a process to ensure that all
information staff have read and understood the health and safety policies and
• an injury procedures and this should be part of the induction process.
management
program Safe work practices should be regularly reassessed to reflect any
changes made during a review of organisational policy, and to
• communication
ensure that they reflect the current environment and any changes to
of risks to
practice or conditions (e.g. new equipment, changes in casemix or
consumers /
staffing levels), and that any identified areas for improvements are
patients and
incorporated. Staff involved in the development and implementation
visitors
of safe work practices should also be involved in their evaluation.
and is
implemented,
evaluated, and
improved as
required.

Standard 15
Systems for Safety


be achieved by:
The day procedure centre must have an injury management policy

and a return-to-work program that reflects the requirements of the
appropriate State / Territory legislation. Correct injury management
ensures the prompt, safe and durable return-to-work of an injured
worker.4 The organisation’s return-to-work program should outline the
policies and procedures implemented to assist injured workers with
their return to the workplace, as well as providing all other relevant
information, such as the means by which treatment or rehabilitation
may be accessed. Staff must be made aware of the return-to-work
program (via posters or newsletters) and all related information must
be freely accessible.
Prompt Points
How are safe work practices developed in the organisation? Who is
responsible for this? How is compliance with safe work practices
monitored? How are instances of non-compliance managed?
How often are existing safe work practices evaluated? What recent
changes have been made to existing safe work practices as a result
of evaluation?
Is there regular mandatory training in safety management systems
that meets specific staff needs, for example, manual handling?
15.2.2 Staff Depending upon their size, day procedure centres should have a health
with formal WHS and safety officer and/or a Work Health and Safety (WHS) Committee.
responsibilities In organisations of 20 or more staff, a Committee is appropriate, and
are appropriately there must be employee representation.
trained.
Staff who accept formal WHS responsibilities are usually required to
undergo accredited training, and organisations should provide access
to such training and allow all time necessary for it to be completed.
Organisations are required to consult with staff with respect to WHS

issues, and should be able to provide evidence of how their preferred
consultation mechanism is utilised, such as WHS minutes, safety
bulletins / alerts, or evidence of health and safety officer meetings
with staff. Smaller organisations may fulfil their staff consultation
requirements through regular staff / team meetings where WHS
is a standing agenda item and staff are required to provide input.
There should be documented evidence of the consultative process,
such as minutes.
These should also be evidence of feedback from staff on WHS

issues, which should inform the evaluation and improvement of the
organisation’s WHS system.

Standard 15
Systems for Safety


be achieved by:
Prompt Points
Do staff understand their responsibilities in WHS? Are there
competency checks in key areas? What WHS training is provided
for staff?
What training has been undertaken by the organisation’s WHS
representatives?
What records are there of meetings where WHS is an agenda item?
15.2.3 A register Dangerous goods and hazardous substances are those materials that:
of dangerous • are referenced in the National Occupational Health and Safety
goods and Commission List of Designated Hazardous Substances or the
hazardous Approved Criteria for Classifying Hazardous Substances 5
substances is
• are listed in the Australian Dangerous Goods (ADG) Code for
maintained and
the Transport of Dangerous Goods by Road and Rail 6
Material Safety
Data Sheets • meet the classification criteria of the ADG Code.
(MSDSs) are
The application of risk management principles and compliance with
available to staff.
each State / Territory hazardous substances code of practice is
essential in ensuring the safety and wellbeing of consumers / patients,
staff, visitors and contractors.
Where no individual policies for the management of hazardous

materials exist, the risk management policy should cover areas
such as:
• storage / security / isolation / inventory management
• signage / information / labelling / identification (including
information from provider)
• handling / use
• spillage (including emergency procedures)
• exposure control, monitoring and health surveillance (records of any
monitoring or health surveillance should be kept for 30 years)
• personal protective equipment
• records of dangerous goods and hazardous substances
• transport
• disposal
• induction and training
• licensing
• maintenance / inspection – review of controls
• workplace legislation – hazardous substances, dangerous goods
• biological hazards.

Standard 15
Systems for Safety


be achieved by:
The day procedure centre should keep a register of all dangerous

goods and hazardous substances; this may form part of the
organisational risk register. Material Safety Data Sheets (MSDSs)
should be available for staff at point of use and for applicable
emergency agencies such as the fire brigade. Dangerous goods and
hazardous substances are to be properly labelled in accordance
with relevant standards and guidelines, and maintained on a master
register in the workplace. Labels should never be altered and goods /
substances should only be stored in their original containers.
Where dangerous goods and hazardous substances are stored

and where staff are working with these substances, organisations
should ensure that the relevant Australian standards are met in
terms of space, segregation, spill control, ventilation and transport.
For example, stored oxygen is a dangerous good. Risks can be
minimised by ensuring that all appropriate safety measures (i.e. chains
for securing the cylinders, trolleys for moving them) are in place.
Chemicals and cleaning solutions bought in domestic quantities from

a supermarket or other supplier should be handled according to the
manufacturer’s instructions. Since these products have not been
developed specifically for healthcare settings, they should be used
sparingly within the organisation. In any healthcare organisation,
higher standards apply than in the home, and products are
tested accordingly.
Prompt Points
What Australian standards are referenced in the organisation’s
policies and procedures relating to dangerous goods and
hazardous substances?
Are completed checklists and action plans to address
identified hazard deficiencies available? Are they compliant
with State / Territory requirements?
Are Material Safety Data Sheets and a master index available
to all staff?

Standard 15
Systems for Safety


be achieved by:
15.3 Monitoring 15.3.1 There Day procedure centres in which radiation is not used should consult
compliance is evidence of their ACHS Customer Services Manager to discuss a ‘Not Applicable’
with the evaluation and rating for this action.
radiation safety improvement of
management the radiation safety While sources of radiation are essential to modern health care,
plan and taking management potential exposure needs to be managed according to the relevant
remedial action plan, which: code(s) of practice; the development of policies and procedures to
where required. support this management will be a requirement for many organisations.
• is coordinated
with external The three main concepts to be considered in protecting staff from
authorities radiation are time, distance and shielding. These three concepts use
• includes the ALARA (As Low As Reasonably Achievable) principle for limiting
radiation exposure to radiation and this principle should be considered at all
equipment, times where there is risk of exposure.
a register for
all radioactive Depending on their size, organisations should have a radiation safety
substances, officer and/or a Radiation Safety Committee, as required by legislation.
and safe Day procedure centres should implement a radiation management plan
disposal of all that complies with the Australian Radiation Protection and Nuclear
radioactive Safety Agency (ARPANSA) Code of Practice for Radiation Protection
waste in the Medical Applications of Ionizing Radiation.7
• ensures staff The radiation management plan should note those persons responsible
exposure to for handling and purchase of any radioactive substances, licences
radiation is and compliance with any legislation or standards. There should be
kept as low a register of radioactive substances and relevant equipment onsite
as reasonably at any time that is regularly updated.
achievable
(ALARA) Radiation protection standards and guidelines that pertain to exposure
and dosage can be found on the ARPANSA website.8
• keeps
consumer In organisations where lasers are used, policies and procedures should
/ patient reference AS/NZS 4173:2004 Guide to the safe use of lasers in health
radiation to a care.9 All licences and safety arrangements should be in place.
minimum whilst
maintaining Control procedures and safe systems of work with radioactive
good diagnostic substances and/or radiation apparatus, including lasers,
quality should address:
• includes a • room shielding
personal • exposure control
radiation
• personal monitoring
monitoring
system and any • health surveillance, with records kept for the period stated in any
relevant area relevant legislation
monitoring. • licensing checks conducted by the appropriate authorities
• evidence of appropriate professional qualifications or industry
approved training courses
• registration and compliance testing of x-ray apparatus as required
by the relevant authorities

Standard 15
Systems for Safety


be achieved by:
• storage and disposal of radioactive substances

• signage with relevant information, labelling and identification,
including any information from the provider
• safe handling and use of radioactive substances, including
emergency procedures in case of spillage.
The organisation’s radiation safety management plan should include

monitoring for compliance, and the capacity for remedial action to be
taken in the event of any non-compliance. All aspects of the radiation
safety management plan should be regularly evaluated by the radiation
safety officer and/or a radiation safety committee, and improvements
made as required.
Prompt Points
Who is responsible for developing and implementing the
organisation’s radiation safety management plan? How often is the
plan evaluated? What recent changes have been made as a result
of evaluation?
How is compliance with the organisation’s radiation safety
management plan monitored? What action is taken in the event
of an instance of non-compliance?
How often are the results of employee radiation exposure testing
reviewed? How is this documented?
How often is the radiation shielding (physical barriers and aprons)
checked?

Standard 15
Systems for Safety
Criterion 2: Buildings, Plant and Equipment

Buildings, signage, plant, medical devices, equipment, supplies, utilities and consumables are managed safely
and used efficiently and effectively
The organisation’s management of its buildings, plant As their supply, storage and use has a direct impact
and equipment requires the development of policy and upon the consumer / patient, the organisation may
procedures drawn from relevant legislation, codes of prefer to classify and manage medical gases as
practice and Australian standards, and which address ‘a medical device’. The regulators and flow-meters with
how the organisation will maximise the safety and which medical gases are operated are, however, medical
comfort, and supply the needs, of the community it devices by definition, and should be managed as such.
serves. The Australasian Health Infrastructure Alliance,
officially endorsed for use by Australian States / In order to be efficient and effective, the organisation’s
Territories and by the Ministry of Health, New Zealand, management of its buildings, signage, plant, equipment,
has developed the Australasian Health Facilities supplies, utilities and consumables should be supported
Guidelines (AusHFG)10, a comprehensive guide to by a well-planned and well-resourced system of
the planning, design, building and refurbishment maintenance and hazard control.
of healthcare facilities. It also covers the planning,
Maintenance is an essential aspect of the organisation’s
selection and installation of plant and equipment,
management of its buildings, plant and equipment.
aspects of sustainability, access features for those with
However, maintenance should not merely be reactive:
special needs, and workplace design and ergonomics.
the organisation should implement a planned and
A medical device is “any instrument, apparatus or coordinated system of preventive maintenance and
appliance, including software, whether used alone or in hazard reduction.
combination, together with any accessories necessary
If the day procedure centre operates vehicles, it must
for correct operation, which makes physical or electrical
have policy and procedure to govern their operation,
contact with the patient, or transfers energy to or from
maintenance and licensing.
the patient, or detects such energy transfer to or from
the patient, or is intended to diagnose, treat or monitor
a patient”.11
This includes, but is not limited to, devices used for:

• life support: anaesthesia machines, ventilators,
heart-lung machines, etc.
• monitoring: bedside monitors, telemetry
monitors, etc.
• treatment: lasers, electrosurgery, diathermy, etc.
• diagnostics: pathology laboratory analysers,
radiology equipment, endoscopes, etc.
• physical support: hospital beds, specialty beds, etc.

Standard 15
Systems for Safety

Buildings, Plant and Equipment
Buildings, signage, plant, medical devices, equipment, supplies, utilities and consumables are managed
safely and used efficiently and effectively.

be achieved by:
15.4 15.4.1 The Effective management of buildings, plant, medical devices and other
Implementing procurement, equipment, utilities, consumables and supplies is required to support
a procurement, management, the provision of safe care and services, as well as to minimise risk to
management, risk reduction consumers / patients and staff.
risk reduction and maintenance
and maintenance system includes: Statutory requirements and codes of practice should be considered
system that when reviewing the current or planned functional design and layout of
• buildings /
is planned, the day procedure centre. For example, the location of air conditioning
workplaces
prioritised, units should be considered in relation to consumer / patient recovery
• plant areas and/or examination rooms, while the storage of pathology
budgeted for and
documented. • medical devices items and specimens should address both access and security.
/ equipment Organisational design and layout should meet licensor requirements
• other equipment for the State / Territory, and plans for changes or developments will
require interaction with local government. Reviews by specialists,
• supplies
equipment suppliers and/or providers may help ensure that all relevant
• utilities legislation is considered.
• consumables
The process for assessment of new plant, medical devices, other
• workplace
equipment, supplies and consumables should include:
design.
• compliance with relevant legislative requirements,
codes of practice, Australian standards and guidelines
• intended use and user and consumer / patient needs
• cost benefits
• safety, including manual handling issues
• infection control, including waste management issues
• energy efficiency and environmental sustainability
• training needs
• storage and distribution.
The day procedure centre should have documented management

strategies for all medical devices used within its facilities. AS/NZS
3551:2004 Technical management programs for medical devices11
details the minimum requirements of an effective strategy for the
management of medical devices.
The process for assessment of new medical devices should include

consideration of their clinical efficacy and effectiveness, human
factors, WHS, infection control, cost of ownership and clinical life, and
should be undertaken in consultation with all relevant staff. However,
ultimately the health, wellbeing and safety of the consumer / patient
must be the overriding consideration in the selection and procurement
of any medical device.

Standard 15
Systems for Safety

Buildings, Plant and Equipment (continued)

be achieved by:
Documented processes for the procurement, upgrading and

replacement of equipment and supplies should be in place. A program
to address breakdown or any planned, deferred and/or outstanding
maintenance requirements should be developed as well as planned
redundancy of out-dated or updated devices. Efficient management
of supplies and consumables requires that systems of ordering,
storage, distribution, and control of inventory be implemented and
comply with relevant standards or guidelines for management. Items
designed for single use should not be reused unless the organisation
has specific policies and guidelines for safe reuse incorporating
relevant statutory requirements, codes of practice and Australian
standards. There should also be a system to manage the recall of
any supplies or consumables, as per bulletins from the Therapeutic
Goods Administration.
Utilities are the basic services that the organisation uses to function,
including water, power, ventilation, medical gases and suction
systems, and communications systems. The effective management
of utilities is required to minimise risk of failure, or of internal or
external emergencies. Policies governing the use of utilities should
cover emergency management, addressed in this Standard, item 15.7,
and sustainability, addressed in item 15.15.
The day procedure centre’s information technology (IT) system should

be supported by a redundancy system and have an external back-up
system to guard against the consequences of IT failure.
Prompt Points
Who is consulted when the day procedure centre is considering
the acquisition or replacement of medical devices? How is this
process undertaken?
Who carries out maintenance on the day procedure centre’s plant /
equipment? How often is it carried out? What records are kept?
How does the day procedure centre prioritise maintenance, repairs
and/or replacement of plant, medical devices and other equipment?

Standard 15
Systems for Safety


be achieved by:
15.4.2 Plant and Installation of plant and equipment should be in accordance with the
other equipment manufacturers’ specifications, with the plant / equipment appropriately
are installed tested and commissioned and all necessary licences obtained. Current
and operated in information and scientific data from manufacturers relating to their
accordance with products’ requirements should be available for reference and guidance
manufacturer for both the operation and maintenance of plant and equipment.
specifications
and plant logs Plant logs and maintenance processes should ensure that plant /
are maintained. equipment is maintained and serviced by people trained in
maintenance of that equipment and in accordance with manufacturer
specifications and relevant standards.
The safe operation of electrically operated equipment used in health

care should be monitored in regard to electrical shock, thermal, radiant
and mechanical hazards. Organisations should refer to State / Territory
legislation, Australian standards, and any other relevant guidelines.
Specialised equipment should only be operated by trained staff to

minimise the likelihood of injury and to obtain the best results.
Many medical devices require specific training and some require

licensing of the individuals who will operate the device. The day
procedure centre must ensure that all those involved in the operation of
medical devices have undergone all necessary training, are competent,
and that where required, all correct licences have been obtained.
Increasingly, medical devices are utilising elements of information

and communication technology (ICT). A growing number of medical
devices are in essence a desktop computer, notebook or network
server running dedicated medical software, or a system incorporating
a desktop(s), notebook(s) or server(s). However, all such devices
should be managed as medical devices, not as ICT. Medical devices,
whether networked or not, and medical networks should be managed
and maintained, including the software component, by competent
biomedical engineers or biomedical technicians. This task may be
assigned to the manufacturer or the manufacturer’s agent.
Only applications software (including antivirus software) and software

updates, patches and service packs authorised by the device
manufacturer should be loaded onto a medical device, a networked
medical device or any device attached (including wirelessly) to a
medical network. The National E-Health Transition Authority (NEHTA)
provides specifications for IT applications with which vendors
should comply.

Standard 15
Systems for Safety


be achieved by:
Installation, calibration, maintenance and, finally, decommissioning and

disposal of medical devices should be carried out by registered and/
or appropriately qualified, trained and competent individuals. Records
should be kept of all medical device maintenance. Responsibility
should also be assigned for the cleaning, sterilisation and/or
recommissioning of each individual device, as this is a specialised
task that does not fall within the province of the organisation’s general
cleaning staff.12
Prompt Points
What plant / equipment within the day procedure centre require the
operator(s) to be licensed? How is correct licensing of operators,
including drivers of vehicles, monitored?
What processes and approval mechanisms can the day procedure
centre demonstrate with respect to the management of medical
devices, including record keeping, risk evaluation, scope of routine
testing programs, contract management and resource availability?
For what plant / equipment are logs kept? Who updates the logs?
Who checks the logs?
How and by whom is the day procedure centre’s program of
preventive maintenance planned?
15.5 Reducing 15.5.1 Incidents Within the day procedure centre’s risk management framework, there
the risk of and hazards must be a system for identifying, documenting, evaluating and reducing
incidents associated with: the risk associated with buildings, signage, plant, equipment, utilities,
and hazards • buildings / supplies and consumables. This should encompass the reporting of all
associated with workplaces relevant incidents, identified hazards and near misses, by all individuals
buildings, plant, within the organisation. A culture of near miss reporting is especially
• plant
medical devices, to be encouraged, as near misses are a vital indicator of developing
equipment, • medical problems, and are sometimes underreported due to the perception
utilities, devices / that no ‘actual’ incident occurred.
consumables equipment
and supplies. • other equipment Prompt Points
• supplies How does the day procedure centre encourage the reporting
of near misses within its management of buildings, signage,
• utilities
plant, equipment, utilities, supplies and consumables?
• consumables
How are reported incidents reviewed? Are incidents rated to assist
are documented with investigation? Who is responsible for reviewing incidents?
and evaluated,
What improvements have been made to the day procedure
and action is taken
centre’s maintenance and hazard reduction systems, and why
to reduce risk.
were they made?

Standard 15
Systems for Safety


be achieved by:
15.5.2 The safety The AusHFG10 is intended to promote a best-practice approach

and accessibility to health facility planning, and is subjected to a continuous review
of buildings / process to ensure that the contents reflect contemporary models
workplaces, of care and health planning practice. It also lists all appropriate
and the safe jurisdictional legislation, including work health and safety (WHS)
and consistent legislation, and relevant Australian standards. Using this document
operation of plant as a guide, day procedure centres should develop policy and
and equipment, procedures that will provide an effective managerial framework.
are evaluated, and
improvements To assist facility managers, the Institute of Hospital Engineering
are made to Australia (IHEA) has developed a hospital facility benchmarking
reduce risk. process, called AssetMark. Further information can be found at:
http://www.ihea.org.au/page/assetmark_benchmarking.html
In existing facilities, or where an area is designated for a new purpose,

it can be difficult to redesign workspaces without major renovation.
If the day procedure centre intends to adapt an existing space for
a new purpose, it should plan the changes and manage the area
so as to ensure compliance with relevant WHS legislation. Planning
and development should strive for continual improvements to the
environment and for a reduction in risk, by evaluating the workplace
and making changes as necessary.
As part of its system of planning, the day procedure centre should

recognise that over time, buildings, plant, medical devices and other
equipment may require maintenance and/or repair, or to be replaced.
Events such as these should be expected, prioritised and budgeted
for, in order to ensure that safety is not compromised. Success or the
need for improvement in the area of workplace planning / design may
be gauged by surveying consumers / patients, visitors and staff.
Prompt Points
If an existing facility was adapted, what measures were taken
to ensure that the environment was appropriate to the work?
What legislation / guidelines were consulted when planning
for disabled access to the day procedure centre?

Standard 15
Systems for Safety


be achieved by:
15.6 Ensuring 15.6.1 Access to Clear signage is an important aspect of any healthcare organisation.
that physical the organisation is External signage should provide at a minimum the following
access to the facilitated by: information:
organisation’s • clear internal • appropriate routes of access
facilities meets and external • hours of access
the identified signage
needs of the • after-hours access (where applicable)
• the use of
community. • telephone numbers
relevant
languages and • details of other healthcare organisations in the area, particularly the
multilingual / nearest emergency facility.
international
External signage may also relate to such management issues
symbols
as designated parking / non-parking zones or the enforcement
• the provision of a non‑smoking policy.
of disability
access Internal signage should provide clear and appropriate directions
• facility design for consumers / patients, as well as all necessary health and safety
that meets information including with regard to non-smoking areas, restricted
legislative mobile phone usage and the presence of any hazards. All exits must
requirements be clearly marked.
and/or is based Signage should also consider special needs, as appropriate to the day
on recognised procedure centre’s community. The conditions of access for persons
guidelines. with a disability will be governed by State / Territory legislation.
Designated routes of access should be clearly indicated. With an

ageing population, an increasing number of consumers / patients and
visitors may have impaired eyesight, and this should be taken into
consideration when designing and positioning signage; lighting is also
an important concern. The organisation may need or wish to provide
Braille and tactile signs; such signage is governed by the Building
Code of Australia.
Prompt Points
How often are the day procedure centre’s signage arrangements
reassessed? On what basis are changes to the signage made?
What special needs signage is found within this day procedure
centre?

Standard 15
Systems for Safety
Criterion 3: Emergency Management

Emergency management supports safe practice and a safe environment
Preparedness is critical to ensure that the day Should the day procedure centre experience or be
procedure centre responds to any emergency in an involved in an emergency, inevitably there will be lessons
appropriate and timely manner. Emergency management to be learned about its systems and procedures.
systems must be regularly reviewed and updated in light Every aspect of the review that follows such an incident
of current best-practice evidence, as well as internal should be thoroughly documented, to demonstrate
factors such as alterations to buildings and changes in the resultant changes made to any or all aspects of
staffing or services provided. The day procedure centre the pre‑existing plan, including evacuation plans,
must be proactive in the management of its emergency staff training and communication systems.
procedures, and never allow its circumstances and
its planning to be out of step. When a review of the
system results in recommendations for change,
there should be clear documentation of the process,
including the timeframe within which the changes will
be implemented.

Standard 15
Systems for Safety

Emergency Management
Emergency management supports safe practice and a safe environment.

be achieved by:
15.7 15.7.1 There An emergency or a disaster is “a serious disruption to community

Implementing is evidence of life that threatens or causes death or injury in that community, and/
systems for evaluation and or damage to property, which is beyond the day-to-day capacity
prevention, improvement of of the prescribed statutory authorities, and which requires special
preparedness, the emergency mobilisation and organisation of resources other than those normally
response and management available to those authorities”.13 Clarification of any expected role for
recovery in systems, which the organisation in external emergency planning can be sought through
emergencies, include: local government, but this involvement would be rare in the day
including triage • identification procedure centre context. While it may not be called upon in a general
and deployment of potential emergency in the same manner as a large hospital, it is important
of medical internal and that the day procedure centre plan and prepare for any likely external
teams where external and internal emergencies that might impact upon its functioning.
appropriate, that emergencies Potential external emergencies, which may occur as a result of the
comply with: organisation’s location, include bushfire and flooding. Planning for
• coordination
• legislation external emergencies may be coordinated with the relevant authorities.
with relevant
• Australian external An internal emergency is one that occurs upon the premises and
standards authorities may have adverse consequences for consumers / patients, staff and
• codes of • installation of visitors, such as fire, failure of essential services, structural damage or
practice an appropriate a bomb threat. Day procedure centres should also plan and prepare
• industry communication for the rapid deterioration of a consumer / patient, which is addressed
guidelines. system in Standard 9, and the collapse of an unexpected person (a staff
• development member, visitor or contractor) and/or a collapse in an unexpected
of a response, place. Organisations should ensure that staff are trained at least
evacuation and in basic life-saving techniques, that there are emergency trolleys
relocation plan available, and that the equipment and emergency drugs stored on the
trolleys are regularly checked.
• display of
relevant Evacuation plans should be developed for the day procedure centre
signage and and prominently displayed, ideally as a diagram(s) showing exit paths.
evacuation Staff must be made aware of the significance of the various alarms
routes used, and trained in correct reactions and assembly points. Evacuation
• planning for drills should be planned and carried out so that all staff, including
business contracted and agency staff, are familiar with the proper course
continuity. of action.
External service providers, such as contractors and agency nurses,

should undertake orientation to ensure they are aware of organisational
requirements, and be briefed on the emergency communication system
and evacuation procedures.
The day procedure centre should develop an emergency

communication plan as appropriate to its size, design and function,
and which ensures that there are effective methods for activating
external services such as fire-fighting authorities.

Standard 15
Systems for Safety

Emergency Management (continued)

be achieved by:
The organisation should have a business continuity plan to ensure

the continued availability of essential services during and after
an emergency, and which addresses all functions and resources
associated with the provision of these services14, including lighting,
power, water, ventilation and medical gases.
Prompt Points
How does the organisation ensure that any external suppliers are
traced outside the building if an evacuation has been called?
What plans are in place if the designated assembly area is not
accessible? Do evacuation plans cover instances where relocation
is required?
What guidance is provided to clinicians on the appropriate
response to an alarm during a procedure?
In the event of an emergency, who manages the allocation of
duties? What policies / procedures allow the coordinator to
reallocate staff to an alternative role? How would this be tracked?
In the event of drastic understaffing due to a natural disaster or an
epidemic, how would the day procedure centre assess its ability
to maintain services?
15.8 Ensuring 15.8.1 There The day procedure centre must not only plan for emergencies, but
correct is evidence of ensure that staff, including contractors, are educated in all aspects
organisational evaluation and of those plans, and trained in putting them into effect. Emergency
response to improvement procedures should be presented to all staff at orientation, and at
emergencies of staff training least annually in education sessions. The training should reiterate
and disasters. and competence the components of the various plans and the stages of response.
in emergency Theoretical exercises should be supported by drills.
procedures,
which includes: Compliance is crucial, and comprehensive records should be kept
of staff completion of both the theoretical and practical aspects
• education at
of evacuation and emergency response training, including first aid
orientation
certification. The day procedure centre’s management of the education
• annual training and training of its staff must also be rigorously evaluated and improved
in emergency, when necessary. Changes can be based upon advice from external
evacuation experts, and also upon feedback from staff on approaches to training,
and relocation dissemination of information, or practical issues that may impact
procedures upon an effective emergency response, including evacuation and
• regularly relocation procedures.
conducted
emergency
practice / drill
exercises

Standard 15
Systems for Safety


be achieved by:
(continued) Fire safety officers, or fire wardens, as appropriate to the size and
type of the day procedure centre, should be appointed from amongst
• the the staff. In a small organisation a single warden may be sufficient,
appointment while larger facilities will require the involvement of more individuals
of an with differing levels of responsibility (for example, Floor Warden,
appropriately Deputy Chief Fire Warden, Chief Fire Warden). Various companies
trained fire provide accredited training for those individuals willing to accept the
officer position of fire warden, and the day procedure centre should provide
• access to first the funds and the time for such training to be completed. The identity
aid equipment and internal contact details of all fire wardens should be clearly
and supplies, posted within the day procedure centre.
and training of
relevant staff. Healthcare organisations, including day procedure centres, must meet
jurisdictional requirements in terms of numbers of trained first aid
officers and access to appropriate first aid kits.
Kits should reflect the type and level of identified risk in that workplace
and should be regularly checked to ensure items are replenished
and within their expiry dates. First aid supplies and trained personnel
should be available in all areas of the day procedure centre, including
non-clinical areas, and the names and contact details of individuals
with first aid responsibilities posted.
Prompt Points
How many fire wardens / safety officers does the day procedure
centre have? Where are the wardens’ details posted?
What emergency rehearsals does the day procedure centre use
to ensure preparedness? What staff take part in these rehearsals?
How does the organisation ensure that contract staff are
adequately trained in emergency and evacuation procedures?
How does the day procedure centre ensure that all staff are familiar
with the components of its fire safety plan?
What percentage of the day procedure centre’s staff completed
fire drill and fire-fighting training within the last calendar year?
How is non-compliance followed up and what action is taken?
Where are first aid kits situated within the organisation? Is there
a system of checking and re-stocking supplies?

Standard 15
Systems for Safety


be achieved by:
15.9 Assessing 15.9.1 There Within the scope of this criterion, the expression ‘full fire report’ is
compliance is documented used to describe an inspection that includes a review of fire safety risks
of buildings evidence that associated with a building. The terms used to describe building fire
with relevant an authorised safety certificates and reports vary between jurisdictions.
jurisdictional external provider
fire codes and undertakes a full A full fire report is required at least once within the EQuIPNational
documenting fire report on the cycle, or according to notified jurisdictional variations; for example, the
plans in premises at least maximum accepted time since the last review for Victorian healthcare
response to any once within each facilities is five years, though in other States / Territories it is four years.
recommendations EQuIPNational The assessor who prepares the full fire report should use the Building
from inspections. cycle and/or in Code of Australia (BCA) as a guide for their review of fire safety risk
accordance with and should report their findings in relation to the building’s structure,
jurisdictional its safety installations / measures, their performance and maintenance.
legislation.
The person preparing the full fire report should:
• have experience and/or a qualification that includes building
fire safety risk mitigation
• be familiar with the BCA
• be external to the organisation.
The requirements for day procedure centres in terms of fire inspections

are the same for any Building Code of Australia class 9 building.
If further information in relation to fire inspections is required,
contact your ACHS Customer Services Manager.
Legislation / regulations governing fire safety management vary

between jurisdictions. It is the responsibility of the day procedure
centre to consult with the relevant authorities and to determine the
appropriate inspection and maintenance schedule(s) for the safety
measures within its facilities. ‘Safety measures’ include detection
systems, alarms and extinguishing equipment. The inspection and
testing of fire / emergency equipment should comply with relevant
statutory requirements, codes of practice and Australian standards.
Fire-fighting equipment should be positioned appropriately throughout
the organisation.
Prompt Points
When was the day procedure centre’s last cycle of inspection
and maintenance on essential safety measures undertaken?

Standard 15
Systems for Safety


be achieved by:
15.9.2 There is Organisational fire plans should be reviewed and revised annually.
a documented In addition, where there are known fire risks associated with the
plan to implement building(s) or site, the day procedure centre should have an action
recommendations plan that addresses the management of that fire risk. The action
from the fire plan should record the day procedure centre’s response to any
inspection. recommendations made in the full fire report and set out actions
already taken or proposed, the rationale on which they are based,
and the planned timetable for compliance. The timetable should show
evidence of priority being given to:
• recommendations which have a direct bearing on issues of safety
for consumers / patients, staff and visitors
• early compliance with recommendations that are readily achievable.
The external fire inspection report demonstrating BCA compliance and

any subsequent action plan must be forwarded to the ACHS six weeks
prior to the onsite survey.
Experience indicates that it may take several months for organisations

to obtain all the necessary documentation. For this reason, it is
strongly recommended that organisations initiate the fire inspection
cycle 12 months prior to the onsite survey.
Prompt Points
What actions were taken in response to the last full fire report?
What actions are proposed in the future?

Standard 15
Systems for Safety
Criterion 4: Physical and Personal Security

Security management supports safe practice and a safe environment
Security can be divided into four broad areas: Day procedure centres are required to identify their
• Procedural security concerns the policies and major security risks. Consideration needs to be given
procedures put in place by an organisation to to the environment, work practices, work arrangements
provide an environment that enhances the safety and equipment used. Information to assist organisations
of employees, consumers / patients and visitors. to manage security is available in AS 4485:1997
Security for health care facilities.
• Physical security refers to the steps taken to
prevent and/or minimise the incidence of verbal The day procedure centre should have an effective risk
and physical acts of aggression and violence within management plan to address violence and aggression
the workplace, either by or towards employees, in the workplace. The focus should be on prevention.
consumers / patients and visitors. However, when a violent incident does occur, action
• Personal security, in a healthcare setting, refers to should be taken to minimise its impact and prevent its
the right of consumers / patients and visitors to be recurrence as far as possible, regardless of its source.
confident of the credentials and background of the Appropriate support should be provided for affected
individuals with whom they interact in that setting. staff, such as debriefing, and encouragement to access
• Logical security is that aspect of security professional counselling and assistance from the
management that utilises communications, organisation’s employee assistance program.
Information Technology (IT) and Information
Management (IM), and refers to those security
features that are built into communications, IT and IM
systems. Further information about logical security
and its implementation and management can be
found within Standard 13, action 13.8.1.

Standard 15
Systems for Safety

Physical and Personal Security
Security management supports safe practice and a safe environment.

be achieved by:
15.10 15.10.1 Service Security management is a vital and wide-ranging issue in any
Implementing planning includes healthcare setting, encompassing not only the physical and emotional
policy and strategies safety of individuals, but the protection of buildings, plant, equipment
systems for the for security and other assets. AS 4485:1997 Security for health care facilities
management of management. provides a suitable framework.
security risks
that reference Policy should consider the following issues:
any relevant: • security and safety of staff, consumers / patients and visitors
• legislation • security of information
• Australian • security of personal belongings
standards • security of assets
• codes of • security of pharmaceuticals
practice
• security of payroll
• industry
• defined responsibilities for management and staff, and delegated
guidelines.
responsibility for the security system
• security assessment, as required by jurisdictional guidelines,
undertaken by an accredited consultant.
The day procedure centre should implement policy to cover all aspects
of security and identified risks. Organisations need to consider highly
vulnerable and at-risk groups of consumers / patients when developing
policies to ensure that risks associated with these groups are managed
appropriately. The size and location of a day procedure centre and
the nature of the community it serves will influence the content of
policies, however their content should be shaped by jurisdictional
legislation, Australian standards, codes of practice, and relevant
industry guidelines.
Strategies for security management should be included in service

planning. This will involve allowing for the resources needed to ensure
the day procedure centre’s security, such as provision of personal /
duress alarms, installation of panic buttons and their connection to
police or a security company, appropriate lighting, video surveillance
and/or the provision of security staff if needed. Organisations should
also consider architectural design that improves surveillance of critical
service areas, such as plant rooms, and the protection of personnel,
for example, service counter design and access to treatment rooms.
Prompt Points
What legislation / standards / codes of practice are referenced
in the day procedure centre’s security policy?
How does the day procedure centre ensure that all identified
security risks are addressed in policy and procedures? Are security
risks included in the day procedure centre’s risk register?

Standard 15
Systems for Safety

Physical and Personal Security (continued)

be achieved by:
15.10.2 The Organisations are required to identify their major security risks.
organisation- Identification and elimination or mitigation of risks should address
wide system physical, environmental and personal security. This will require
to identify and consideration of staffing arrangements, work practices, equipment,
assess security the environment, and the presence of onsite visitors and contractors.
risks, determine
priorities and When identifying where the day procedure centre may be at risk, the
eliminate risks or nature and source of the harm that could occur needs to be identified.
implement controls Organisations should consider:
is evaluated, • What could happen (or what could go wrong)?
and improved • How would it happen?
as required.
• What harm it would cause?
• Who or what would be harmed?
As part of its commitment to providing a safe working environment,

the day procedure centre should ensure that lighting is adequate
in areas such as car parks, corridors, access paths and storage
facilities. An access control system for registering, managing and
monitoring individual levels of access, including the allocation and use
of key and/or swipe cards, should be in place, kept up to date and
regularly reviewed. Access controls to specific areas, including locks
on drug storage areas, reduced face-to-face contact during supply
of pharmaceuticals, and designated escape routes can improve the
physical safety of staff.
Personal security includes pre-employment checking and human

resources policies and procedures. Relevant credentials should be
provided by all staff and copies kept in personal records. In settings
where staff are working with or in contact with children, appropriate
checks should be completed.15 Identification should be worn by
all staff.
The day procedure centre’s responsibility to provide a safe working

environment extends to all individuals entering the workplace, including
any external service providers or contractors. The day procedure
centre must provide these individuals with all relevant security
information, both in order that they may be protected, and to ensure
that in turn they comply with all security policies and procedures.
Organisational security is an aspect of risk management. Security

risks should be identified and risk-rated, and eliminated or controlled.
The system used to identify and respond to security risks should be
regularly evaluated, and improved as required. The investigation of
associated incidents (violence, security breaches, non-compliance
with policy, theft) will inform this process.

Standard 15
Systems for Safety


be achieved by:
Prompt Points
How often is the day procedure centre’s security management
system evaluated? Who is involved in this process? What changes
were made as a result of the most recent evaluation?
What incidents involving a security issue have been reported
during the past twelve months? How have the outcomes of incident
investigation been used to improve organisational security?
Does the day procedure centre have areas to which access
is restricted? How is access to those areas monitored
and/or controlled?
15.11 Involving 15.11.1 Staff National and State / Territory legislation requires that employers
staff and relevant are consulted in consult with employees to identify hazards, assess the risk, determine
authorities in decision making and implement control measures, develop policies and procedures to
decision making that affects minimise the risk, decide on training requirements and supervise and
around issues that organisational and monitor the risk control measures.
affect security personal risk, and
management. are informed of Employers must take all reasonably practicable steps to protect
security risks and the health and safety at work of all employees. The best way to
responsibilities. ensure that all reasonably practicable steps have been taken is to
apply a consultative risk management process to the identification,
assessment and control of risks.
Day procedure centres need to ensure that:

• the risk management policy and procedure have been developed in
consultation with the employees performing the relevant functions
• risk assessments of consumers / patients occur, with alternative
care options provided for those who are excluded on the basis of
risk assessment or those where a risk assessment is not an option
due to time constraints
• risks and risk control strategies that are implemented are
communicated to staff
• the effectiveness of the policies and the controls that are in place
is demonstrated
• appropriate training for staff occurs including training in aggressive
behaviour management and manual handling, commensurate with
the working conditions of the employee
• appropriate emergency support equipment, such as mobile phones
or other communication equipment, is made available to staff
suitable to the location of the service.
The procedures developed in any organisation must be understood,

with relevant staff training provided where necessary. A mechanism
to guarantee that policies and procedures have been read and
understood should be in place. This can be in the form of a register
or part of the annual review of key performance indicators.

Standard 15
Systems for Safety


be achieved by:
Prompt Points
How often are staff consulted regarding matters of security in
the workplace? What form does this consultation take?
How does the day procedure centre educate its staff about security
matters? How often is this information updated and disseminated?
15.11.2 Security Security management plans may be developed to address physical

management security, personal security or logical security. A security management
plans are plan that requires contact with an external entity to address security
coordinated with issues should be developed in consultation with external entities, such
relevant external as the local police or an external security service. Strategies to prevent
authorities. and address violence in healthcare organisations are most effective
when clinical staff, security staff, management and external workers
work collaboratively as part of a team.
An external, accredited consultant engaged to perform an

organisational security assessment can provide input to the security
management plan.
In addition, if the response to violence, activation of duress alarms

or other instances of breaches in security is to contact the police,
the management plan should have input from the police to ensure
contact is made in the correct way and at the correct time.
Prompt Points
What external consultation has occurred in the development
of security management plans?
What external authorities are to be contacted in the event of
a security incident? Have these organisations been consulted
in the development of the security management plan?

Standard 15
Systems for Safety


be achieved by:
15.12 Minimising 15.12.1 The The term ‘violence and aggression’ encompasses any incident in which
violence and violence and an individual is abused, threatened or assaulted. Such an incident
aggression in aggression may involve verbal, physical or psychological abuse, threats or other
the workplace management intimidating behaviours, intentional physical attacks, aggravated
through an plan is evaluated assault, threats with an offensive weapon, sexual harassment,
organisation- to ensure that or sexual assault.
wide violence it includes:
and aggression While the nature of day procedure centres may reduce the risk of
• policies /
management violent incidents, they may nevertheless occur, as may instances of
procedures
plan. bullying and harassment. ‘Zero tolerance’ means that in all violent or
for the
aggressive incidents, appropriate action will be taken to protect staff,
minimisation
consumers / patients and visitors from the effects of such behaviour.16
and
management The day procedure centre should adopt a policy of zero tolerance,
of violence and and implement a violence and aggression management program
aggression that includes:
• staff education • policies addressing internal (intra-organisational) violence,
and training aggression and bullying between staff at all levels as well as visitors
• appropriate • a focus on the elimination of violent behaviour and, where
response to risks cannot be eliminated, the reduction of risk to the lowest
incidents. possible level
• control strategies for violence and aggression, developed
in consultation with staff
• protocols for reporting violent incidents
• a working environment that supports zero tolerance and
management commitment to the program
• staff education about responding to violent incidents.
Security and consumer / patient safety are key concerns in any

healthcare organisation. Management should demonstrate its support
for zero tolerance of violence and aggression through a commitment
to education and training, and an effective response when incidents
are reported.
The integrity of policies and procedures can only be assured by

the methods employed to train staff in current procedures and by
continuously reviewing and updating those procedures as required
following consultation with staff. In addition, all aspects of the violence
and aggression management and zero tolerance programs should be
evaluated, and improved as required. This process should include a
review of organisational response to any incidents involving violence
or aggression.
Prompt Points
How does the day procedure centre respond to the report of
a violent incident? What changes have been made to security
processes as a result?

Standard 15
Systems for Safety
Criterion 5: Waste and Environmental Management

Waste and environmental management supports safe practice and a safe and sustainable environment
Within a healthcare organisation, waste management Apart from producing solid waste, healthcare
requires not only the collection and disposal of waste, organisations also contribute to carbon emissions
but also control of all associated risks, including that of through such actions as the combustion of fossil
infection. Healthcare organisations generate both clinical fuels, the use of transportation, the consumption of
and non-clinical (general) waste. Furthermore, changes electricity and paper, and the production of refrigerants.
in the approach to infection control have resulted in a Day procedure centres should have policy in place to
significant increase in the volume of waste generated, reduce carbon emissions based upon the principles
due to the shift towards single-use, disposable clinical of avoidance, modification, and reduction of usage.18
products. Health care, like other industries, must now Electronic, or ‘e-waste’, refers to the disposal of
also deal with the problem of e-waste. superseded computers, mobile phones, televisions,
and other electronic and battery-operated devices19,
Segregation, or the division of waste into various which at the present time are considered another
categories according to its nature, source and hazard form of hazardous waste. 20
level, allows simultaneously for the control of risk,
and for financial gain through both the recovery of Strict policies and procedures in waste management
reusable and recyclable materials and the avoidance of are necessary in order to:
unnecessary handling / destruction of non-hazardous • protect the health and safety of the public
material. At both Federal and State / Territory levels,
• provide a safe work environment
policies of sustainability have been embraced in
Australia; these are shaped around strategies aimed at • reduce waste handling and disposal volumes / costs
environmental, social and financial gain through greater without compromising health care
responsibility in the use of resources.17 The expression • minimise the environmental impact, including as a
‘greenhouse gas’ in fact refers to a combination of result of carbon emissions, of waste generation,
six gases, of which carbon dioxide (CO 2 ) is a major treatment and disposal.
one; the term ‘carbon emission’ usually refers to
the generation of all gases that contribute to global
warming and climate change. 2

Standard 15
Systems for Safety

Waste and Environmental Management
Waste and environmental management supports safe practice and a safe and sustainable environment.

be achieved by:
15.13 15.13.1 The The day procedure centre’s management of waste will require policy
Implementing a waste and and procedures to address both the internal and external aspects
system for the environmental of the process, and coordination with relevant external authorities.
management management The transportation of waste is governed by legislation, codes of
of waste. system is practice and guidelines, which should be consulted where applicable,
evaluated to including the Australian Code for the Transport of Dangerous Goods
ensure that by Road and Rail.6 A list of the relevant competent authorities may be
it includes: found at the website of the Department of Infrastructure and Transport.
• development
The waste management system will typically include the use of external
and
service providers, or contractors, who will collect, transport and
implementation
dispose of accumulated waste of all kinds. It is the responsibility of the
of policy
day procedure centre to ensure that all waste is correctly segregated,
• coordination packaged and identified prior to off-site transportation; and also to
with external ensure that all those involved in the management of waste are correctly
authorities licensed and operating according to all relevant legislation and codes
• staff instruction of practice, as addressed in Standard 14, item 14.5.
and provision
of information The collection, storage and disposal of certain kinds of waste, such as
on their radioactive, cytotoxic or pharmaceutical waste, may require specific
responsibilities. training and even licensing of the individuals concerned in its handling.
It is the day procedure centre’s responsibility to ensure that staff are
made aware of their obligations in this respect, to provide access
to the appropriate training / licensing, and to supply all appropriate
personal protective equipment. The day procedure centre must also
ensure that untrained and/or unlicensed individuals are not permitted
to handle the waste in question.
Within the day procedure centre, all staff will generate waste, and all
staff must take responsibility for the correct identification, segregation
and disposal of waste. The day procedure centre should not assume
that staff will be able to correctly classify any given form of waste, nor
rely entirely upon its signage, but should provide instruction as to the
correct procedures. The content of this instruction should be refined
over time to ensure that all necessary information is being provided.
Wherever appropriate collection / processing facilities are available, a

recycling program should be a major aspect of the organisation’s waste
minimisation strategy. At both a Federal and State / Territory level,
guidelines for sustainability require that organisations pursue a policy
of reduce, reuse, recycle. 21 However, in implementing such a policy,
the duty of care must always take precedence; and the day procedure
centre should therefore shape its strategy around its obligations in the
management of hazardous waste and infection control.

Standard 15
Systems for Safety

Waste and Environmental Management (continued)

be achieved by:
As improvements in waste management are often qualitative rather

than quantitative in nature, the day procedure centre should consider
how best to determine how successfully its policies have been
implemented. One option is a waste audit. Various companies offer
waste auditing as a service, and even specialise in the auditing of
hazardous waste. The organisation could also introduce a survey
system, which can encompass both practical aspects of waste
measurement such as a count of overfilled waste receptacles or a spot
check of whether waste is being disposed of in the correct bin, and the
opportunity for staff feedback, in order to measure satisfaction with
the waste management policy by those working within its guidelines.
Apportioning the ratio of infectious, general and recyclable waste over
time can also be useful to guide improvements in sustainability.
Prompt Points
How does the day procedure centre ensure that its waste
management policies and procedures are correctly implemented?
Does the day procedure centre use an external service provider
for the collection, transport and/or disposal of clinical and related
waste? How was the provider chosen?
How does the day procedure centre ensure that the external
service provider is compliant with the requirements of the
relevant authorities?
How does the organisation instruct staff as to their responsibilities
in waste management? How are staff encouraged to assist in the
day procedure centre’s environmental management?
15.14 15.14.1 Controls The healthcare industry produces a wide variety of waste, some of
Implementing are implemented which poses a hazard to staff, consumers / patients, the public and
systems based to manage: those employed to transport and dispose of the waste. Hazardous
on recycling, • identification waste can be generated in any healthcare setting and must be
reducing appropriately managed. Waste management streams should be
• handling
and reusing identified and indicated via suitable signage.
processes and • separation and
identifying waste segregation Hazardous waste comprises both clinical and non-clinical waste.
management of clinical, Clinical waste is broadly defined as “having the potential to cause
streams through radioactive, disease, injury or public offence” 22: it includes human tissue waste,
signage to ensure hazardous and laboratory waste, sharps, animal tissue waste, and any material
separation and non-clinical waste, contaminated with any of the former. Medical procedures may also
segregation of and the controls generate material contaminated with chemicals, pharmaceuticals,
waste within the are evaluated, cytotoxic drugs or radioactivity.
organisation. and improved
as required.

Standard 15
Systems for Safety


be achieved by:
The segregation and disposal of clinical waste must be managed with

accordance with State / Territory requirements, and must conform to:
• relevant statutory requirements
• work health and safety guidelines
• the requirements of the relevant environmental protection agencies
and health departments
• any requirements of local government.
Although healthcare organisations generate many unique forms of

waste that must be carefully managed, they also generate waste
common to all walks of life, including corrosives, organic and liquid
waste, food scraps, paper and other recyclables.
Strict segregation of waste is vital from a policy, a financial and an

environmental perspective. Correct disposal of hazardous waste is
required to meet the organisation’s duty of care to the health and
safety of its consumers / patients, the general public, and its staff
and contractors. The cost of appropriate treatment and destruction
of hazardous waste is up to 30 times that of the cost of disposal of
general waste 23, so stringent segregation processes that prevent
the mixing of general and hazardous waste will prevent unnecessary
expense. Non-clinical waste must also be correctly segregated to
ensure that organics and liquids are stored and transported safely,
and that all recyclables are recovered and disposed of correctly.
Prompt Points
What different forms of waste are produced by the day procedure
centre? What proportion of the waste is recycled rather than
discarded to landfill?
What is the day procedure centre doing to minimise its waste
production?
What controls does the day procedure centre use to identify,
handle and segregate waste appropriately?

Standard 15
Systems for Safety


be achieved by:
15.15 15.15.1 The The day procedure centre should have policy and procedures to
Implementing system to: ensure that its use of energy and water is efficient and sustainable.
systems to • increase the These should address considerations such as purchasing electrical
manage resource efficiency of equipment with a high energy rating, and programs to conserve energy
sustainability. energy and and water (switching off equipment, good plumbing maintenance, etc.).
water use
All staff must be made aware of their responsibilities with
• improve regard to sustainability and the reduction of carbon emissions.
environmental The organisation must work continually towards improving its
sustainability environmental management, and may wish to encourage staff to
• reduce carbon suggest and/or implement their own changes and improvements
emissions to existing workplace systems.
is evaluated,
As a means of calculating an organisation’s energy and emissions
and improved
data, and measuring the success of its environmental management
as required.
policies, day procedure centres may conduct an internal assessment
and develop an action plan from the results. The Federal Government’s
Department of Climate Change and Energy Efficiency offers an
Online System for Comprehensive Activity Reporting (OSCAR),
which some organisations may wish to utilise, available at:
http://www.oscar.gov.au
Prompt Points
How does the day procedure centre act to reduce its
environmental impact?
How has the day procedure centre improved the efficiency
of its energy and water usage?

Standard 15
Systems for Safety
References
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Centre for Health Assets Australasia, UNSW; 2009.
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equipment, and maintenance of associated environments in health care facilities.
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ManagementPreparing_for_EmergenciesBusiness_Continuitiy on 15 August 2012.
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Working with children checks and police checks. Canberra ACT; Australian Government. Accessed from
http://www.aifs.gov.au/cfca/pubs/factsheets/a141887/index.html on 15 August 2012.
16. NSW Health. Zero tolerance. Response to violence in the NSW health workplace. Policy and framework
guidelines. Sydney; NSW Health; 2003.
17. Department of Environment, Water, Heritage and the Arts. National waste policy: less waste, more resources.
National waste policy fact sheet. Canberra ACT; Australian Government; 2009.

Standard 15
Systems for Safety
EQuIPNational
References Day Procedure Centres Standards
18. Victorian Environment Protection Authority (EPA). Draft carbon management principles – EPA discussion paper.
Melbourne; Victorian Government; 2007.
19. Hyder Consulting. Waste and recycling in Australia. Canberra ACT; Australian Department of Environment,
Water, Heritage and the Arts; 2008.
20. Canberra Environment and Sustainability Resource Centre. Electronic waste management and minimisation for
local governments: An education and training program. Canberra ACT; Australian Department of Environment,
Water, Heritage and the Arts; 2009.
21. Sustainability Victoria. Recycling and reusing in your workplace. ResourceSmart. Melbourne; Victorian
Government; 2008.
22. WA Department of Health. Clinical and Related Waste Management Policy. Perth WA; Government of Western
Australia; 2009.
23. Sulo Environmental Technology. Cast study: Waste management. Somersby NSW; Sulo Pty Ltd. Accessed
from http://www.sulo.com.au/wp-content/uploads/PDF/Clinical_Case_Study.pdf on 19 November 2012.

Acknowledgements
The Australian Council on Healthcare Standards (ACHS) acknowledges the individuals who
committed their knowledge, experience and, more significantly, their time to the development
of EQuIPNational Day Procedure Centres.
The revision of EQuIP programs is led by the ACHS Standards Committee, whose role is to
steer the direction and content of the standards review and to advise on the applicability of the
standards for implementation and accreditation. The Standards Committee is a subcommittee
of the ACHS Board and reports its recommendations directly to the Board.
EQuIPNational Day Procedure Centres has been developed with the assistance of relevant
experts, surveyors, day procedure centre representatives, and ACHS Customer Service
Managers and Surveyors.
ACHS gratefully acknowledges the generous contribution of the Australian Day Surgery
Council (ADSC) and the Australian Day Hospital Association (ADHA) in the development of
the guidelines for EQuIPNational Day Procedure Centres.
ACHS Board of Directors

Adjunct Associate Professor Karen Linegar Ms Helen Dowling
(President) BPharm, Dip Hosp Pharm (Admin), Grad Dip QI HCare,
RN, RM, BAppSc(Nurs), BBus, MHA, Dip Com Law, CHP, FSHP, AICD
FRCNA, JP Health Professions Council of Australia
Royal College of Nursing
Mr Tony Lawson
Mr John Smith PSM (Vice‑President) BA, BSoc.Admin, FIPAA, FAIM, CPMgr
MHA, Grad Dip HSM, AFACHSM, CHE, FAHSFMA, Consumers’ Health Forum of Australia
AFAHRI, AFAIM, FAICD
Australian Healthcare and Hospitals Association Dr David Lord
MBBS, DPM, FRANZCP
Mr Stephen Walker (Treasurer) Royal Australian and New Zealand College of
Ass Dip Eng, BBus, Grad Dip Acc, AFCHSE, AICD Psychiatrists
Australian Private Hospital Association
Ms Michele McKinnon
Ms Jennie Baker DipAppSc(Nurs), BBus(Health Admin), MHA
BHSc(Mgt), BBus(IR), MLegSt, MIR, FCHSM, CHE Department of Health, South Australia
Australasian College of Health Service Management
Mr Michael Roff
Professor Michael Cleary Grad Cert Mgt
MBBS, FACEM, FRACMA, MBA, AFACHSE, MHA Australian Private Hospitals Association
Queensland Health
Dr Noela Whitby AM
Professor Geoffrey Dobb MBBS, Grad Dip Hum Nut, FRACGP, FAICD
BSc, MB, BS, FRCP, FRCA, FANZCA, FCICM, FAMA Royal Australian College of General Practitioners
Australian Medical Association

Acknowledgements (continued)
ACHS Standards Committee Adj Assoc Prof Karen Linegar – ex officio

RN, RM, BAppSc (Nurs), BBus, MHA, DipComLaw, JP,
Dr Philip Hoyle (Committee Chair) FRCNA
MBBS, MHA, FRACMA ACHS President
ACHS Surveyor Executive Director of Nursing and Midwifery, North West
Medical Director, Royal Adelaide Hospital, Adelaide, SA Area Health Service, Latrobe, Tas
Ms Chen Anderson Ms Alison McMillan
BAppSc (Nurs), PGradDipHlthSc (HlthRes&Eval), LLB, RN, BEd, MBA
FAAQHC Victorian Chief Nurse and Midwifery Officer, Dept of
Group Manager-Clinical Risk, St John of God Health Human Services, Melbourne, Vic
Care, Perth, WA
Ms Debra Pearce
Dr Kit-sing (Derrick) Au RN, GradDipNurs, GradDipLegStud, CertPeriNurs
MD, LMCHK, FHKAM, FHKCP, MRCP Vice President, Australian Day Hospital Association
Chief Executive, Kowloon Hospital and Hong Kong Eye Manager, Director of Nursing, Spring Hill Specialist Day
Hospital, Hong Kong Hospital, Brisbane, Qld
Ms Margo Carberry Dr Mark Stephens
RN, DipBus, C&FHN, AFAAQHC MBBS, FRACP
ACHS Surveyor ACHS Councillor
Community Health Manager, Hunter New England Australian Private Hospitals Association
Health Service, Narrabri, NSW Secretary, Australian Day Surgery Council
Medical Director, Chesterville Day Hospital,
Ms Helen Dowling
Cheltenham, Vic
BPharm, DipHospPharm(Admin), GradDipQI HCare,
CHP, FSHP, AICD Mr Stephen Walker
ACHS Councillor, ACHS Board member, ACHS Surveyor BBus, GradDipAcc, DipEng, AICD
Chief Executive Officer, The Society of Hospital ACHS Councillor, ACHS Board member
Pharmacists of Australia, Vic Chief Executive, St Andrew’s Hospital, Adelaide, SA
Assoc Prof Brett Emmerson Ms Patricia Warn
MBBS, MHA, FRANZCP, FRACMA BA
ACHS Councillor, ACHS Surveyor Representative Consumers’ Health Forum, Sydney, NSW
Executive Director, Division of Mental Health Services,
Metropolitan North Service District, Brisbane, Qld
Mr Brian Johnston – ex officio

DipPubAdmin, BHA, FCHSE, FAICD, FAIM
ACHS Chief Executive
Mr John Kenny
BSc, GradDipQA
Consultant
Representative DAA, Christchurch, NZ

ACHS Executive Team
Brian Johnston
Chief Executive
John Hodge
Acting Executive Director, Customer Services
Lena Low
Executive Director, Corporate Services
Linda O’Connor
Executive Director, Development Unit
ACHS EQuIPNational Day Procedure

Centres Project Team
Linda O’Connor
Executive Director, Development Unit
Deborah Jones
Manager, Standards and Program Development,
EQuIPNational Day Procedure Centres Project Manager
Elizabeth Kingsley
Project Officer, Standards and Program Development
Gabrielle Pilgrim
Project Officer, Standards and Program Development
Ian McManus
Communications Manager
Lesley Bateman
Project Administration

EQuIPNational Standards
Published by the Australian Council on Healthcare Standards (ACHS)
Copies available from the ACHS Publications Service
Phone: + 61 2 9281 9955
Fax: + 61 2 9211 9633
Copyright © The Australian Council on Healthcare Standards (ACHS)
This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may be reproduced
by any process without prior written permission from The Australian Council on Healthcare Standards. Requests
and enquiries concerning reproduction and rights should be addressed to the Chief Executive, The Australian
Council on Healthcare Standards, 5 Macarthur Street, Ultimo NSW 2007 Australia
Recommended citation: The Australian Council on Healthcare Standards (ACHS) EQuIPNational Day Procedure
Centres Standards and Guidelines. Sydney Australia; ACHS; 2012.
EQuIPNational Day Procedure Centres Standards and Guidelines
First Published 2012
ISBN 13: 978-1-921806-41-4 (paperback)
ISBN 13: 978-1-921806-42-1 (web)
EQuIPNational
Safety. Quality. Performance.

Ach067 Equip National Day Procedures Completeweb

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EQuIPNational

Day Procedure Centres Standards

About the Australian Council on Healthcare Standards 6

Layout of the EQuIPNational Day Procedure Centres Standards 7

Standard 11: Service and Care Delivery 9

Standard 12: Workforce Planning and Management 14

Standard 13: Information Management 17

Standard 14: Organisational Systems 21

Standard 15: Systems for Safety 24

Standard 11: Service and Care Delivery 30

Standard 12: Workforce Planning and Management 62

Standard 13: Information Management 87

Standard 14: Organisational Systems 107

Standard 15: Systems for Safety 126

EQuIPNational Day Procedure Centres Standards and Guidelines 1

Adjunct Associate Professor Karen Linegar FCNA

2 EQuIPNational Day Procedure Centres Standards and Guidelines

th e pr ors ste am te a nin, won iz.in

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Day Procedure Centres

SAFETY. QUALITY. PERFORMANCE.

EQuIPNational Day Procedure Centres Standards and Guidelines 3

4 EQuIPNational Day Procedure Centres Standards and Guidelines

2. Partnering with Consumers

3. Preventing and Controlling Healthcare Associated Infections

5. Patient Identification and Procedure Matching

7. Blood and Blood Products

8. Preventing and Managing Pressure Injuries

9. Recognising and Responding to Clinical Deterioration in Acute Health Care

10. Preventing Falls and Harm from Falls

11. Service and Care Delivery

12. Workforce Planning and Management

13. Information Management

14. Operational Systems

15. Systems for Safety

EQuIPNational Day Procedure Centres Standards and Guidelines 5

About the Australian Council on Healthcare Standards

6 EQuIPNational Day Procedure Centres Standards and Guidelines

1. A governance or stewardship function • a statement on the context in which the Standard

This is Book 1: EQuIPNational Day Procedure

EQuIPNational Day Procedure Centres Standards and Guidelines 7

8 EQuIPNational Day Procedure Centres Standards and Guidelines

Standard 11: Service and Care Delivery

5. Assessment, Planning and Delivery

6. Discharge / Transfer of Care

EQuIPNational Day Procedure Centres Standards and Guidelines – Standard 11 9

Information and Admission to Services

The organisation provides information on available health services to facilitate admission.

This criterion will be achieved by: Actions required:

11.1.2 The organisation’s processes for disseminating information

Consumer / Patient Consent

About the Australian Council on Healthcare Standards 6

Layout of the EQuIPNational Day Procedure Centres Standards 7

Standard 11: Service and Care Delivery 9

Standard 12: Workforce Planning and Management 14

Standard 13: Information Management 17

Standard 14: Organisational Systems 21

Standard 15: Systems for Safety 24

Standard 11: Service and Care Delivery 30

Standard 12: Workforce Planning and Management 62

Standard 13: Information Management 87

Standard 14: Organisational Systems 107

Standard 15: Systems for Safety 126

5. Assessment, Planning and Delivery

5. Waste and Environmental Management